Okay, mine is a, is, how many of you are internists in the room? Nobody, okay. So mine is an ex, I had this experience a few years ago. It was a very complex patient in the sense that she was from Europe, very high demand, her family was involved in the medical field and we had done her, these are my disclosures, we had done her surgery on the other side, on the left side a few months before. So she came in, you know, we were supposed to do the same thing on the right side and go on and have a good outcome. But this illustrates a point where you go in very confident, you think about all the curveballs and then the curveball happened. So this is a cardiac complication that occurred during surgery. It's been seen in shoulder arthroscopy with anterior scalene block and it's been reported that there's been, of course, hypotensive bradycardic events during shoulder scopes. So this was a 47-year-old ex-ballerina dancer and those of us who have treated ballerinas, they're very meticulous and they're very fit. So as I said, we were going in after having done the right at the hip in the past on the other side and she did really well. So we went ahead and did the surgery on the right side. The surgery actually from start to finish was good until we placed the last suture on the mid-anterior portal. So as I said here, towards the end, we just used, I used the Ringer's Lactate for my fluid. And after the infusion of the new bag was hanged out, 3-liter bag, she became hypertensive, tachycardic, and her temperature dropped to 34C. And then my anesthesiologist tells me that the PEEP is increased and she has pink frotty sputum. So and this is at the end of the case. Actually when I, at the end of the case, our fellows closed the portals. But for some reason, I stayed there. And so that didn't look good. Then she had diffused crackles on the exam, on the lungs. And of course, pulmonary edema was diagnosed. And then we diarhyster with Lasix. And they did a 3-suction pass in the lungs. About 700 ml was suctioned. So I called Dr., one of our physician, actually his own staff, he's a very good cardiologist. He works with our ski team. Great guy. Came right up to the operating room. And I was in our surgery center, which is in the hospital. And basically, it says here, it showed no gross abnormalities. So there was a trans-thoracic echo done. And also we did an abdominal ultrasound to see if there was any fluid. The first thing that came to my mind is there's too much fluid in the abdomen. It's pushing on her IVC or something like that. But the abdomen was fine. And she had sinus rhythm with nonspecific inferior lateral ST changes. And the chest X-ray showed diffused alveolar infiltrates. So it was at the end of the case, thank God, the case was done. We took her down from the OR to the imaging, where we ruled out a PE by chest CT pulmonary angiogram. And by that time, most of the fluid, the lung fills were clear. And we thought it was resolution of our pulmonary edema. And the AKG normalized. So within a short period of time, she normalized. So again, the other side went uneventfully. The other side, after the event, we start, I kept her intubated overnight. And she told me the next morning, Dr. Philippon, why did you keep me intubated overnight? I said, well, we had some issues. And she says, well, next time, you should have someone explain to me the intubation and all that. And the worst part of the whole situation was for her to stay intubated overnight. And we took the tube out the next morning. And she was great. But then I start talking to her. And then she said, oh, I forgot to tell you, on my right side, I was at MGH a few years ago. And I had a complex abdominal surgery for a spigelian hernia, which is between the rectus and the, it's a hernia that goes between the rectus and the obliques. And she told me that she had, the surgeon told her after the surgery, it was a little more complicated than usual. So we never heard. She told me after the case. So then I start thinking, maybe there was a path between the interarticular psoas. She had a communicum bursa. So maybe the fluid dissected not only in the reticular space, but in the abdominal area as well, more in the wall. So we start thinking, maybe she, because of the fluid dissection, the way she had surgery, there was pockets where there was no real abdominal distension there. And it caused, we thought it caused phrenic nerve irritation. So that was our diagnosis. And what's interesting, what we learned from this case is that the timing of the event was right after the fluid that we put in the, it was at room temperature, which was, the room was actually was low. And we start looking into this, that a corporeal temperature drop could result in cardio and pulmonary concern. And we know that if we warm up our irrigation fluid up to 30 degrees Cs, there's a risk of decrease in core body temperature. And I remember when I was in Florida at Holy Cross, my patient used to be in the, go to the recovery room very warm. And my, at that time, our protocol was to keep our fluid warm. And when I moved to Vail, I stopped doing that until this case. So I'll just share with you the effect of warm irrigation solution on core body temperature and hypertroscopy. So there's a study done by Perotti. And you look at two groups, warm irrigation solution fluid, warm to 30 to C, and a control group that kept at room temperature, which is 22 in that case. And he noted that the decrease in core body temperature by half a degree Celsius or greater was observed in 66% of the patient in the control group versus 28% in the warm solution group. And at least one core body temperature of less than 36 degrees C was recorded in 48% of the control group patient versus 14% of the warm solution group. So it was, the trend was 4X versus the control group. So mild hypothermia is associated with increased myocardial work load and adverse cardiac events. And mild hypothermia can also result in increased oxygen demand. And impaired oxygen delivery to our tissue. So this is just from an article from anesthesiology in 2001. When you look at the major consequence of mild period of hypothermia in humans. So for me, after having that experience, which was not pleasant, we started looking in the hypothermia and potential complication that goes from mood infection, all kind of possible side effects from the hypothermia. Also we started looking at the drug use. Fentanyl inhibits shivering and increased risk of hypothermia. So we also work with our anesthesiologists, with our fentanyl users in the surgery. And also sedative can have an impact on hypothermia as well. And I use a spinal epidural. In this case it was not a spinal epidural, it was a general. But that also inhibits central tumor regulation. So this is a paper from Board, which found that the mean maximum drop in core body temperature in the room temperature was 1.67C. As compared to warm irrigation, which decreased to 0.33C, which is significant. So I think from that research and from that event for us, we