Clinical Case 148: An Imperfect Storm
Here is a complicated clinical case for your consideration.
About once every three months I am allocated to a theatre list with our visiting Vascular Surgeon. This is a challenging list as the patients are all receiving, or due to receive dialysis for their renal failure. These are sick folk. Almost all have diabetes, ischemic heart disease and the other complications of end-stage renal disease.
The goal of the list is to give as little actual anaesthetic as possible and rely upon regional blocks and local anesthetic techniques. Occasionally we do end up having to give a GA… but that is not where this story is heading.
Towards the end of a successful list (where no anesthesia was delivered !) we received a call from the ED – there was a patient there whom the ED team wanted our visiting Vascular surgeon to review…. He seemed to be in trouble… so we finished up the last case and wandered into ED to see what was going on. The next ten minutes was a constant unveiling of an Imperfect Anaesthetic Storm.
The patient was an 80 year old man who had recently travelled to Broome to recover from “ a big operation” with his family. He had been discharged from a metropolitan centre of excellence a few days ago. He was now one week post bilateral, open, iliac artery stenting. He has come in today complaining of feeling generally unwell, febrile and a painful swelling to the left groin wound.
As our visiting Surgeon goes in to examine the patient the resident handed me a copy of the discharge summary… it is not pretty!
Here are the basic facts….
- 80 yo man with severe peripheral vascular disease
- Previously has had ischemic heart disease and now 10 years post CABG x 3
- Multiple DVTs & PEs. On lifelong Apixaban… and yes, he took it this morning!
- Rheumatoid arthritis – on chronic prednisolone and methotrexate…
- Pre-operative echo report from last week – moderate LV dysfunction with severe aortic stenosis and an estimated valve area of 0.8 cm2.
- Anaemia with Hb measured at 99 on discharge
- The last line of the discharge letter reads “ noted to be febrile on day of discharge. Source unclear”
After reading through all of this and going through some serious cognitive backflips in my head the Surgeon returns…
“What do you think?” I ask…
“We need to operate now. That groin is about to go!” “This is a do or die scenario.”
He thinks that this an infected haematoma that is now a pulsating mass under the stretching suture line.
Of course, our surgical friend is due to fly out in 3 hours and after that we are back to our usual theatre team…. none of whom would be super keen to operate on a redo-iliac graft disaster…
So I go to do my own assessment. Our man is looking pale and has a weak radial pulse at 110 per minute. He has a good looking airway and the DC summary says nothing about anaesthetic complications.
He tells me his angina has been well controlled since his CABG and he can walk a few hundred metres but is limited by the claudication until recently.
As we are running through the consent and I ask about his acceptance of a blood transfusion if necessary … he stops me and says:
“That reminds me I am supposed to show you this card…” he pulls a laminated card from his wallet. The card lists a range of transfusion incompatibility antibodies… some of which I didn’t know existed… until now. My simple country doc brain read the scenario like this…
- Old, sick man – likely septic with limited cardiovascular reserve…
- Unable to be cross-matched
- BUT I do have a great Vascular surgeon ready to go who can control the bleeding…. I hope.
So – what is the plan?
Delaying the case and / or arranging transfer are not really possible. This needs to be done here and now and we only have a short window where our Surgeon can do it.
Transfer is going to happen, but only once we have control of the situation.
Next on the hit list is to limit the damage and try and reverse / fix what we can…
- Reversing apixaban – what works vs. what have we got?
- Big time antibiotics to cover MRSA
- Stress dose steroids – get these on board now before the BP starts to drop
So how does one go about giving this anaesthesia in a small rural hospital with no ICU and limited pharmacy or transfusion resources?
There are many variables at play here. I like to break these down into the ones tht I can control / fix / act upon vs. those that are unmovable and just need to be accepted as the “dealt hand”.
When I discussed this case with my colleagues many were keen to have a palliative discussion with the patient and the family before embarking upon further risky surgery. This is one of the features of rural generalism – we tend to think broadly about the bigger picture , rather than looking at a patient and their problem from just our specialist perspective – many GPAs are also active in palliative care or other areas. This is something that we did consider here.
