Favorite MAC tricks?

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Toothpickwars

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Was doing a deep brain stimulator lead implant yesterday with low dose precedex/prop gtts. Gave glyco upfront but pt started coughing halfway through the case. Tried the usual suction, 100mcg fentanyl, 100mg lido, and tessalon perles, still coughing intermittently while pinned in the neurosurg head frame.

Discussed with my old school attending who had me do superior laryngeal nerve blocks and it immediately stopped the coughing!

Definitely going in my bag of tricks. Anyone else have useful tips to help pt comfort during these long MAC cases where pt has to remain still and cooperative?
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Strap on a tight fitting mask attached to the anesthesia circuit and turn on some sevo. My buddy does this for all his “MAC” TAVRs.
 
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Toothpickwars said:
Was doing a deep brain stimulator lead implant yesterday with low dose precedex/prop gtts. Gave glyco upfront but pt started coughing halfway through the case. Tried the usual suction, 100mcg fentanyl, 100mg lido, and tessalon perles, still coughing intermittently while pinned in the neurosurg head frame.

Discussed with my old school attending who had me do superior laryngeal nerve blocks and it immediately stopped the coughing!

Definitely going in my bag of tricks. Anyone else have useful tips to help pt comfort during these long MAC cases where pt has to remain still and cooperative?
Click to expand...
Who in the hell has tessalon perles in the OR? And gives them to a pt. sedated with propofol!
 
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For OSA in DBS cases, I put a nerve stimulator on their foot in case if they are over sedated you can easily provide a strong tetany stimulus that consistently makes them breathe again. Its a fantastic tool for oversedation!
 
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I give roc and put this little tube in the mouth, flip switch on oven looking machine
Then go have coffee
 
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ethilo said:
For OSA in DBS cases, I put a nerve stimulator on their foot in case if they are over sedated you can easily provide a strong tetany stimulus that consistently makes them breathe again. Its a fantastic tool for oversedation!
Click to expand...

This is an amazing idea
 
Arch Guillotti said:
Who in the hell has tessalon perles in the OR? And gives them to a pt. sedated with propofol!
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We had the prop off at this point. Pt was responsive to commands. My attg got them from pharmacy and had him crush them in his mouth and suck on them. Idk, like I said, old school.
 
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Toothpickwars said:
We had the prop off at this point. Pt was responsive to commands. My attg got them from pharmacy and had him crush them in his mouth and suck on them. Idk, like I said, old school.
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tessalon perles dont even work outpatient
 
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So I’m almost 30 years out of med school and I learned about tessalon perles today. Must have skipped class that day.
 
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Arch Guillotti said:
Who in the hell has tessalon perles in the OR? And gives them to a pt. sedated with propofol!
Click to expand...
We had the prop off at this point. Pt was responsive to commands. My attg got them from pharmacy and had him crush them in his mouth and suck on them. Idk, like I said, old school.
 
We did these wide awake w/ hand holding.

Sounds like a challenging MAC.

Let em watch a movie or something.

Slugs of prop once leads placed successfully.
 
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Toothpickwars said:
We had the prop off at this point. Pt was responsive to commands. My attg got them from pharmacy and had him crush them in his mouth and suck on them. Idk, like I said, old school.
Click to expand...
Can confirm, biting them and sucking on the juices (no euphemism) numbs the back of the throat real good. Did it when I was deployed and couldn't drink water properly for a couple hours.
 
MirrorTodd said:
Can confirm, biting them and sucking on the juices (no euphemism) numbs the back of the throat real good. Did it when I was deployed and couldn't drink water properly for a couple hours.
Click to expand...
Interesting- anyone ever use them in this fashion to help with topicalization for an AFOI?
 
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ethilo said:
For OSA in DBS cases, I put a nerve stimulator on their foot in case if they are over sedated you can easily provide a strong tetany stimulus that consistently makes them breathe again. Its a fantastic tool for oversedation!
Click to expand...
I LOVE THIS!
 
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Toothpickwars said:
Was doing a deep brain stimulator lead implant yesterday with low dose precedex/prop gtts. Gave glyco upfront but pt started coughing halfway through the case. Tried the usual suction, 100mcg fentanyl, 100mg lido, and tessalon perles, still coughing intermittently while pinned in the neurosurg head frame.

Discussed with my old school attending who had me do superior laryngeal nerve blocks and it immediately stopped the coughing!

Definitely going in my bag of tricks. Anyone else have useful tips to help pt comfort during these long MAC cases where pt has to remain still and cooperative?
Click to expand...
That is impressive. You did SLN blocks right then and there intra-aop?
 
If they are coughing during MAC, it means they are light.. Go up on the propofol until couging stops.. BUt go up by 10mcg/kg/min every minute or so until you hit your target so you dont get apnea..

No need to add fentanyl precedex sevo etc etc.. usually these things complicate matters for you
 
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Aheadbyacentury said:
If they are coughing during MAC, it means they are light.. Go up on the propofol until couging stops..
Click to expand...

No offense but this is awful advice for a patient coughing during a DBS placement.
 
