Another patient disaster. What would you have done differently?

[BuzzPhreed]

When you are on-call your weekend is pretty much blown. So what better way to use it than to go over some cases that landed people in hot water. In this case the old 2:00 AM urgent (but apparently not emergent) c-section in a failure to progress. The solo CRNA at the helm and let's take the transcript from there...

(Case transcript can be found here.)

Dr. Costello [the on-call obstetrician] ordered anesthesia services and Certified Registered Nurse Anesthetist (CRNA) Greg Mahoney was assigned to administer the anesthesia to Cathy [Glassman].   Mahoney discussed the options available with Cathy and her husband, Jerome Glassman.   Dr. Costello was not a part of this discussion.   A spinal rather than a general anesthetic was chosen and administered by Mahoney.

The incident occurred in 1994. This was well before Kansas opted-out of CMS requirements which happened in 2003. We should assume (and the entire legal proceeding mentioned is based in part on this assumption) that Dr. Costello is the 'supervising' physician in this instance. Nonetheless spinal anesthesia would be the correct choice if an epidural was not already in place. So far so good.

As the surgery began, the testimony of what happened became inconsistent.

 

Uh-oh. Already differing accounts of what happened next.

Dr. Costello claimed he only nicked the skin with the first incision. Jerome testified the first incision was 4 to 6 inches in length and Cathy said:  “I can feel that, you'll have to stop, its not deadened.”

I tend to believe the OB/Gyn here. After all the husband is not going to look over the drape at this point and watch the surgery. At least that is not common practice nor what I allow when the babydaddy is in the surgical delivery suite. Even if he were able to look over the drape the point where the Pfannenstiel incision is made on a gravid abdomen would not be easily visible from his perspective unless he happened to see a reflection in an overhead surgical light, etc. (which most dads I've found aren't swift enough to figure out).

Let's assume that the OB/Gyn is correct. He nicked the skin. He may even have only Allis tested it at this point. Who knows for sure except the people in the room. I'm giving the benefit of the doubt to the surgeon. He says he nicked the skin, he nicked the skin.

Jerome stated a mask was placed over Cathy's face, CRNA Mahoney said “go ahead,” and Dr. Costello deepened the original incision.   At this point, Jerome was excluded from the operating room.

Okay. Stop here. It is clear that the block has failed in this patient or at least is inadequate to proceed with the surgery. There is some dispute as to whether or not there is a small skin incision (likely) or a larger skin incision. It is also unclear whether this represented truly a failed spinal, or if the transcript is wrong and she had been laboring with an epidural that failed. Again the facts reported may be different than actually what happened.

Nonetheless you know have a prepped and draped anxious woman with a failure to progress imminently undergoing c-section with a failed neuraxial anesthestic who has had the procedure started. Things that are not clear: was the baby in distress? What was the exact timing of the events? Where there other mitigating factors in this delivery (mother's health, etc.)? This information is not available. Let's assume that the mother is otherwise healthy, the baby is not in imminent distress (hence no need to "crash" the section in the first place), and that the timing of the case proceeded in such a way that CRNA Mahoney was able to adequately prep for every contingency. But put yourself in his shoes. It is early in the morning and you are now stuck in this situation.

What would you have done next?

(The link will take you to the case but don't cheat. We'll get there eventually.)

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[IlDestriero]

Prop, sux, tube.
Been there, done that, have the T-shirt, didn't get sued.

 

[Noyac]

I'm on call this weekend as well. So I find myself trying to kill time.

Tube her!

I must be doing a lot of call lately.

 

[okayplayer]

Prop, sux, tube.
Been there, done that, have the T-shirt, didn't get sued.

I'm not even really sure what the alternative is if the OB has already made an incision. If the patient fails the clamp test only and incision hasn't yet been made and the fetus is not in distress you could repeat the spinal if you really felt strongly about not putting this patient to sleep.

LUD, Bicitra, meticulous preoxygenation, prop/SCh RSI with cricoid (for medico legal reasons), tube.

 

[BuzzPhreed]

Prop, sux, tube.
Been there, done that, have the T-shirt, didn't get sued.

I'm on call this weekend as well. So I find myself trying to kill time.

Tube her!

I must be doing a lot of call lately.

Alright. Excellent. Let's continue...

