Crazy wakeup in morbidly obese patient

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osoprop28

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Wanted to get anybody's thoughts on how they would've handled it.

Last week, there was a 600 lb patient undergo ECT. We were thinking of either doing it under LMA or ETT, but she was mallampati I and surprisingly easy to mask ventilate with oral airway) once she went to sleep. We used methohexital, ketamine, sux (while ramped and reversed T).

Psych performed ECT and patient desatted to 70s (which was expected). I placed oral airway back in and ventilate back up to 95% and everything was going well.

Once she started waking up, she got extremely combative, took out the oral airway, and started desaturating, then pulled out her IV and disconnected her monitors, and it was almost impossible to hold her down.

I don't even know what her saturation dropped to since the monitors were off and we were trying to place IV and monitors back on for couple minutes, while I'm trying to ventilate the patient.

Ultimately, after about 5 minutes of fighting, patient calmed down and started breathing on her own and everything was fine.

But at that moment, if I still had trouble ventilating and she remained combative, what would you guys do without IV or monitors? My only thought was to replace oral airway and hope for the best. I don't think she would've taken an LMA at that stage, and IM meds would take so long before it kicks in (she would probably go into hypoxic arrest before IM ketamine/sux kicks in). I was thinking maybe slug her with propofol or precedex if this happens next time (with IV in place). Any thoughts?
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If the patient is combative the pulse ox is probably not going to be very accurate.
Secondly could we assume that the patient is oxygenating pretty well if she is able to generate this much energy in her confused state?
 
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osoprop28 said:
Wanted to get anybody's thoughts on how they would've handled it.

Last week, there was a 600 lb patient undergo ECT. We were thinking of either doing it under LMA or ETT, but she was mallampati I and surprisingly easy to mask ventilate with oral airway) once she went to sleep. We used methohexital, ketamine, sux (while ramped and reversed T).

Psych performed ECT and patient desatted to 70s (which was expected). I placed oral airway back in and ventilate back up to 95% and everything was going well.

Once she started waking up, she got extremely combative, took out the oral airway, and started desaturating, then pulled out her IV and disconnected her monitors, and it was almost impossible to hold her down.

I don't even know what her saturation dropped to since the monitors were off and we were trying to place IV and monitors back on for couple minutes, while I'm trying to ventilate the patient.

Ultimately, after about 5 minutes of fighting, patient calmed down and started breathing on her own and everything was fine.

But at that moment, if I still had trouble ventilating and she remained combative, what would you guys do without IV or monitors? My only thought was to replace oral airway and hope for the best. I don't think she would've taken an LMA at that stage, and IM meds would take so long before it kicks in (she would probably go into hypoxic arrest before IM ketamine/sux kicks in). I was thinking maybe slug her with propofol or precedex if this happens next time (with IV in place). Any thoughts?
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i remember doing these in residency. it was prop/etomidate then sux then ETT. secure airway and pull tube when patient is awake. might have avoided your problems.
 
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Does your shop typically use ketamine for ECTs?

agreed if they are fighting you and not turning blue probably satting fine. They usually loosen up when they are coding/about to code.

What were dosages and timing of drugs given? Hypercapnic from a couple minutes if suboptimal ventilation? Still recovering from sux after brevital wore off?

I probably would have rode it out like you did unless patient dictated otherwise. Turning blue and squeaking with inability to ventilate I would have slammed home some IM sux even given the recent IV dose and be ready to treat bradycardia and or code.

only given IM SUX to an adult once in an emergent situation and it felt like it took forever. Probably only a a couple minutes but felt like forever.
 
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LineAndBerry said:
If the patient is combative the pulse ox is probably not going to be very accurate.
Secondly could we assume that the patient is oxygenating pretty well if she is able to generate this much energy in her confused state?
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That was my thought so I tried not to fight her too much and see how she does. But I was still nervous given her high risk of airway obstruction and rapid desaturation so felt the need to place the mask near her face, which in hindsight might have pissed her off even more.
 
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DocMcCoy said:
Does your shop typically use ketamine for ECTs?

agreed if they are fighting you and not turning blue probably satting fine. They usually loosen up when they are coding/about to code.

What were dosages and timing of drugs given? Hypercapnic from a couple minutes if suboptimal ventilation? Still recovering from sux after brevital wore off?

I probably would have rode it out like you did unless patient dictated otherwise. Turning blue and squeaking with inability to ventilate I would have slammed home some IM sux even given the recent IV dose and be ready to treat bradycardia and or code.

only given IM SUX to an adult once in an emergent situation and it felt like it took forever. Probably only a a couple minutes but felt like forever.
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Our psychiatrist love ketamine. although for this lady, we gave 100mg of ketamine (usually give around 50mg) along with 100mg methohexital and 100mg sux. I think maybe we went too heavy on the ketamine causing dissociation and agitation?

