Page 117 - JSOM Summer 2023

FIGURE 1 Injuries at presentation. FIGURE 2 View of field OR.

As the designated anesthetist, 18D(b) drew medications, la- ketamine use based on observed lack of patient responsiveness
beled syringes, prepared fluids, and calculated drip rates with and vital sign fluctuations. Early on into the procedure, the
the estimated patient weight of 50-kg. Medications, fluids, an patient’s apparent medication tolerance raised concern regard-
automated external defibrillator (AED), and advanced airway ing medication volumes that the ODA had at their disposal.
supplies (endotracheal intubation, cricothyroidotomy, King LT
kit and (Tacmed Solution, suction) were staged near the head With fear that they may be unable to complete both amputa-
of the litter. 18D(b) administered an initial sedation dose of tions with a sufficient level of narcotics, IV diphenhydramine
IV ketamine 150mg, IV ondansetron 4mg, and IV midazolam 100mg was administered as an acute adjunct.
2mg. The patient was secured to the litter and loaded into a
vehicle for transport to the awaiting surgical suite. Upon ar- Vital signs remained stable for the first three hours of surgery.
rival, 18D(b) directed final patient preparation and position- The patient maintained an airway independent of further ad-
ing then administered IV ketamine 50mg and IV tranexamic juncts and demonstrated no visible or observable indications
acid (TXA) 1g in 100mL of isotonic saline for surgical induc- of pain. As the right leg tourniquets were removed, vitals began
tion. Clothing was removed, hypothermia blankets applied, to trend downwards, particularly BP which at its lowest was
eyes were taped shut, and a second 18-G IV was placed in the measured at 90/55. Two units of whole blood were pressure
right arm. Trending vitals were recorded every five minutes infused followed by slow administration of calcium chloride
for continuity and monitoring. An Eclipse Oxygen Condenser 2g via a second liter of Plasmalyte A. The patient responded
(Eclipse, https://eclipseoxygen.com/) was used to administer well with a steady return to hemodynamic stability without
oxygen at 3L/min via nonrebreather mask. Sonorous respira- the necessity of vasopressors. Following completion of the
tions prompted placement of an oropharyngeal airway (OPA) right leg amputation, 18D(a) conducted an anatomic regional
that was inserted with ease compared to an earlier resisted at- block of the left leg and the assisting medics prepared of the
tempt prior to induction. A BuddyLite fluid warmer (Belmont second site. The left leg procedure did not offer any further
Medical, https://belmontmedtech.com/portable-iv-pump) was challenges from an anesthesia perspective.
used to administer all subsequent fluids to combat hypo-
thermic conditions. 18D(b) performed an anatomic regional Intraoperatively, the patient received IV acetaminophen 1g
block of the patient’s right femoral nerve and sciatic nerve and IM ketorolac 30mg. As 18D(a) began to finalize the sec-
utilizing IV bupivicaine 25mg at each site. Without an avail- ond amputation and prepare to close, a final TXA 1g and
able ultrasound or Stimuplex needles (Braun, https://www. cefazolin 1g were infused intravenously. The ketamine admin-
bbraunusa.com/en/products/b/stimuplex-a.html), Military Ad- istration was discontinued when 18D(a) estimated 30 minutes
vanced Re gional Anesthesia and Analgesia (MARAA) guide- remaining of surgical time in order to expedite post-op recov-
lines were used as a reference to enable this procedure. 18D(a) ery. As the surgical site closure was coming to an end, the non-
inserted a Foley catheter and the supporting medics prepared rebreather mask was removed and the OPA transitioned to a
the right leg by shaving and cleaning the entirety of the leg nasopharyngeal airway (NPA).
from hip to knee. 18D(c) and a supporting medic prepared to
act as first and second assistants throughout the procedures. In total, the patient received 2 units of whole blood, 2L of
Plasmalyte A (with 50mEq NaCO & CaCl 2g), 1L 0.09%
3
Initially, the patient responded well to the push of IV ket- NaCl (with Ketamine 3g), and three 100mL NaCl (with TXA
amine. However, with only a 15gtts/mL macrodrip set, ad- & cefazolin) throughout the seven-hour course of anesthesia.
justments proved to be difficult and limited the ability to Minimal estimated blood loss of approximately 200–400mL
adequately titrate to the patient’s response. Ultimately, 18D(b) facilitated stability of the patient. Urine output was monitored
settled on administering approximately 4mg/min of ketamine averaging 120mL/hr supporting continued kidney function. Fre-
via drip throughout the duration of the procedures. This was quent lung auscultation helped to comfort the providers that
augmented with regular 15-minute pushes of IV ketamine pulmonary edema was not forming, though the patient did
50mg and an occasional 1mg push of midazolam. A surgical remain mildly tachypneic with an average respiratory rate be-
plane was established and maintained with minimal additional tween 20–25 breaths per minute. The insertion of an OPA was

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