There was also testimony that Dr. Costello immediately discontinued the surgery. Because the spinal was "spotty," Mahoney [the CRNA] determined that additional anesthesia was necessary. A general anesthesia was chosen. Mahoney placed an oxygen mask over Cathy's mouth for 3 to 4 minutes... [sic]. Mahoney then administered Curare (a muscle relaxant), Sodium Pentothal (sleeping agent and respiration depressant which makes it impossible for the patient to breath on her own), and Anectine (paralyzes the muscles completely).

According to Dr. Costello, he continued with the surgery and performed a second incision only after Mahoney had administered the general anesthesia and after he asked of Mahoney, "May I start?" and Mahoney told him to proceed. Mahoney said Dr. Costello asked him if the oxygen tube was in place. Mahoney responded, "I said no, it's not. You can go ahead and take the baby." Dr. Costello then continued the surgery.

Okay. So the CRNA says 'go ahead and continue' but he hasn't yet secured the airway. Now the OB/Gyn proceeds nonetheless. In essence he's gotten the green light from the CRNA to proceed.

This is 1994. I'm assuming he gave her "curare" as a defasiculating dose. Or that the testimony is wrong. Personally I would not have chosen that at this point. Just straight to "pent, sux, tube." This is also the pre-Glidescope era. But, he had a problem. He actually hadn't secured the airway.

It's easy to Monday-morning quarterback at this point. Was the airway bad? We don't know. Did he have an LMA (or Bullard or some other back-up airway device that was available in 1994)? The point is he couldn't get the tube in.

With the help of nurse Barb King [the circulating nurse], Mahoney attempted to intubate [sic]. A pulse oximeter measuring the oxygen content was attached. [Sic]. Mahoney placed the tube. Dr. Costello made a third incision into the abdomen to remove the infant and encountered dark, red blood (an indicator that the patient is not receiving an adequate supply of oxygen). Dr. Costello testified he was unaware the patient had not been properly intubated until he encountered dark, red blood in the patient's abdomen. Furthermore, at that time the tone from the oximeter indicated a sharp decrease in Cathy's oxygen level.

"What we have here is a failure to communicate."

According to nurse [the circulating nurse] King, Mahoney pulled the tube, masked the patient in order to supply her with oxygen, and placed a second tube. Nurse King was reading the oximeter and testified that Cathy's oxygen level rose and fell several more times. Mahoney testified he tried to maintain Cathy's airway with a bag [sic] and an oxygen mask until the baby was delivered at 5:37 a.m.

They went into the OR at roughly 2:00 AM and the baby was delivered at 5:37 AM. Hmmm.....

This is a total sh*tstorm at this point. Let's stop here again. What was and was not done properly? If this wasn't an emergent case and you had an inkling that this patient was a difficult airway would you now have gone back and re-considered trying the spinal again?

 

[Noyac]

If it was a confirmed difficult airway I may have done something different. If I thought she had a small chance of being difficult but as every preggo (not really sure why ) is considered to be somewhat more difficult than the general population then I would have proceeded with intubation.

 

[BuzzPhreed]

If it was a confirmed difficult airway I may have done something different. If I thought she had a small chance of being difficult but as every preggo (not really sure why ) is considered to be somewhat more difficult than the general population then I would have proceeded with intubation.

Yes, I agree. 100%. These are details we don't know, clearly.

But the fact is that the CRNA said "proceed" and then didn't really communicate very well with the OB/Gyn that he was having difficulty. I'm not sure what was going through his mind at this point (besides 'oh ****'), but I think there may be an inherent hubris sometimes in not wanting to appear out of control or like you don't know what you're doing.

I can say this for certain. That was beaten out of me in residency. Like a lot of residents I'm sure I had my cocky moments but the length and breadth of my training put me in situations where I was in over my head. This happened mostly midway in my CA2 year when I had just gotten to the point where I felt like 'hey, I got this'. It was during those really difficult cardiac and thoracic rotations, as well as the complex OB and complex peds cases, that I learned to say 'I need help'. And then you learn how to get through those situations with help. And I think that's part of what might have happened here, at least as you read the testimony. This CRNA didn't know how to say "STOP I need help" and/or he didn't have that help available. It's not clear which is the case.

 

[Noyac]

I think it is sort of clear. Crna didn't have help available. Couldn't intubate and a **** storm came next.

I had one c/s in residency that was emergent. The pt had a failed epidural earlier in the day by both the resident and the attending. Now emergent c/s and no time for spinal. I'm a CA-1 and I induce as told with my attending right there. It's 3am btw. I can't see jack ****. I fail twice and my attending takes over. He fails at least twice. Mom is asleep and baby is down. I put the mask back on her and I can ventilate her. Thank you god. We tell OB to go for it and I mask her through the entire case. Attending made me swear not to tell anyone.