The combativeness occurred probably 5-7 min after meds were given? I was ventilating her until I noticed her taking spontaneous breaths so it could be that but he had this exact dose during his last ECT and she did perfectly fine without any issues.

I felt we were heading into hypoxic arrest if she didn't turn around without an IV, so thankfully it worked out...
 
osoprop28 said:
But at that moment, if I still had trouble ventilating and she remained combative, what would you guys do without IV or monitors?
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Prob same as you. Very little anyway. A bit of therapeutic hypoxia would soften her cough. Plus i aint wrestling a 600lbs bear

osoprop28 said:
Our psychiatrist love ketamine. although for this lady, we gave 100mg of ketamine
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Well let them draw it up then... At least tell them the patients getting it and just wet the syringe with it. iirc it decreases the seizure duration also, and the emergence isnt great as you have demonstrated
Ect is prop remi sux hyperventilate next.
24 patients and on the golf course for half 1. Admittedly i havent given it to a 600 pounder but weve had a few 350lbs and that went fine

Some of the guys here have this big fancy cocktail, that i dont understand and i dont see much difference really
 
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don't forget IO as rescue vascular access. admittedly would have added some more "ugly" to this scene, but when you need access, you need access.
 
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Planktonmd said:
I think inducing general anesthesia on a 600 pound patient without intubation is absolutely crazy.
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If patient is sitting upright and you can pop in an OA..its pretty easy

Last thing you want to do is paralyze and intubate a 600lb patient if avoidable..you still have to extubate them and they are far more likely to laryngospasm and desaturate.
 
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osoprop28 said:
Our psychiatrist love ketamine. although for this lady, we gave 100mg of ketamine (usually give around 50mg) along with 100mg methohexital and 100mg sux. I think maybe we went too heavy on the ketamine causing dissociation and agitation?

The combativeness occurred probably 5-7 min after meds were given? I was ventilating her until I noticed her taking spontaneous breaths so it could be that but he had this exact dose during his last ECT and she did perfectly fine without any issues.

I felt we were heading into hypoxic arrest if she didn't turn around without an IV, so thankfully it worked out...
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Why does your psychiatrist love ketamine for ECTs? It's an anti-epileptic...
 
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dhb said:
I'd say 100mg of ketamine for a 10min case is worse: she's waking up in a big K hole.
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but think of the opiate sparing effects of ketamine, so worth it
 
osoprop28 said:
Wanted to get anybody's thoughts on how they would've handled it.

Last week, there was a 600 lb patient undergo ECT. We were thinking of either doing it under LMA or ETT, but she was mallampati I and surprisingly easy to mask ventilate with oral airway) once she went to sleep. We used methohexital, ketamine, sux (while ramped and reversed T).

Psych performed ECT and patient desatted to 70s (which was expected). I placed oral airway back in and ventilate back up to 95% and everything was going well.

Once she started waking up, she got extremely combative, took out the oral airway, and started desaturating, then pulled out her IV and disconnected her monitors, and it was almost impossible to hold her down.

I don't even know what her saturation dropped to since the monitors were off and we were trying to place IV and monitors back on for couple minutes, while I'm trying to ventilate the patient.

Ultimately, after about 5 minutes of fighting, patient calmed down and started breathing on her own and everything was fine.

But at that moment, if I still had trouble ventilating and she remained combative, what would you guys do without IV or monitors? My only thought was to replace oral airway and hope for the best. I don't think she would've taken an LMA at that stage, and IM meds would take so long before it kicks in (she would probably go into hypoxic arrest before IM ketamine/sux kicks in). I was thinking maybe slug her with propofol or precedex if this happens next time (with IV in place). Any thoughts?
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i dont disagree with the masking approach here,

i think masking at the head of the bed, with a ventilator there, with an airway, paralyzed, ramped, under control - i do think thats ok for this short case despite this person being huge.. lets not forget intubating and extubating comes with its own consequences in these patients and keeping it simple goes a long way..

this is clearly a bad reaction to ketamine which is a psychotomimetic drug more than anything else, i personally would not give to this disturbed population, you dont want to go down that rabbit hole with these people

an unruly 600lb patient with no IV is a situation you should not let yourself get in

but if you are in it, you turn the sevo to 8 % and force the mask, you also give a huge dose of IM ketamine and get ready to intubate
 
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The psychiatrist may be requesting the ketamine for its own antidepressant effect. Both ECT and ketamine are used for treatment resistant depression. I haven’t heard of them used together but I’m not a psychiatrist.
 
nimbus said:
The psychiatrist may be requesting the ketamine for its own antidepressant effect. Both ECT and ketamine are used for treatment resistant depression. I haven’t heard of them used together but I’m not a psychiatrist.
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Does a bolus dose have any backing as antidepressant therapy? I thought the data (and practice) was limited to lengthy, low dose infusions.
 