However, this man had only one week ago undergone the primary operation with the expectation of improving his quality of life. Although this is clearly not the outcome that he expected he remained hopeful of recovery. To my mind this was a “fixable issue” that had unfortunately occurred in a small, remote hospital. Had he still been in a tertiary centre then this would have been a relatively simple decision. As my mate Tim Leeuwenberg says “Critical illness does not respect geography”… on the other hand the central mantra of Broomedocs is that our rual patients should not recieve lesser care by virtue of the geography – that is our job as rural generalists – to bring ‘great care, out there’! Practically, on this day that meant that whilst we had a capable team and capacity to act then we should do so.
So, we are going to operate. What next. Resuscitation. We need to be ready for the worst case scenario and have the physiology primed.
That means getting great IV access. Here I want a big proximal line to allow us to get large volume boluses in quickly if the plug falls out of the bath tub. I also want a robust long line through which I can run vasopressors reliably.
This man needs an arterial line. Without knowing the BP we can easily get the haemodynamics very wrong, very quickly. This seems straightforward… until we start looking for a place to insert an arterial catheter… recall that he has had both femoral arteries opened and repaired a week ago…. and one is full of pus! We love the radial artery… but his is barely palpable. Of course, ultrasound is the key to any tricky access problem. Unfortunately the radial vessels are tiny and ultrasound reveals tiny, densely calcified forearm vessels. Moving up the arms we come to the elbow and things are not any better. Luckily the brachial arteries are larger and we manged to locate a short segment hat was relative free of atherosclerosis. Now, this is not the “usual” place to put an arterial line but there is actually a bit of data to suggest that in such a sick patient that the more proximal lines (eg. axillary or femoral) will actually give a better measurement of true cardiac output over the more peripheral radial lines (especially in a patient with tiny, calcified vessels).
Next – stress-dose steroids. One could argue that this man was only on a low dose of chronic glucocorticoids… but no. My general rule for deciding on who gets a blast of hydrocortisone is this: ” If you THINK about stress dose steroids – then GIVE stress dose steroids!” There is little downside, many possible benefits and if you wait until the BP starts tanking then it is probably too late. So JUST DO IT!
Now, off to consider the Haematology of this case. Apixaban is potentially reversible if we give some PCC (aka Prothrombinex in Australia). We can also give a dose of vitamin K which may be helpful to some extent if there is an abnormal INR – having said that there is not much to lose from a dose of vitamin K … so, once again, just do it!
“What about Andexanet alfa?” I hear the really smart and up-to-date readers ask… well this is one of those moments where being in the bush is just great. We do not stock it. This is useful as:
- It is ridiculously expensive
- There is no actual evidence that it does anything for patients (ie. more than changing lab results)
- It just might be harmful based upon the published data (listen to our podcast here)
- Hence – the decision to not use it is an easy one! JUST say NO!
Obviously we want to have some blood on hand to allow us to transfuse if needed. However, our patient’s immune-incompatibility issues will make this tricky. On a good day we can cross match most patients but this one is really going to test our lab staff. Another aspect of small hospitals that I really love is the ability to walk over and have a chat with our staff (admin, lab, radiology, allied health etc). So I collected some blood for cross-matching, borrowed the patient’s laminated card, called the Haematologist at the city hospital and walked to our lab to try and come up with a plan. Getting all the brains required together in one place is invaluable in these scenarios. After a quick trawl through the local blood bank and discussion about the “least worst” options we resolved that we did not have any red cells that were likely to be completely “OK” but if it were truly a do-or-die scenario then our generic O-neg would be the best bet…
This problem goes into the “not under my control” box. However, it may be in the Surgeon’s realm – if we can get rapid control of the bleeding, then we hope that we will not need to transfuse at all. That would be ideal.
OK, we are getting ready to head in to the operating theatre to try and get control of this situation. Our patient needs an anaesthetic… but exactly which type of anaesthetic and how do we do this?
It is always nice to consider regional / spinal anaesthesia. It is generally a good option for sick patients with “blockable” problems. For example, we do the majority of our septic, diabetic foot procedures under a popliteal sciatic block and it works well. However, this man has multiple contraindications to a spinal and there is no regional block I can do that will cover the possible incisions required here. Although the iliac may be blocked by an inguinal field block it will not cover if the incision needs to be extended or if the abdomen needs to be opened to get proximal control! So I took the regional anaesthesia options off the table early.