 

[Spinach Dip]

I think it is sort of clear. Crna didn't have help available. Couldn't intubate and a **** storm came next.

I had one c/s in residency that was emergent. The pt had a failed epidural earlier in the day by both the resident and the attending. Now emergent c/s and no time for spinal. I'm a CA-1 and I induce as told with my attending right there. It's 3am btw. I can't see jack ****. I fail twice and my attending takes over. He fails at least twice. Mom is asleep and baby is down. I put the mask back on her and I can ventilate her. Thank you god. We tell OB to go for it and I mask her through the entire case. Attending made me swear not to tell anyone.

Oops.

 

[BuzzPhreed]

I think it is sort of clear. Crna didn't have help available. Couldn't intubate and a **** storm came next.

Your personal anecdote aside...

After the baby was delivered, there were continued efforts to oxygenate Cathy. Mahoney administered additional Anectine and attempted another intubation. Mahoney had difficulty because he encountered airway resistance. Additional assistance from other hospital staff was provided in an attempt to resuscitate Cathy. Their efforts failed and Cathy died due to hypoxia brought about by inadequate anesthetic induction and a failure to intubate prior to initiation of the cesarean section.

I think that's key here. 'Prior to' ceasarean section.

Now none of us were there. But, would you have maybe sat her up and tried the spinal again? I think this was the 'perfect storm' starting with not wanting to inconvenience the team in the middle of the early morning. It continued on with the hubris of the CRNA not telling the OB/Gyn (for whatever reason) that he was in the **** and needed advanced-level help (beyond that of a well-meaning but usually-inadequate OB circulator nurse), or to at least stop until he got the situation under control.

The result? Someone died. And someone (now 20-years-old) never got to know her mother.

For what its worth, I've never been in this situation myself in private practice. I recognize the potential for total meltdown and I'm not afraid to say 'STOP' in these situations. I think this is the big failure here. The OB/Gyns I work with treat me as an important equal and part of the team. Maybe, just maybe, this CRNA dude felt some pressure to look like Slick Johnson and not say anything.

 

[IlDestriero]

If you can't intubate, tricks and/or gadgets, LMA, etc. fail, and you can't ventilate and the patient is circling the drain you cut the neck. Failing to recognize how far in the $hit you are and then failing to go to the final step in the lost airway algorithm in a timely manner are the source of frequent potentially avoidable tragedy and 7 figure settlements.
Know what to do, when to do it, and then just do it. A trach and subsequent repair is infinitely better than hypoxic injury and/or death.

 

[BuzzPhreed]

Cutting the neck should have occurred. Agreed. It wasn't clear how well he was mask ventilating her but it obviously wasn't well enough to prevent her death.

After the baby was delivered, there were continued efforts to oxygenate Cathy. Mahoney administered additional Anectine and attempted another intubation. Mahoney had difficulty because he encountered airway resistance. Additional assistance from other hospital staff was provided in an attempt to resuscitate Cathy. Their efforts failed and Cathy died due to hypoxia brought about by inadequate anesthetic induction and a failure to intubate prior to initiation of the cesarean section.

A handful of times I've been in the situation where a spinal is inadequate. As I recall the classic examples have been redheads and it often starts after the baby is out and when they are sewing the uterus back together. Laying someone down and starting the case with an adequate Allis test and then a failure is something different. Also the cases that have happened to me have been during the light of day when it is easier to martial help.

In this case it was the middle of the night. I think the tragedy started when the decision was made not to re-try the spinal. It is very hard to feel like you're inconveniencing someone by making them break the sterile field, doubly so in the middle of the night. But it is often very lonely place to be at zero dark thirty on-call by yourself no matter who you are.

After the decision was made to proceed (we weren't there and maybe the cut was big enough that he couldn't sit her up and re-try the spinal) the next tragic error happened when he couldn't get the tube in and he didn't immediately notify everyone in the room that he was having difficulty then call for appropriate help. In this case you call the ER doc or the Intensivist (who may or may not have been in house in 1994). You call whomever you think can help you. The key there is to get hands on and eyes on the situation before the patient dies. People to get equipment. Different maybe more experienced hands to try the intubation. Etc.