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Urzuz said:
No offense but this is awful advice for a patient coughing during a DBS placement.
Click to expand...

Seriously guys—- tessalon pearls?

The treatment is to alert the surgeon so that he/she can apply more bone wax or irrigate the field until the entrainment stops.

A DBS is a sitting craniotomy; the highest risk procedure for VAE. This has to be on your radar.
 
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The implant hole was small, 1cm, seemed well waxed, and our pt had difficulty clearing secretions even preop so suspicion for VAE was low from my attending but definitely a trance home for me. After the SLN blocks he did spit up some good phlegm but yes, we did it while he was awake, sitting and in head pins.

Agree with Arch, they needed him able to follow commands for the lead placement. GABA agonists abolish the tremor so deeper prop not an option at this point.

Ordinarily would either deepen with prop/opiate/precedex and gently suction or lighten anesthetic so pt could clear secretions.
 
jwk said:
I LOVE THIS!
Click to expand...
It's also a good tool for patients that "aren't waking up" after a GA. You can put the nerve stimulator on their pec muscle and give them some tetany. I'd say the stimulation is more stimulating than a sternal rub but 1) Not as aggressive-appearing to everyone else in the room. and 2) very simple, "on demand stimulus," and less work involved than a sternal rub and 3) the patient feels nothing when the stimulus is removed. If you put it on their pec muscle, just watch out for their arm flying up, they might swat you!
 
Toothpickwars said:
The implant hole was small, 1cm, seemed well waxed, and our pt had difficulty clearing secretions even preop so suspicion for VAE was low from my attending but definitely a trance home for me. After the SLN blocks he did spit up some good phlegm but yes, we did it while he was awake, sitting and in head pins.

Agree with Arch, they needed him able to follow commands for the lead placement. GABA agonists abolish the tremor so deeper prop not an option at this point.

Ordinarily would either deepen with prop/opiate/precedex and gently suction or lighten anesthetic so pt could clear secretions.
Click to expand...

Remi works well, I prefer increasing that as much as tolerated and keeping prop relatively low. Precedex isn’t super titratable so I leave that on at like 0.5-075 as some low basal sedation.

The nerve block is a cool idea though, how did you do it? Frame still on?
 
FiO2@21 said:
Remi works well, I prefer increasing that as much as tolerated and keeping prop relatively low. Precedex isn’t super titratable so I leave that on at like 0.5-075 as some low basal sedation.

The nerve block is a cool idea though, how did you do it? Frame still on?
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I think remi would be a good choice for this, we use it almost exclusively for our tavrs, keeps them nice and still.

Yep, in the frame, sitting up, just told him what we were doing, palpated his hyoid greater cornu, bounced a 1/2” 25ga needle just inferior to it, 2cc 2% lido per side.
 
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What Remi dose do you use? Honestly in this elderly parkinsons population I would be hesitant.
 
I once saw a resident cause a respiratory arrest that led to a code using remi for a MAC. Patient had one IV, was running at a slow drip, with some dead space between the IV and where the remi was plugged in. Patient in the IR suite, in the C arm with their head turned away from the anesthesia machine and the radiologists standing between the anesthesia space and the patient’s head. Patient was getting some dialysis access thing done, so was somewhat volume overloaded and didn’t have a ton of pulmonary reserve. Radiologist asked for some IV heparin, resident gave it and then flushed the line, bolusing an unknown amount of remi in the process. Took a moment for the resident to get to the patients head after she started to desat, at which point she proved a somewhat difficult mask airway, and by then the patient had started to brady down.

The whole thing was sloppy and could have been avoided if the person in the room was more on the ball, but the lesson I took away was to be very selective about when I let residents or CRNAs use remi for MAC cases. When I do allow it, I ask them to keep the IV dripping fast enough to be an effective carrier and be mindful of dead space in the line, but at some point when you’re supervising I feel like you need to idiot-proof your anesthesia to meet the lowest common denominator
 
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Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!
 
CavGas said:
Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!
Click to expand...

Try an lma?
 
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That is a crap ton of fentanyl for a chole! Lidocain lube on the cuff solves most all coughing.
CavGas said:
Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!
Click to expand...
 
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CavGas said:
Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!
Click to expand...

Lidocaine 4% LTA before u put in the tube
 
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Hork Bajir said:
I once saw a resident cause a respiratory arrest that led to a code using remi for a MAC. Patient had one IV, was running at a slow drip, with some dead space between the IV and where the remi was plugged in. Patient in the IR suite, in the C arm with their head turned away from the anesthesia machine and the radiologists standing between the anesthesia space and the patient’s head. Patient was getting some dialysis access thing done, so was somewhat volume overloaded and didn’t have a ton of pulmonary reserve. Radiologist asked for some IV heparin, resident gave it and then flushed the line, bolusing an unknown amount of remi in the process. Took a moment for the resident to get to the patients head after she started to desat, at which point she proved a somewhat difficult mask airway, and by then the patient had started to brady down.