So he will need a general anaesthetic. There is a high probability that this anaesthetic will morph into a prolonged retrieval to the tertiary centre. Therefore we need to think ahead and plan for that possibility. We have an arterial line in place, several big IV cannulas and the option to place a central lie if needed (though this can wait until after the actual induction.)
We all know about the “anatomically difficult” airway. This is something that we drill, we practice AFOI, cricoid access etc… however this man has a “physiologically challenging” airway. We need to sublimate him from awake and breathing to asleep and ventilated with the least possible interference with his homeostasis. We know from the notes that he was not difficult to intubate… but this is a new game today. We need a plan that allows us to make this transition as smooth as silk.
My plan was to have all the options ready to go:
Induction agents: a little propofol, a moderate amount of ketamine, some fentanyl and then have some more propofol ready to go if needed.
Paralysis: I want to spend as little time as possible “fiddling” in the airway. So a generous dose of rocuronium is always my plan when I want to achieve rapid muscle relaxation and keep it. We are not likely to need to wake this man any time soon… and there is always suggamadex if we do have a surgical win!
Vasopressors: Here I want to have some infusions ready to go. Noradrenaline is good to counteract the vasoplegia of our anaesthesia and the sepsis. Some push dose adrenaline at the ready in case we drift into bradycardia or need to move the heart rapidly.
Volume: I do not want to run this chap “dry”. He may not need a lot of fluid resuscitation, but given that we are about to take control of his breathing and can deliver plenty of PEEP if needed I would rather he be slightly on the fullish side of euvolemia. We can adjust this as we go once we know how much bleeding there is and what his kidneys, heart and lungs are doing. I want to have the ultrasound with echo probe at the ready to allow me to look at the heart, lungs and IVC in a dynamic manner.
Team: There is probably enough happening here to justify having two GP-anaesthetists in the room. That is not always a possibility in small towns. I do like to delegate a theatre nurse to watching the arterial line and monitor closely to keep my awareness of the situation whilst I am focused on the airway with pre-discussed actions eg. “if the BP drops below 100 we will start the Norad” or ” if the heart rate is less than 60/min we will give 20 mics of adrenaline.” Obviously it is best to have a colleague who is capable of titrating drugs as we go… but that was no the case when this man needed his care.
Cross-Drape Communication: in this case we need to know exactly what is happening as the procedure progresses. Watching and anticipating the next move with the surgeon is crucial. Is there a lot of bleeding, do they have control of the vessels? What is the plan to fix the problem?
So what actually happened in this case?
The arterial line took a lot longer to insert than the usual arterial set up… however, this was one of my “must have” items so no moving ahead until it was all working well.
The induction was really very smooth. The BP stayed where it was and we even needed to add a little more propofol for hypertension a few minutes after intubation. No vasopressors required in the first 20 minutes.
The actual procedure involved re-opening the week old incision and removing a large purulent haematoma that was overlying the iliac vessels. As soon as this clot was removed a jet of blood shot across the field… there was a 1 cm defect in the anterior wall of the iliac artery which was the source of the bleeding.
Fortunately the Surgeon was able to get control above the defect and clamp the vessels. So we didn’t lose more than a few hundred mils of blood. Then the issue became – what to do next?
The vessel needed grafting and our small hospital has limited options for this as we do not really do much vascular surgery. So the plan was to create a patch from autologous vein and oversew the defect. This actually worked quite nicely and the bleeding was controlled…. however, in the presence of all that infection this too would likely fail in time, but we had bought our patient some time for transfer.
Retrieval was arranged by air and we elected to wake and extubate our man as it is much more logistically and technically simpler to transfer him without all the machinery required for an ICU attached. He did eventually require a noradrenaline infusion for his septic shock… but I saw this as a win.
POST SCRIPT: 2 days after a successful and uneventful transfer the patient did re-rupture through the graft and required an urgent return to theatre in the tertiary hospital.
Parting thoughts from my mate Dr Greg Coates: It’s better to be good than lucky. But it sure is good to be lucky.
….and the more I practice the luckier I get….
Great case Case. Bush medicine is far more challenging than Ivory Tower medicine in my opinion. Impressive how how best basics are often the best choice.
Great case. I presume you have some form of II (given that you sound like you’re doing fistuloplasties) – did you consider trying to get control above with a wire guided fogarty into the iliac, or was that too much for your centre? (I’ve seen bilateral internal iliac fogarties, preemptively placed, for potential placental bleeding for example).