I think there may have been a touch of hubris at play here. That seems to come across if you read between the lines. I have seen this with some CRNAs who openly say they don't need help to do a case or feel like they need to challenge every decision. I don't know Nurse Mahoney personally (obviously) or what his level of training was at the point that this happened, but there was clearly multiple failures here that ended in a patients death. He wasted valuable time not communicating to the OB/Gyn that he was having trouble. And then he continued to try to intubate her initially without calling for help.

It's not clear how much time elapsed but in this case you swallow your pride and you call for help. I'm not sure that this is part and parcel to the training of a CRNA. It should be if it isn't. Mostly lately I've just heard the hubris of them telling us they're our equals. And that mentality is a recipe for disaster and creates the overweening overconfidence that potentially prevents them from asking for help when they need it.

 

[Noyac]

Now none of us were there. But, would you have maybe sat her up and tried the spinal again? I think this was the 'perfect storm' starting with not wanting to inconvenience the team in the middle of the early morning. It continued on with the hubris of the CRNA not telling the OB/Gyn (for whatever reason) that he was in the **** and needed advanced-level help (beyond that of a well-meaning but usually-inadequate OB circulator nurse), or to at least stop until he got the situation under control.

The result? Someone died. And someone (now 20-years-old) never got to know her mother.

I don't come to the say conclusion you do here.

 

[Noyac]

"Additional assistance from other hospital staff was provided in an attempt to resuscitate Cathy. Their efforts failed and Cathy died due to hypoxia brought about by inadequate anesthetic induction and a failure to intubateprior to initiation of the cesarean section."

This?

 

[Noyac]

Buzz, are you ever working alone with no other anesthesiologist or crna present at your current gig?

 

[007livesforever]

f you take the surgeons word then clearly a spinal should have been tried again, if you take the word of the CRNA then that was not really an option. As for airway options the LMA had only been approved for use in the US in 1992, it may not have even been in this facility at the time and ditto for other options we take quite for granted now. Should he have called for help? Well yes, but this sense of Hubris is not limited to CRNA's. In one program I saw the chair of the dept hold up a case for 1 hour attempting to start an a-line stuck the patient over 10 times and refused to allow anyone else to try. Even the most team oriented of us get tunnel vision at least once in our career, the only difference is who pays and how much. Fortunately most of the time no one is hurt and we walk away learning that we are not nearly as good as we think. I have no doubt we kind find similar incidents even today. The key point here is that to practice safely one must jettison your ego and really truly believe in caring for the patient more then your reputation.

 

[BLADEMDA]

Let's review the practice of OB anesthesia in 1994 (I'm very familiar with that year):

1. I had used LMAs since 1992 but they were not readily available for general use at that time. It would be 1996/1997 before they would be more common place and most practices didn't have the LMA until closer to 1998.

2. Failed airways for OB were a potential disaster. Epidurals were more common in 1994 than Spinals for sections but the transition to SAB was becoming the norm.
Whitacre needles were available and commonly used for C sections.

3. Repeating the SAB was NOT a common practice in 1994 (nor is it today) and conversion to GA was the norm. The Glidescope was not available but the Bullard was in use and I had one in 1994 for these situations.

4. ETCO2- This was the standard in 1994 and the CRNA's failure to confirm ETCO2 on his monitor was malpractice.

This case was a failure to OXYGENATE the patient and NOT just a failure to intubate. The main reason for this disaster was failing to use his monitors (ETCO2 and Saturation) to recognize an esophageal intubation. I want to see ETCO2 before assuming the ETT is in the trachea.

 

[BLADEMDA]

What would I do today?

1. SAB for all sections unless contraindicated or using a pre-existing Epidural
2. Conversion to GA is still the norm for failed SAB (which should be less than 1% in skilled hands)
3. Glidescope Backup availability in the room
4. LMA in the room


Leave your ego at home. Use your monitors and react quickly to lack of ETCO2 on the monitor.

Anaesth Intensive Care. 2010 Nov;38(6):1023-8.
The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases.
Halaseh BK1, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H.
Author information

• 1Department of Anesthesia, Farah Hospital, Amman, Jordan.

Abstract
Rapid sequence induction is currently the recommended technique in general anaesthesia for caesarean section. However, the usefulness of the ProSeal laryngeal mask airway as a rescue airway in the event of difficult or failed intubation has been recognised in numerous case reports. In this study, we report the experience of the use of the ProSeal laryngeal mask in 3000 elective caesarean sections in a single centre, using a method of insertion that allows a rapid establishment of a patent airway together with gastric drainage

 

[BuzzPhreed]

Buzz, are you ever working alone with no other anesthesiologist or crna present at your current gig?