The whole thing was sloppy and could have been avoided if the person in the room was more on the ball, but the lesson I took away was to be very selective about when I let residents or CRNAs use remi for MAC cases. When I do allow it, I ask them to keep the IV dripping fast enough to be an effective carrier and be mindful of dead space in the line, but at some point when you’re supervising I feel like you need to idiot-proof your anesthesia to meet the lowest common denominator
Click to expand...

My personal rule, anytime I have an anesthetic that relies on IV agents (endo not included), I need two separate IVs.

Scary story, I use remi in the place of sux sometimes for thyroids so I could see how flushing a remi line could easily get you in trouble.
 
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FiO2@21 said:
Scary story, I use remi in the place of sux sometimes for thyroids so I could see how flushing a remi line could easily get you in trouble.
Click to expand...

Just for giggles?

One of my attending blouses remi for induction once. Couldn’t ventilate, just attributed to chest wall rigidity. He sort of just laughed about it, because he “knows” how short acting remi is. I was not amused. Not sure if I will ever use that technique, or why would I…..
 
IMGASMD said:
Just for giggles?

One of my attending blouses remi for induction once. Couldn’t ventilate, just attributed to chest wall rigidity. He sort of just laughed about it, because he “knows” how short acting remi is. I was not amused. Not sure if I will ever use that technique, or why would I…..
Click to expand...
To facilitate intubation in a pt. that you want to avoid muscle relaxants in such as myasthenia.
 
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CavGas said:
Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!
Click to expand...
Main stem or secretions?
 
CavGas said:
Hey everybody!
I was reading this thread and I thought I 'd ask here since the discussion started as cough related..

Over the last month or so I 've had 3-4 patients, young,fit ASA 1-2 having minor surgery ( i.e. hernia, ENT stuff etc ) ,for which they received minimal opioids, have a reallyyyyy nasty post - extubation cough. They had no pain at the surgery site but were miserable cos of this persistent cough. Only 1 of them was a smoker and in my limited experience I 've never seen this happen when the patient receives heavy handed opioid ( i.e around 350ug fent for a lap chole would be average here)
I was wondering what could cause this and how could it be treated in the PACU? ( more opioid? lidocaine? some magic nebulizer?)

Intubation was not complicated for any of them and they didn't really strain at the extubation phase..

Thanks in advance for the answers!
Click to expand...
I think on some level all intubations are traumatic to the larynx and glottis, here’s an article talking about risk factors for post intubation sore throat/cough: http://www.medicinearticle.com/JMR_20175_07.pdf

Included are time/traumatic factors in intubation/extubation, tube size, #of suction attempts, blood on/in tube, etc.

Things I’ve seen work are drugs that help pharmacologically (steroids in a long case, IV opiate/lidocaine) or topically (Lido LTA/paste/alkalinized in cuff). I’d be curious to try a lido neb, transtracheal lido, or SLN blocks in PACU for relief although maybe the coughing is not such a bad thing in going healthy pts.

If no contra indications, LMAs seem to reduce the risk of cough as well, 84%cough for ETT vs 14% for LMA in this one study (n=52): Comparison of early postoperative recovery between... : Medicine
 
Hork Bajir said:
I once saw a resident cause a respiratory arrest that led to a code using remi for a MAC. Patient had one IV, was running at a slow drip, with some dead space between the IV and where the remi was plugged in. Patient in the IR suite, in the C arm with their head turned away from the anesthesia machine and the radiologists standing between the anesthesia space and the patient’s head. Patient was getting some dialysis access thing done, so was somewhat volume overloaded and didn’t have a ton of pulmonary reserve. Radiologist asked for some IV heparin, resident gave it and then flushed the line, bolusing an unknown amount of remi in the process. Took a moment for the resident to get to the patients head after she started to desat, at which point she proved a somewhat difficult mask airway, and by then the patient had started to brady down.

The whole thing was sloppy and could have been avoided if the person in the room was more on the ball, but the lesson I took away was to be very selective about when I let residents or CRNAs use remi for MAC cases. When I do allow it, I ask them to keep the IV dripping fast enough to be an effective carrier and be mindful of dead space in the line, but at some point when you’re supervising I feel like you need to idiot-proof your anesthesia to meet the lowest common denominator
Click to expand...
You could also insist that they infuse a carrier fluid at 100cc/hr on the pump with the remi plugged in as distal as possible. With our tubing, each drop of carrier is 1/20th of an ml so I usually run 1-2 drops a second or the equivalent of 90-180ml a minute.
 
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Toothpickwars said:
You could also insist that they infuse a carrier fluid at 100cc/hr on the pump with the remi plugged in as distal as possible. With our tubing, each drop of carrier is 1/20th of an ml so I usually run 1-2 drops a second or the equivalent of 90-180ml a minute.
Click to expand...

5-10 liters/hr?
 
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IMGASMD said:
Just for giggles?

One of my attending blouses remi for induction once. Couldn’t ventilate, just attributed to chest wall rigidity. He sort of just laughed about it, because he “knows” how short acting remi is. I was not amused. Not sure if I will ever use that technique, or why would I…..
Click to expand...

Yes for excellent intubating conditions that don’t need RSI but can’t get roc. Like thyroids with EMG tubes.
 
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