Morning ReportAalap Shah, MD

Elizabeth Eastburn, DO11.17.2015

# Procedures

I

II

III72

2ASA

Cases by ASA Classification

# Patients

GS 5

Ortho3

Optho1

Onc1

GI1

Cases by Surgical Service

0

1

2

3

4

5

6

GS Ortho Optho GI Onc

Cases by Surgical Service and ASA

I II IIIASA

Cases by Surgical Service and ASA

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

0-1 mon 1-12 mon 1-2 year 3-11 year 12-17 year 18+ year

Cases by Patient Age

Weekend Cases 10/16-10/19

ASA 1 ASA 2 ASA 3

10 y/o M with supracondylar humerus fx s/p CRPP, long-arm cast

14 y/o F with B-cell ALL s/p PICC placement and LP for IT chemo

2 y/o F with aplastic anemia, CMV enteritis vs GVHD s/p EGD/flex sig

14 y/o M with L. 2nd digit fx s/p CRPP

15 y/o M with SBO s/p PICC placement

9 y/o M with hepatitis –induced aplastic anemia, candidiasis s/p PICC placement

18mo F with R. 4th finger near-amp s/p soft-tissue release

9yo F with appendicitis s/p lap appy

14yo M with R. testicular rupture s/p repair and scrotal exploration

18mo M with appendicitis (ruptured) s/p appendectomy

5yo F with L. eyelid preseptalcellulitis s/p EUA

15 y/o M with SBO

HPI

• 15 y/o M with diffuse abdominal pain x 6 months and SBO. Transferred from OSH.

• 20 lb weight loss x 6 months

• Plan for PICC and PN, with plan for lap-assisted abdominal exploration later in week

PMHx: - Intermittent, mid-abdomen- No previous [abdominal] surgery- +Post-prandial pain - No rectal bleeding, perianal sx or extra-GI s/sx

Labs:CBC: WBC 5.8, Hct 35.9, Plt 265, PBS wnlBMP: Na 130, K 4.2, Cl 91, Glu 72, BUN 14, Cr 0.6LFTs: Alb 3.5, Pre-albumin

Amylase/lipase wnlOSH FOBT +

15 y/o M with SBO

• Urgency of Abdominal Exploration?

• DDx?

• Fluid repletion / electrolyte goals

• Are you worried about the FOBT +?

• Would you place an NG prior to anesthesia?

• What is refeeding syndrome?

Anesthetic Plan?

• Pre-med: 2mg IV midazolam

• Airway: Natural airway, NC

• Induction: Propofol 120mg

• Analgesia: Fentanyl 50 mcg

Post-Anesthesia

• Started PN

• To OR for lap-assisted SBR --? 4cm terminal ileum w/ stricture removed

– C/f IBD given transmural inflammation and fissuring, previous perforation site

• Transitioned to PO diet on POD5, discharge with f/u colonoscopy

SBO: Management Pearls

• Non-operative management successful in 65-81% of cases w/o peritonitis

– Without the presence of free air, SBO is a medical diagnosis

• Electrolyte abnormalities:

– hypo Na, K, H/Cl volume contraction alkalosis

– Refeeding sx phosphate, glucose, thiamine depletion in response to carbs K, Mg depletion Cardiac arrhythmias, respiratory muscle strength during anesthesia emergence, etc.,

• DDx is vast, but why do we care?

– Infection SIRS low SVR state, preload goals

– Hernia r/o strangulated components

– Chronic + wt loss r/o oncogenesis

– Adhesion/previous surg Bleeding, longer duration, opioid-induced ileus

– IBD

• NG provides symptomatic relief, decreases need for intraoperative decompression