Yes. And I have done the middle-o-the-night c-section by myself too. It is a very scary, lonely place. Again this was 1994 and I know that this dude probably didn't have an ILMA laying around. The point is, I try to make extra-certain that I have all of my contingency plans lined-up so I'm not setting myself up for failure.

My experience has been that CRNAs are just not armed with the depth or breadth of training that we are and there is a palpable hubris coming from some of them. It's like your 16-year-old kid learning how to drive who already thinks he can drive better than you after a month.

When I walk into a situation, I know that I am the last line of defense. When I'm called to the ED or to the unit to tube someone I know it's because everyone else has failed. Often CRNAs have the false reassurance as part of their thinking that they will call (and I've been on the receiving end of "I can't get the tube in" calls from them) and this might be how they start their approach to a problem. In this case he recognized that he was failing but didn't either plan well enough from the start or didn't notify the correct people in a timely manner that he was failing. Why? Who knows. But the patient died. There but for the grace of God - and prior proper planning - go I.

f you take the surgeons word then clearly a spinal should have been tried again, if you take the word of the CRNA then that was not really an option.

Well it was actually the patients husband. Not the CRNA.

As for airway options the LMA had only been approved for use in the US in 1992, it may not have even been in this facility at the time and ditto for other options we take quite for granted now. Should he have called for help? Well yes, but this sense of Hubris is not limited to CRNA's.

Not arguing that. I'm saying that there is often an extra "I'll show 'em" that CRNAs have. A sort of chip on their shoulder. Most of you know what I'm talking about.

In one program I saw the chair of the dept hold up a case for 1 hour attempting to start an a-line stuck the patient over 10 times and refused to allow anyone else to try.

That's a tricky situation. And emblematic of a dickhead. Many of them rise to chair positions for some reason.

Even the most team oriented of us get tunnel vision at least once in our career, the only difference is who pays and how much. Fortunately most of the time no one is hurt and we walk away learning that we are not nearly as good as we think. I have no doubt we kind find similar incidents even today. The key point here is that to practice safely one must jettison your ego and really truly believe in caring for the patient more then your reputation.

I'm not faulting the guy for trying to get out of a jam. I'm faulting him for getting in the jam in the first place, and then not adequately notifying people he was in a jam. That's the difference. Otherwise I'm not disagreeing with anything you're saying.

 

[007livesforever]

the point was nearly all of us will put ourselves in a jam at least once in our career.

 

[BuzzPhreed]

the point was nearly all of us will put ourselves in a jam at least once in our career.

7P's

 

[BLADEMDA]

the point was nearly all of us will put ourselves in a jam at least once in our career.

Once? I wish it was only once in my practice. These days ASA 4 is replacing the ASA 3 and the potential for a DISASTER exists on a daily basis.

You better develop the skills to get out of that "jam" or patients will die.

 

[Noyac]

My experience has been that CRNAs are just not armed with the depth or breadth of training that we are and there is a palpable hubris coming from some of them. It's like your 16-year-old kid learning how to drive who already thinks he can drive better than you after a month.

Truth!

 

[Noyac]

I'm thinking back and putting myself in this situation. I'm pretty damn sure I would not have repeated the spinal even if the surgeon had not made a cut unless I was sure I didn't get it in the first time which I wouldn't have gone forward with anyway. Once I place a spinal, if it doesn't work I'm not going to go back in and put more local in there. Maybe I would place an epidural that is a bit more controllable but I don't want a high spinal event. And if this crna had gone this route it is very likely he would have ended up in the same predicament. High spinal then lose of respiratory effort then convert to GA and again a failed intubation.

 

[BuzzPhreed]

(Post-call... gotta run... wifey not happy that I'm up and not playing with her...)

Just gotta say tht I prob would've retried the spinal too. Had a Bullard and everything else available and set-up in the OR well before I even got in this situation at the beginning of my call. Agin dont' know if this is part of CRNA training in 1994. Have seen CRNAs now ridiculously over-setting up tho. There's so much **** on top pf the blue bell cart that I don't know how they know what's what in an emergency. Have a plan. Have a back-up plan. Have a back-up plan for the back up plan. And call for reinforcements early if you are in the ****. Even in the middle of the night. ED doc. Intensivist. Even just an extra pair of hands. And be ready to cric her if all else fails.

