combative post op pt, what works well

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urge

urge

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In your EXPERIENCE (I know what the text books say), what works well for a post op pt who is disoriented and combative? Let's say the pt is morbidly obese and has sleep apnea, so zonking him out is not a viable option. What's your approach?
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Most common cause of post-op agitation? Hypoxia.

Having said that, I usually zonk 'em anyway before they hurt themselves (or, worse, me). Physostigmine works great if they are awake but confused and disoriented. A little touch of propofol & lidocaine (especially in rammy kids) works well.

And, if you have a little fentanyl left, this can work too. I used this the other day for a guy who I reversed and got breathing, but was literally about to jump off the OR table and start running around when I extubated Strong as a bull too). He was in his sixties and woke-up like a 15-year-old football player. He was hypercapnic, and I can only suspect that he was air hungry. The fentanyl (50mcg) worked like a charm. In the PACU, he didn't remember a damn thing.

There's a lot of different feet out there, and you gotta find the shoe that fits.

-copro
 
coprolalia said:
Most common cause of post-op agitation? Hypoxia.

Having said that, I usually zonk 'em anyway before they hurt themselves (or, worse, me). Physostigmine works great if they are awake but confused and disoriented. A little touch of propofol & lidocaine (especially in rammy kids) works well.

-copro
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:)
You love this stuff don't you??
 
My personal favorite is our Latin CT anesthesiologist during recent reversal of a "large" man. He was reaching for his tube, trying to roll over, etc. Dr. says "If they fight, give them a little anti-fight medicine" while reaching for the Midaz.
 
or just soften them up a little...... 0.25 mg vecuronium iv
 
I just reviewed two case tonight were the pt was combative and the hospitalist gave ativan. One guy died and the other nearly coded and was transfered to the ICU.

You had better have a good idea why they are confused and combative.

With that being said, i like small doses of propofol. It works well and its gone fast if it is the wrong thing.
 
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Noyac said:
I just reviewed two case tonight were the pt was combative and the hospitalist gave ativan. One guy died and the other nearly coded and was transfered to the ICU.

You had better have a good idea why they are confused and combative.

With that being said, i like small doses of propofol. It works well and its gone fast if it is the wrong thing.
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The same hospitalist bagged two patients with ativan?
 
Has anyone tried precedex in this setting?

How likely are you to give physo if you didn't use any anticholinergics?
 
urge said:
Has anyone tried precedex in this setting?

How likely are you to give physo if you didn't use any anticholinergics?
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Precedex could be a great idea after you rule out the obvious causes of post op agitation.
I think that in the elderly there is always a component of acetylcholine deficiency in the brain that would respond at least partially to a cholinesterase inhibitor.
 
Jeff05 said:
haldol iv.
drop also works well.
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One word of caution about using Neuroleptics:
These are powerful drugs with equally powerful side effects.
2 weeks ago a hospitalist gives an elderly post op guy 5 mg of Haldol to control his agitation, few hours later an ICU nurse comes to our office and begs me to come see the guy, I walk to the ICU and see a spastic old man breathing about 50 /min, HR= 170 with a temperature of 43.5 degrees (110 F), he had an MI and went into acute renal failure next day despite aggressive cooling and Dantrolene.
 
Planktonmd said:
Precedex could be a great idea after you rule out the obvious causes of post op agitation.
I think that in the elderly there is always a component of acetylcholine deficiency in the brain that would respond at least partially to a cholinesterase inhibitor.
Click to expand...

Expensive though. But if it works, oh well.

I personally have never given physostigmine. I'll probably forget about it by the time I see one again.
 
I had a pt like this recently. No hypension, hypoglycemia, hypothermia, hypoxia... Woke up swinging at everyone. Wanted to see his mom, although he was like 70 y/o. Claimed we were trying to kill him... I tried some versed and fentanyl but his sleep apnea was a limiting factor, as he desat after every dose, but kept swinging at the nurses. I tried some precedex, against my own judgment, based on another anesthesiologist's rec. I gave a load pretty quickly but truthfully I think it was a waste of time and money. He never really got sedated by it. I asked for some physo but everyone had a "deer in the headlights" face when I mentioned it. It had already been like 10 min with the precedex load (100 mcg) and drip going at .5, but the guy kept going, and I was supposed to start another case. I was already pissed of by this, so I asked for haldol. In less than 2 min the problem was over. Precedex sounds like a good idea but it's not. Takes too long to work. I have never given physo. I'm curious how long it takes to work. Does anyone have any experience with it?
 
