#breadcrusts

Learning points from Kamaliah.

A Malay Lady, 80 years of age with small cell lung cancer, of extensive stage  Atezo, carboplatin and etoposide with a course of allopurinol on the side presented with recurrent red angry rashes sparing nothing except her very eyelashes the face trunk arms and all over her legs but without the characteristic SJS skin breaks It is easy to assume that it is immunotherapy related.

Once again, an application of the “symptoms in a cancer patient” approach

Non-cancer related causes include penicilin rash (just had penicillins) Tumour-related causes include paraneoplastic syndromes Treatment related causes include anti-cancer therapy related - atezolizumab supportive drug related - Allopurinol

Learning from that day’s internal jugular central venous catheter (CVC) insertion

1) Recognising the indication for insertion of CVC

- is it urgent?

- if it is urgent, why was the femoral vein not the first choice? was the anatomy unfavourable?

- if it is not urgent, can i hold it off till I have optimised the patient further with fluids?

2) Choice of site

- if IJ is chosen as the site, is there anything that makes it more challenging/more risky?

> carotid artery below the IJ, small IJ

> dynamically collapsing IJ with inspiration/expiration (pt is heavily ventilated, fast respiratory rate

- can I choose a safer site then? 

> contralateral IJ, femoral vein

3) If the IJ site is more risky than usual and I don’t have other available sites, can I optimise the site?

- fluid resuscitation to maximise venous distension

- Trendelenburg positionin

4) If backflow in the syringes once IJ puncture is attempted suggests arterial blood, (bright red and/or pulsatile), how do I confirm it?

- do not put in the guidewire yet; send an undiluted ABG sample first, and then place the guidewire in partially to maintain access

- things to take note on the ABG is the SpO2 (expected <75% for venous blood) and lower Pao2. you may get a mixed reading (higher than venous but lower than arterial if aspiration took place while going through both artery and vein.

- confirm placement on ultrasound

- if in doubt, remove the needle and re-attempt cannulation. ITS NOT TOO LATE TILL YOU DILATE the cannulation tract.

today’s lessons

Preparing for your best by preparing for the worst

Today, i attempted to intubate a grotty patient, someone with immunotherapy-induced myocarditis. 

We gave him 2mg of midaz, and 50mg of rocuronium and 3mins after that, his heart just 

stopped.

and so did mine. 

Prompt resuscitation commence, with a rapid fluid bolus and some shots of phenylephrine. 

Lesson learnt:

Preparing for a successful procedure, also means

1) having your checklists, your standard

> preparation: esp of patient position

> choose your sedation

> choose your paralytic

> mentally rehearse your intubation

> trust your training

2) prepare your game plan for

a) side effects of sedation

b) when your first intubation fails

> adjuncts OR

> airway team

A team always goes on field with game plan A, and game plan B. 

Similarly, a spec ops team has an infil plan and multiple exfil plans. 

Natka in Darkness