 

[urge]

1 I trained at an OB powerhouse. We were taught not to repeat failed spinals because you have no clue how much drug to inject to get a reasonable level. Chances are you will overdose and have to intubate the woman emergently. Pent sux tube is the next step.

2 Once the patient is induced and paralyzed, I see no point to tell the OB to stop and wait for the tube. Either the tube goes in and everything is fine, or it doest and the woman codes, but the baby is coming out regardless per ACLS protocol.

3 Not sure why he gave curare and sux together. Maybe a defasciculating dose?

What I see done wrong: failed intubation, failed ventilation, failure to ask for help, and failure to tell OB to hurry up as **** is hitting the fan. I have a feeling that there wasn't any good help around to ask for.

 

[Noyac]

Would or would not retry SAB?

I would not is what I was saying.

 

[anes]

1 I trained at an OB powerhouse. We were taught not to repeat failed spinals because you have no clue how much drug to inject to get a reasonable level. Chances are you will overdose and have to intubate the woman emergently. Pent sux tube is the next step.

2 Once the patient is induced and paralyzed, I see no point to tell the OB to stop and wait for the tube. Either the tube goes in and everything is fine, or it doest and the woman codes, but the baby is coming out regardless per ACLS protocol.

3 Not sure why he gave curare and sux together. Maybe a defasciculating dose?

What I see done wrong: failed intubation, failed ventilation, failure to ask for help. I have a feeling that there wasn't any good to ask for help around to ask for.

Agreed. You're screwed.

 

[Noyac]

1 I trained at an OB powerhouse. We were taught not to repeat failed spinals because you have no clue how much drug to inject to get a reasonable level. Chances are you will overdose and have to intubate the woman emergently. Pent sux tube is the next step.

2 Once the patient is induced and paralyzed, I see no point to tell the OB to stop and wait for the tube. Either the tube goes in and everything is fine, or it doest and the woman codes, but the baby is coming out regardless per ACLS protocol.

3 Not sure why he gave curare and sux together. Maybe a defasciculating dose?

What I see done wrong: failed intubation, failed ventilation, failure to ask for help. I have a feeling that there wasn't any good to ask for help around to ask for.

This^^^is exactly what I've been preaching here.

Btw, curare was standard back then as a defasiculating med. It fell out of practice for obvious reasons. Nurses are not trained to think outside the box, they do it the same way every time.

 

[anes]

One question I have though. Why did he repeat the Sux? Was she trying to breath?

 

[Mman]

My personal backup plans

1) if spinal has truly failed and isn't coming up high enough or whatever, I will repeat the spinal with a dose of 0.5 ml of hyperbaric 0.75% bupivicaine. It's a small dose and unlikely to cause a high spinal (in the setting of my initial dose of 1.5 ml) and if I'm really worried I'll put them in reverse t-berg after I place it. But that's assuming we aren't so far into the surgery that I can no longer do that.

2) 50% nitrous via facemask. Can get you through a decent amount of discomfort while providing minimal depression to the baby and keeping mom breathing just fine.

3) GA. If airway looks reasonable I'll have glidescope in room and just induce. OB knows to stop what they are doing while I'm doing this and I don't give the go ahead to proceed until I confirm etCO2.

4) IV ketamine if their airway looks like I'd rather not go there



I've probably repeated about 10 spinals on patients with no adverse events. I always go with a very small dose the 2nd time, though, as I am a bit paranoid about the possibility of a high spinal. I figure the morbidity from the 2nd spinal is still probably less than a GA.

 

[Noyac]

One question I have though. Why did he repeat the Sux? Was she trying to breath?

I never saw this until I went into PP with a group who employed many crna's. They do it all the time. No telling why this did it. I hope it wasn't cuz the pt started breathing again but I have a sick feeling in my gut that says it is.

 

[Noyac]

My personal backup plans

1) if spinal has truly failed and isn't coming up high enough or whatever, I will repeat the spinal with a dose of 0.5 ml of hyperbaric 0.75% bupivicaine. It's a small dose and unlikely to cause a high spinal (in the setting of my initial dose of 1.5 ml) and if I'm really worried I'll put them in reverse t-berg after I place it. But that's assuming we aren't so far into the surgery that I can no longer do that.

2) 50% nitrous via facemask. Can get you through a decent amount of discomfort while providing minimal depression to the baby and keeping mom breathing just fine.