started warming our fluid. Every patient I do surgery on, I have my nurse, my sickly nurse, she monitors the temperature of my fluid. I monitor the temperature in the room and also I tell my anesthesiologist to check my patient temperature as well. So now we've done a fair amount of patients since that event and we haven't had any adverse event regarding to that. So in summary, I think, I know this is a rare complication, but I think keeping in mind that you should monitor your enzyme out of your irrigation fluid, but also the temperature of your irrigation fluid. I think that's, even if it's rare, it can have a deficit of complication. And thank God I had a good cardiologist in my hospital to help me with this. She did great. And I'll tell you a funny story. A couple years later we had a shortage of propofol in the U.S. I don't know if you remember that. So this lady's husband owned propofol. So I called him up, I said, you know, we're short of propofol. Next day we were filled with propofol in our hospital. So the outcome was very good. She was, she's very happy with her hips, but this was a life-threatening situation that could have turned into a disaster. And again, I was, it was, we were lucky we had a good team that helped us to get this patient along. And she's still doing great. She's an older lady now, she doesn't dance ballet anymore, but maybe she does recursionally, but she's doing well. So I'm happy to answer any questions. Also I forgot to mention we're at 8,000 feet in veil, so that might have something to do with the cold temperature. Just kidding. Question, Mark, any thoughts on outflow? Yes. So in my practice for my first few years, I didn't use outflow and I noticed a huge amount of fluid extravasation in the soft tissue spaces. And then just for no reason at all, I just started using outflow and that seemed to drop that amount of extravasation down. There's pressure monitor, there's non-pressure monitored outflow. What are your thoughts and what are you currently doing in that regard? I don't use an outflow portal, but I think it's a great idea. I keep my pressure very low, between 30 and 50. I use a very good pump that, it's like based on an old Devo pump that we had in the past. Works really well for me. So my flow, the pressure is really low, but I still keep track and I don't use, and sometimes I'll have extravasation, like you're talking about. But with keeping the, and then I monitor it. If I really, really see that it's ballooning, I'll sometimes dissect the area a little bit with a hemostat and get that pocket off. But I think it's a good idea to have an outflow portal and then monitor your ins and outs. I've learned that also to make sure that it's not going somewhere you don't want to, like in the internal space or in the thigh. Especially actually, I don't know if you guys have ever checked your CK after a surgery just to measure your muscle damage from the irrigation. It's pretty high and it's aggravated by what you just said, I think. So we have to be aware of that. Sometimes this thigh gets really big. So I think it's important to monitor your in and out and have maybe an outflow portal. And I also learned that operating at different surgery centers, just picking one number for the pressure is not accurate. You have to know your system which you're using. If you're using different systems in different places, you might have to adjust. One center I use 25, the other one's 30 or 35. But what I also do when I get people off traction and flex up the hip for the peripheral compartment, I reduce the pressure at that point. So it go down another 10, 15% because of points, whatever the scale is. Because I found that's when you start swelling up often, once the tension is off in the tissues, a lot of extravasates into the soft tissue. So I even decrease, obviously you want to see stuff, but I typically go down another 10, 15 points on the scale and the pressure. Cool. Yeah. What do you mean by an outflow portal, like a posterolateral cannula? So it's not an outflow, I don't use an outflow portal per se. I attach outflow to the cannula. So once I establish the cannulas and I'm starting to put anchors in, I put cannulas in for the anchors. And a lot of the anchors actually, or a lot of the cannulas have an outflow option. And then I'll connect that to a pressure monitored outflow tubing. And it has dramatically reduced the amount of fluid extravasation in the soft tissues because it just pumps it through the cannula. I mean, you get some, but it's way less. So it connects from your working cannula to the pump system? Correct. Correct. One quick question actually, and it's not exactly related to this, but it is related to the extravasation. How many people here have anesthesiologists that do blocks on their hip patients? Okay. Mark, you have blocks. What kind of block do your anesthesiologists do? So we do an alofacial block, but now recently Dr. Rockwell, which is a great guy that we just have, he developed a new block that's a little variation of alofacial block. And for us, it's been helpful. It's not perfect because we still have pain laterally sometime after surgery, but it's helpful I think. And I use a spinal epidural as well. I leave this epidural in after surgery for a few hours. Of the people who do have the anesthesiologist block their patients, who does fascia iliaca blocks? Okay. What do you do, Chad? Yeah. I mean, I get half and half. I get two of them that blocks and two that don't. And then they do fascia iliaca. Or they do this pain block. Yeah. Yeah. Flavor of the month. I don't know. So last year, Salada presented sort of a block related issue. And we've had some issues with fascia iliaca blocks in our surgical center. So we don't do them anymore in the sense that we looked at the nerve numbness or nerve injury. And it's not significant injury, it's just relative numbness on the medial thigh. It's not post related. And it's about 33% or so of the people who had numbness that had both lateral and medial sided numbness. So we don't do those anymore. But the plexus blocks have worked. Have you guys experienced that at all? Yeah. Yes, I've had that, actually, a few occasions. And we monitor that. But I have a group of three guys only that do it for us. And again, you see the flavor of the month. Sometime you have a guy coming in. So we are very picky about who. Yeah. Because we want the most experience possible. It's a potential issue. Not only with that, also with spinal epidural. You've got to be very consistent with your team. I would like to do the spinal one. Because I think their pain, if they have pain that's been going for the first few hours, and they have spinal, then they probably have no pain. And then no narcotics. And I can't get the STLs to continue to do it. I think it's just about falls or something like that. Oh, yeah. Yes. Battle for it, I guess, another day. Any other questions? All right. Thank you. Thank you, guys.

Dr. Philippon

cardiac complication

surgery

hypertensive symptoms

pulmonary edema