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DrZzZz said:
Does a bolus dose have any backing as antidepressant therapy? I thought the data (and practice) was limited to lengthy, low dose infusions.
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I don’t know.

I’ve read 1-2mg/kg iv over 40min is a standard protocol. But some psychiatrists around here just give it IM. For a 600lb patient, I don’t know if 100mg does anything.
 
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nimbus said:
The psychiatrist may be requesting the ketamine for its own antidepressant effect. Both ECT and ketamine are used for treatment resistant depression. I haven’t heard of them used together but I’m not a psychiatrist.
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If I was 600lb, I would be severely depressed as well.
 
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UscGhost said:
If patient is sitting upright and you can pop in an OA..its pretty easy

Last thing you want to do is paralyze and intubate a 600lb patient if avoidable..you still have to extubate them and they are far more likely to laryngospasm and desaturate.
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They induced GA and paralyzed this 600 lbs patient and thought that mask ventilation was going to be adequate based on nothing but wishful thinking.
This is a very ambitious plan in my opinion.
 
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I didn’t know about repeated succ dosing causing bradycardia, though I can conceptually understand the acetylcholine. how soon is that a risk?
 
nimbus said:
The psychiatrist may be requesting the ketamine for its own antidepressant effect. Both ECT and ketamine are used for treatment resistant depression. I haven’t heard of them used together but I’m not a psychiatrist.
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If you're indeed giving ketamine for mood therapy, shouldn't you be (/be able to) bill for that separately? You're then also doing the intra and post op monitoring for it too. Per another contemporary thread we are suckers for not itemizing things like this and letting others earn from our provided services.
 
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I hate ketamine to begin with. Secondly, although with antidepressant effects, ketamine, as very well said above, does not help ECT. Third, combativeness in this giga population is more likely related to hypoxia and hypercapnia more than anything else. These pt should have a secured bite block and a secondary mean of oxygenation eg nasal cannula at all times.
Although have never practiced this, I have read that flumazenil (although u don’t have any benzos onboard) can fasten wake up and help with consciousness.
 
Lidolover said:
I hate ketamine to begin with. Secondly, although with antidepressant effects, ketamine, as very well said above, does not help ECT. Third, combativeness in this giga population is more likely related to hypoxia and hypercapnia more than anything else. These pt should have a secured bite block and a secondary mean of oxygenation eg nasal cannula at all times.
Although have never practiced this, I have read that flumazenil (although u don’t have any benzos onboard) can fasten wake up and help with consciousness.
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Flumazenil makes people puke their guts out
 
Maybe this patient is a bad candidate for ECT. Feed them a hamburger instead
 
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My ECT is always pretty bland... 30-100mg Propofol and 50-100mg Sux. Never had a problem though. One guy I have regularly used to get agitated in recovery post-ictal; so I midaz him once he's seized.
 
woopedazz said:
My ECT is always pretty bland... 30-100mg Propofol and 50-100mg Sux. Never had a problem though. One guy I have regularly used to get agitated in recovery post-ictal; so I midaz him once he's seized.
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What’s 100 of propofol do to a 600lb patient? He or she will be looking at you talking about when can I eat?
 
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chocomorsel said:
What’s 100 of propofol do to a 600lb patient? He or she will be looking at you talking about when can I eat?
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True, I've never ECT'd anyone close to this weight. Although if he was looking amnestic when he was asking for a hamburger, I'd probably just push the sux anyway... He's 60 seconds away from being post-ictal.
 
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chocomorsel said:
What’s 100 of propofol do to a 600lb patient? He or she will be looking at you talking about when can I eat?
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Sounds like not the best ECT plan. Propofol has antiseizure properties and they are giving less because they want less antiseizure effect. Did they give jt with a bolus of alfentanil? Why not methohexital? Etomidate?
 
coffeebythelake said:
Sounds like not the best ECT plan. Propofol has antiseizure properties and they are giving less because they want less antiseizure effect. Did they give jt with a bolus of alfentanil? Why not methohexital? Etomidate?
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Not licenced in Australia
 
woopedazz said:
Those drugs are not available in Australia.

EDIT: Also why would you use opioids in ECT? Particularly in an OSA patient?
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If you dont have anything other than propofol, and you dont want to use too much of it, then you need another way to deepen thr anwsthetic. An ultra short acting opioid such as alfentanil is frequently used for this purpose. Works in seconds, gone in less than 5 minutes. It doesn't linger so no issue for your big fatty OSA pt.

You dont have etomidate in australia?!
 
coffeebythelake said:
You dont have etomidate in australia?!
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No, but it is in NZ, which our college also encompasses. So we are required to study it, but most of us will never see it in person.
 
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