3) GA. If airway looks reasonable I'll have glidescope in room and just induce. OB knows to stop what they are doing while I'm doing this and I don't give the go ahead to proceed until I confirm etCO2.

4) IV ketamine if their airway looks like I'd rather not go there



I've probably repeated about 10 spinals on patients with no adverse events. I always go with a very small dose the 2nd time, though, as I am a bit paranoid about the possibility of a high spinal. I figure the morbidity from the 2nd spinal is still probably less than a GA.

1) what if it is a spotty spinal?
2) problems here
3)why wait for etco2? You are wasting valuable time. What are gonna do if you can't intubate or ventilate for 10-15 min? Now both pts are dead.
4) that's a personal call. I have no issues with it tho.

 

[Noyac]

This case is seriously wasting some call time for me. Thx

 

[anes]

1) what if it is a spotty spinal?
2) problems here
3)why wait for etco2? You are wasting valuable time. What are gonna do if you can't intubate or ventilate for 10-15 min? Now both pts are dead.
4) that's a personal call. I have no issues with it tho.

Agreed with number 2. If its the beginning of the case then go straight to GA. If the end and spinal is wearing off, then nitrous is okay.

 

[gasp]

2 Once the patient is induced and paralyzed, I see no point to tell the OB to stop and wait for the tube. Either the tube goes in and everything is fine, or it doest and the woman codes, but the baby is coming out regardless per ACLS protocol.


This depends. If its an emergency and baby is down then I agree. If its not an EMERGENCY and the baby was doing ok before induction, I would not tell the surgeon to start until my tube is confirmed in the right place because I still have the option of waking the patient up (if succ was used) if I cannot intubate her properly at this point where as you would not have that option anymore if you tell them to start unless you want to wake up a patient with an open belly.

 

[goosegas]

While I agree with the judgement that the CRNA is the one that is solely responsible for this patient death, that goes against conventional thinking. They found that the OB was 1% responsible and that the CRNA was 99% responsible. If it had been an anesthesiologist, would the OB gotten of completely scot-free?

 

[anes]

While I agree with the judgement that the CRNA is the one that is solely responsible for this patient death, that goes against conventional thinking. They found that the OB was 1% responsible and that the CRNA was 99% responsible. If it had been an anesthesiologist, would the OB gotten of completely scot-free?

Yes. The OB chose to supervise the CRNA. The OB chose the responsibility. If you're supervising a CRNA, then YOU are responsible. The 99% responsibility would be on you.

 

[Mman]

a spotty spinal is probably subdural and not subarachnoid so repeating with a small subarachnoid dose can get the perfect block you need

nitrous via facemask is more helpful with the epidural that isn't working but it is a very safe option to keep in the back of your mind

why wait for CO2? Because I'd rather not have the OB with hands in the patients abdomen causing them to vomit if I have to repeat the DL. Waiting for CO2 takes less than 10 seconds. If the tube is in the goose, I'd much rather spend another 1-2 minutes doing a DL on a patient that isn't actively vomiting while I do it. Remember, we are talking about a controlled situation, not a lost airway. The baby is fine because mom was preoxygenated.

 

[GasEmDee]

1 I trained at an OB powerhouse. We were taught not to repeat failed spinals because you have no clue how much drug to inject to get a reasonable level. Chances are you will overdose and have to intubate the woman emergently. Pent sux tube is the next step.

2 Once the patient is induced and paralyzed, I see no point to tell the OB to stop and wait for the tube. Either the tube goes in and everything is fine, or it doest and the woman codes, but the baby is coming out regardless per ACLS protocol.

This is how I practice. Baby comes out regardless. In addition, it may be easier to ventilate mom after baby comes out.


BTW, I never administer a 2nd spinal for the reason that urge mentioned. If forced to repeat something neuraxial, it is going to be an epidural titrated up in increments. But IMHO its best to proceed to GETA, unless there is something specific about the airway that has me concerned. (If I had a concern about the airway, I might have done an epidural, rather than a spinal, in the first place.)

For the rare spotty spinal:
1. Give small dose of fentanyl.
2. Give 10mg IV ketamine +/- midazolam.
3. If that doesn't succeed, proceed to GA

I am 100% alone (i.e., no CRNA or other anesthesiologist present) in the middle of the night.

For backup, we have:
1. Glidescope turned on immediately and placed in standby
2. A complement of LMAs
3. An additional nurse circulator (usually the charge nurse) called immediately into the room once the decision has been made to intubate. One nurse is to attend exclusively to me for help with the airway, the other to help the OB.