For kids, clonidine 1 mcg/ kg up to 3 mcg/kg is great. They quiet down and keep breathing. I sometimes give it prophylactically at emergence. You can give it iv or in which is nice.
 
urge said:
I had a pt like this recently. No hypension, hypoglycemia, hypothermia, hypoxia... Woke up swinging at everyone. Wanted to see his mom, although he was like 70 y/o. Claimed we were trying to kill him... I tried some versed and fentanyl but his sleep apnea was a limiting factor, as he desat after every dose, but kept swinging at the nurses. I tried some precedex, against my own judgment, based on another anesthesiologist's rec. I gave a load pretty quickly but truthfully I think it was a waste of time and money. He never really got sedated by it. I asked for some physo but everyone had a "deer in the headlights" face when I mentioned it. It had already been like 10 min with the precedex load (100 mcg) and drip going at .5, but the guy kept going, and I was supposed to start another case. I was already pissed of by this, so I asked for haldol. In less than 2 min the problem was over. Precedex sounds like a good idea but it's not. Takes too long to work. I have never given physo. I'm curious how long it takes to work. Does anyone have any experience with it?
Click to expand...
I use Physo maybe once a month since I work in an area where the average age is like 95.
When it works it's like magic and it works very fast (less than 5 minutes).
The nurses look at you and think that you are god.
There are many people out there who don't believe in it and don't use since the evidence is a little shaky, but who cares, it works.
 
urge said:
In your EXPERIENCE (I know what the text books say), what works well for a post op pt who is disoriented and combative? Let's say the pt is morbidly obese and has sleep apnea, so zonking him out is not a viable option. What's your approach?
Click to expand...

Seen this several times: if the case was done without a Foley, a really full bladder will drive a male patient up the wall.

Other post about physostigmine: it also fills a niche as a poor man's romazicon, especially when you don't have any romazicon immediately available.
 
trinityalumnus said:
Seen this several times: if the case was done without a Foley, a really full bladder will drive a male patient up the wall.
Click to expand...

True, a cardiologist friend of mine went to see his father post-op and found him restrained and agitated, he was like wtf is going on. Personnel down plays it saying he's out of it from the surgery. The guy checks his father out and his bladder was the size of a basket-ball. Mental status resolved with foley.
 
Planktonmd said:
One word of caution about using Neuroleptics:
These are powerful drugs with equally powerful side effects.
2 weeks ago a hospitalist gives an elderly post op guy 5 mg of Haldol to control his agitation, few hours later an ICU nurse comes to our office and begs me to come see the guy, I walk to the ICU and see a spastic old man breathing about 50 /min, HR= 170 with a temperature of 43.5 degrees (110 F), he had an MI and went into acute renal failure next day despite aggressive cooling and Dantrolene.
Click to expand...

I'm assuming you guys were thinking NMS?

Did you try anything else, such as large dose benzo and paralysis? Most of the Toxicologists I know don't really think that dantrolene works for NMS, although there is a vocal group that likes it. Unfortunately, there is little evidence for or against it and most of the management recommendations are more consensus than anything else.
 
BADMD said:
I'm assuming you guys were thinking NMS?

Did you try anything else, such as large dose benzo and paralysis? Most of the Toxicologists I know don't really think that dantrolene works for NMS, although there is a vocal group that likes it. Unfortunately, there is little evidence for or against it and most of the management recommendations are more consensus than anything else.
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Yes, It was most likely NMS because the guy had a dozen of general anesthetics in the past without a problem which makes MH unlikely.
The treatment included everything you mentioned:
I Intubated the guy and put him on Vecuronium, We hydrated him aggressively and corrected the acidosis, he had cooling blankets, cool IV fluids and cool gastric lavage.
Dantrolene in NMS remains a viable therapeutic option and this might be due to it's nonspecific muscle relaxant effect rather than a more specific effect like in the case of MH, but in these situations you do everything hoping something will work.
The outcome was not good because it took them too long to recognize what was going on and consult us.
 
about NMS. it is exceptionally rare. it is even more rare in patients who receive a single dose of antipsychotic. most of the medications we give have profound side effects, some, rarely, have fatal side effects. the answer is not to discontinue use of these medications, but to recognize and treat adverse effects early.
 
Planktonmd said:
Yes, It was most likely NMS because the guy had a dozen of general anesthetics in the past without a problem which makes MH unlikely.
The treatment included everything you mentioned:
I Intubated the guy and put him on Vecuronium, We hydrated him aggressively and corrected the acidosis, he had cooling blankets, cool IV fluids and cool gastric lavage.
Dantrolene in NMS remains a viable therapeutic option and this might be due to it's nonspecific muscle relaxant effect rather than a more specific effect like in the case of MH, but in these situations you do everything hoping something will work.
The outcome was not good because it took them too long to recognize what was going on and consult us.
Click to expand...

Did they try ECT?
 
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