– Must weigh against current n/v and patient discomfort with NG placement

– No outcome differences between NG and NJ

Weekend Cases 10/16-10/19ASA 1 ASA 2 ASA 3

10 y/o M with supracondylar humerus fx s/p CRPP, long-arm cast

14 y/o F with B-cell ALL s/p PICC placement and LP for IT chemo

2 y/o F with aplastic anemia, CMV enteritis vs GVHD s/p EGD/flex sig

14 y/o M with L. 2nd digit fx s/p CRPP

15 y/o M with SBO s/p PICC placement

9 y/o M with hepatitis –induced aplastic anemia, candidiasis s/p PICC placement

18mo F with R. 4th finger near-amp s/p soft-tissue release

9yo F with appendicitis s/p lap appy

14yo M with R. testicular rupture s/p repair and scrotal exploration

18mo M with appendicitis (ruptured) s/p appendectomy

5yo F with L. eyelid preseptalcellulitis s/p EUA

2 y/o F CMV enteritis w/ GIB

HPI

• 2 y/o F, now 2 mo s/p BMT for aplastic anemia, admitted 10/8 for fevers, vomiting/diarrhea

• Presenting for colonoscopy

• Inpatient course significant for:

• CMV diagnosis (PCR)

• progressive hypoxic respiratory failure

• Endocarditis, pericardial effusion w/o tamponade

• Transaminitis NOS

• Recent C. diff

• Bloody stools, multiple PRBC and PLT Tx

2y/o F CMV enteritis w/ GIBRx:- Cyclosporine TPN- Furosemide Fat emulsion- Foscarnet- Ciprofloxacin, Voriconzole, IV Vancomycin, Meropenem- Lorazepam / Morphine (+ Morphine NCA)- KCl

Previous Anesthetics:- BMA {6/15, 8/15},

PICC {10/15}- IV induction, Gr 1 View (Mil

1 / Wis 1)- ETT replaced (4.0

3.5)*,**

- *Replaced due to inability to pass

- **no leak

- Previous post-op stridor

VS: 140/91, HR 76 NSR, SpO2 96% (FiO2 30%), RR 20, Temp 37.6

Labs:VBG: 7.41 / 43.7 / 39.0 / 27 [FiO2 30%]CBC: WBC 2.4, Hct 33.5*, Plt 45; ANC 2.29

PT 13.7, INR 1.02*=s/p pRBC (Pretx Hct 19.3)

BMP: Na 146, K 2.7, Cl 112, Glu 135, BUN 11, Cr 0.2LFTs: Alb 1.8, Pre-albumin - ECHO 10/27:

LDH 464 (nl: 110-295) Small echobright focus on BCx: NGTD, CMV + PCR RV inflow, not present 9/14

Anesthetic Plan?

• Emergent case?

• Induction paradigm?

• Monitoring?

• Intubation? Keep Intubated?

• Blood products?

Anesthetic PlanINDUCTION:• RSI induction (Propofol 25mg, Fentanyl 12.5mcg,

Succinylcholine 20mg), pre-existing PICC• Analgesia: Fentanyl 17.5 mcg• Relaxation: Rocuronium 4mg x 3MONITORING: Standard + 22g L. RAD ARTAIRWAY: - 1st attempt swollen

arytenoids, 3.5 cETT, no EtCO2/breath sounds- 2ndWis 1 Grade 2a, 3.5 cETT

LABS: 7.32/49.7/94/25.3 [FiO2 60%]

Post-Anesthesia• Remained intubated x 4 hrs

– Wheezing / decreased air entry– Thoracoabdominal competition d/t abdominal distension

• Severe GVHD– EGD w/ extensive abnormal and friable duodenum, and gastric

mucosa

• Intermittent bloody stools, maintained on complete bowel rest

• Worsening hypoxic hypercarbic respiratory failure (HFNC HFOV)

• Made DNR 11/15 severe hypoxia (ABG pO2 50s, SpO2 40s), wide-complex bradycardia– Passed away 11/15/15 13:30