 

[pgg]

Re: repeating the spinal in this case - OB had already cut when they realized the SAB was inadequate. I can't imagine trying to repeat a spinal after incision.

 

[Mman]

Re: repeating the spinal in this case - OB had already cut when they realized the SAB was inadequate. I can't imagine trying to repeat a spinal after incision.

you are correct. That's only a before incision maneuver if you've sat there for 15 minutes waiting and patient still with too much sensation.

 

[Planktonmd]

You know what happened here?
They panicked and they started acting irrationally...
Obviously an LMA was not present since it's not even mentioned and obviously the OR turned into a circus and people were acting crazy.
But... when he recognized that he could not intubate he should have focused on ventilating the patient and the last thing he should have done is give more sux.
If ventilation was not happening then moving to a surgical airway should have been attempted... obviously that was not even considered.

 

[goosegas]

Yes. The OB chose to supervise the CRNA. The OB chose the responsibility. If you're supervising a CRNA, then YOU are responsible. The 99% responsibility would be on you.

No I think you misunderstand. One of the reasons cited as to why a surgeon should not work with a solo CRNA is that they will be on the hook should something go wrong with the anesthetic. In this case, that didn't happen. Even though the OB was supervising, the court left the vast majority of the blame (99%) on the CRNA. Responsibility didn't get shifted to the OB. Why?
If it had been an anesthesiologist instead of a CRNA, would the court have said 0%OB, 100% anesthesiologist? Or would the court still have said that the OB should have known what was going on?

 

[goosegas]

The baby is fine because mom was preoxygenated.

Really? Your full term patients stay saturated for 1-2 minutes so that you can dink around with airway? Not in my experience.
What if it was a crash c/s? What if baby was in jeopardy and your preoxygentation consisted of a couple of deep breaths. What then?

 

[anes]

No I think you misunderstand. One of the reasons cited as to why a surgeon should not work with a solo CRNA is that they will be on the hook should something go wrong with the anesthetic. In this case, that didn't happen. Even though the OB was supervising, the court left the vast majority of the blame (99%) on the CRNA. Responsibility didn't get shifted to the OB. Why?
If it had been an anesthesiologist instead of a CRNA, would the court have said 0%OB, 100% anesthesiologist? Or would the court still have said that the OB should have known what was going on?

Sorry, I did misunderstand. You're correct.

 

[urge]

2 Once the patient is induced and paralyzed, I see no point to tell the OB to stop and wait for the tube. Either the tube goes in and everything is fine, or it doest and the woman codes, but the baby is coming out regardless per ACLS protocol.


This depends. If its an emergency and baby is down then I agree. If its not an EMERGENCY and the baby was doing ok before induction, I would not tell the surgeon to start until my tube is confirmed in the right place because I still have the option of waking the patient up (if succ was used) if I cannot intubate her properly at this point where as you would not have that option anymore if you tell them to start unless you want to wake up a patient with an open belly.

Do you think when you go that route thing are still going peachy? You wouldn't wake up a patient you can mask. So basically, the mother is severely desated, the stomach is full of air, the baby is descelerating, and you are sweating bullets. Waking a patient up is not an elective "option". I have been there. You basically try to mask like a mad man and hope they wake up before they die.

 

[gasp]

Do you think when you go that route thing are still going peachy? You wouldn't wake up a patient you can mask. So basically, the mother is severely desated, the stomach is full of air, the baby is descelerating, and you are sweating bullets. Waking a patient up is not an elective "option". I have been there. You basically try to mask like a mad man and hope they wake up before they die.

I'm not understanding u.

 

[goosegas]

Waking a patient up is not an elective "option". I have been there. .

I agree. This patient will desat and put baby in jeopardy long before Mom wakes up. Its a crap position to be in. Damned if you do, damned if you don't.

 

[urge]

I'm not understanding u.

Basically, when you say you will wake up the pt to deal with the airway you basically imply an awake fiberoptic ( or whatever you do, but awake fiberoptic is the cadillac of all intubations). If you can mask her, you might as well do an asleep fiberoptic intubation as not to put a patient through the torture of awake intubation. An awake fiberoptic doesn't bring anything to the table over an asleep fiberoptic if masking is ok.

So, waking a patient up happens when you cannot mask or ventilate them. That is not an elective decision, it is a Hail Mary.

Have you ever "had to wake up a patient"?