Case Studies are descriptive studies that are prepared for illustrating novel, unusual, - PowerPoint Presentation

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Case Studies are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in anesthesia practice and they potentially generate new research questions.In compliance with the Health Insurance Portability and Accountability Act (HIPPA) all patient data has been de-identified and every attempt has been made to ensure patient privacy and data security.

Anesthetic Management of a Vascular Surgery Patient at Risk For Alcohol Withdrawal SyndromeElizabeth Pritchard BSN, RN, SRNA

Patient Summary and BackgroundPatient:71-year-old malePresented with severe pain and gangreneScheduled surgery:Femoral-popliteal bypass graft & trans-metatarsal amputation

Comorbidities

:

Peripheral Arterial Disease

Hypertension

Alcohol Use Disorder

Peripheral Arterial DiseaseRisks20% of populationNon-white raceMale genderIncreased ageSmoking Patients with diabetics, hypertension, and CRI

Indications for surgery

Intermittent claudication

Ischemic rest pain

Gangrene

Management

Medical Optimization

~10% myocardial injury

Aortoilliac occlusive disease (AIOD)Atherosclerotic narrowing of AortaCan result in hypoperfusion

Critical limb ischemia

Arterial blood flow compromised

1-2% of PAD patients

Increased risk for limb loss

25%- amputation

25%- fatal cardiovascular event

Risk for stroke & MI

Alcohol UseMetabolized by zero-order kinetics

ACUTE

CNS depression

Disinhibition of inhibitory pathways

Cardiorespiratory Depression

Alcohol Use DisordersIncreased risk for aspirationLiver synthesis dysfunctionDecreased circulating plasma cholinesteraseMAC level alterationsHeart Failure Decreased Lung Volumes

Peripheral nerve and neuropsychiatric diseases

Nutritional deficiencies

Wernicke’s Encephalopathy

Folic Acid deficiency

Neuropathies and weakness

HTN

Alcohol Withdrawal Syndrome (AWS)Up to 50% of patients with AUD will experience AWS Symptoms begin as soon as six hours after decreasing intake

More severe withdrawal due to “kindling” which lowers threshold

Disruption in GABA and NMDA pathways

Seizures can be seen between 6 and 48 hours, hallucinations between 12 and

Delirium tremens (DT) can occur 48-96 hours and can cause tachycardia, hypertension, fever, diaphoresis and delirium

Mortality risk is up to 15%

Preoperative magnesium

Treatment & Prevention Long acting benzodiazepine the night before surgery

Short acting benzodiazepine the morning of surgery

Short acting benzodiazepine for premedication

Clonidine .5mcg/kg/hour

Haloperidol (up to 3.5 mg daily)

Ketamine .5mg/kg

Thiamine 200 mg IV up to 5 days

Stress dose steroids?

Case Study:Patient presentation 71 year-old white malePMH: Hypertension DiabetesPeripheral arterial diseaseAlcohol use disorderPSH:Right to left femoral bypass in 2010 with 4th and 5

th

transmetatarsal

amputation

Aortobifemoral

graft 2010

Discharged to SNF on lisinopril and aspirin.

Lost to follow up and presented in September of 2018 with dry gangrene, pain and contraction of his right lower extremity

Preoperative evaluation and examExtremely thin BMI: 19.1Sitting on the edge of the bed in significant pain and contractedPleasant and answered questionsDenies taking medications or any recent medical careEndorsed 25 beers daily Airway exam concerning for limited ROM

EKG: NSR

VSS: 99.1, HR 89, BP 92/56

Pain: 7/10- 10/10

Open draining black wound

Doppler US showed limited arterial blood flow distal to the knee

Morphine ER BID, Vancomycin and Zosyn

Lisinopril held for low BP

Intraoperative courseExtremely irritable and non-cooperative10/10 pain and photophobia 36 hours since his last drinkBP: 82-95/49-55Midazolam 2mg was given prior to OR

Propofol, fentanyl, rocuronium

Hypotension was treated with phenylephrine and ephedrine

16g IV and radial Artline were placed

Ketamine 50mg was given as an infusion

Additional 3mg midazolam in divided doses

Additional rocuronium

Postoperative course and outcomeEmergence:HypertensiveObstructed airwayPACU:Ekg, CMP with Magnesium (1.6 mEq/L)Hypotension to 72/40Albumin %5 500 ml

Phenylephrine restarted

Transferred to STCU and placed on CIWA protocol and received lorazepam per protocol overnight

POD 1:

Resting comfortably and weaned off phenylephrine

Pleasant and cooperative

Oxycodone 5mg PRN

Discharged to SNF for 3 weeks of physical therapy

Discussion & Lessons learnedStandardized protocols for screening and treatmentOptimizing patient vs emergent surgeryOverlapping disease processesCAD and increased oxygen demandAUD and AWS have high rates of undetected Anesthetic medications can mask signs and symptoms of AWS

Regional anesthesia in patients at risk for AWS?

Missed aspects of recommendations

Preoperative optimization on floor

Questions?What type of screening or assessment do you perform preoperatively on patients that endorse alcohol use both related to withdrawal potential and cardiovascular complications. What communication methods or tools would provide a more comprehensive plan of care for these vulnerable patients?

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