Weekend Cases 10/16-10/19

ASA 1 ASA 2 ASA 3

10 y/o M with supracondylar humerus fx s/p CRPP, long-arm cast

14 y/o F with B-cell ALL s/p PICC placement and LP for IT chemo

2 y/o F with aplastic anemia, CMV enteritis vs GVHD s/p EGD/flex sig

14 y/o M with L. 2nd digit fx s/p CRPP

15 y/o M with SBO s/p PICC placement

9 y/o M with hepatitis –induced aplastic anemia, candidiasis s/p PICC placement

18mo F with R. 4th finger near-amp s/p soft-tissue release

9yo F with appendicitis s/p lap appy

14yo M with R. testicular rupture s/p repair and scrotal exploration

18mo M with appendicitis (ruptured) s/p appendectomy

5yo F with L. eyelid preseptalcellulitis s/p EUA

HPI

• 9 y/o M from Kuwait with hepatitis-induced aplastic anemia and disseminated candidiasis

• Presenting for PICC line replacement

• Previous DL PICC (9/18) with cracked lumen

9 y/o M w/ hepatitis-induced aplastic anemia

• Inpatient course significant for :

• Anemia/thrombocytopenia

• s/p multiple tx (9u aPLT, 3u pRBC)

• Borderline PO intake (Hepatitis, ileus)

• H/o multifocal PNA (9/13), resolved

• R. thigh abscess, s/p IR drainage

• Hepatitis workup: non-typable; concern for Fe overload

9 y/o M w/ hepatitis-induced aplastic anemiaRx:

– MeropenemLevofloxacin, Voriconazole, Amphotericin, Bactrim ppx

– Omeprazole, bowel regimen - PRN Tylenol

– KCl replacement

– Ursodiol

VS: 98/57, HR 105 NSR, SpO2 99 on RA, RR 26, Temp 37.6 (max 38.3)

Labs:

CBC: WBC 0.13, Hgb/Hct 5.0/17.3, Plt 13 [10/29]; ANC 0.02, ALC 0.10

[10/31 Hct artificially high]

BMP: 135, K 3.6, Cl 99, HCO2 27, Glu 101, BUN 10, Cr 0.3

CRP: 14.1, LDH: 70

LFTs: AST 26, ALT 66, Albumin 2.9, Bilirubin wnl

BCx/KOH prep: +Candida tropicans

ECHO: Trivial pericardial effusion

Previous Anesthetics:- R. thigh abscess aspiration (10/22)

- Nat airway (NC), Propofol/Ketamine

- PICC (9/15)

- IV induction, Mac 2 Gr 1 View, 5.5 cETT, midazolam, propofol, morphine

Anesthetic Plan?

• Airway: LMA Unique 2.5

• Induction: Propofol 80mg

– Pre-existing PICC NOT used

– Pre-existing PIV 22g

• Analgesia: Fentanyl 15 mcg

• Products: Platelet Tx (121 cc)

Aplastic Anemia: Management Pearls• Misnomer - Primary failure or immunologically mediated

suppression of multipotent myeloid stem cells– Anemia + thrombocytopenia + neutropenia

• Etiologies: Chemicals, Drugs, infections

• DDx– Fanconi’s Anemia - PNH / c-Mpll– Dyskeratosis Congenita - Shwachman Diamond syndrome

• Electrolyte / Nutritional abnormalities (due to medications)– Hypo Na: SIADH, amphotericin-induced renal tubular

dysfunction– Hypo K: Amphotericin, furosemide (post-transfusion diuresis)– hypo Na, K, H/Cl volume contraction alkalosis

Aplastic Anemia: Management Pearls

• Antibiotic and other badness– Voriconazole visual disturbances (30%), transaminitis, QT

prolongation– Amphotericin – fevers (NLMS-like), renal/hepatic toxicity

• Infection precautions– Sterile technique with IV placement, Airway management (ETT or

LMA)– Apheresis platelets (single donor), leukocyte-reduced/irradiated pRBCs

• Transfusion thresholds / precautions– Institutional: Hgb < 6, Plt < 50; reassess in brisk bleeding scenarios– Non-infectious transfusion complications (TACO/TRALI, Fe overload,

DHTR)

Thank You!

• Elizabeth Eastburn, DO

• Thomas Mancuso, MD [Course Director]

• Carlos Munoz-San Julian, MD; Izabela Leahy, RN BSN MS [Course Planners]

• Jina Sinskey, MD [Slide Template]