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- Feb 22, 2014
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What are everyone's thoughts on this drug? Not going to lie, I rarely if ever used it during residency outside of stat GA C-sections, and only really began using it in peds fellowship for the induction.
So supervising a total laryngectomy on a 74yo patient with a cardiac history. CRNA had him on a good amount of volatile but patient kept "moving" (I think it was more bucking do to the airway manipulation by the surgeon). Despite this apparent bucking this patient's BP which started in the 150/90s was hovering in the 80-90s systolics with MAPs dipping into the 60s. Added a remifentanyl infusion in the background to help try to blunt the stimuli, but CRNA said that he still occasionally was bucking. And again despite this his BP kept dipping. Oh and of course the surgeon was monitoring the patient, so for the first half of the surgery we couldn't use muscle relaxants. So the record (like a lot of ENT cases with varying amounts of stimuli throughout the case, looked like a rollercoaster ride)
So I get relieved for the day around 4pm and give my signout to the next anesthesiologist. And he looks at the record and says what's up with the waves. I tell him about the BP and the bucking. And he just says, "Why didn't you just start nitrous!?" the patient is clearly not anesthetized. He then goes on about how properly anesthetized patients don't move, and that when the surgeon was done monitoring and we were allowed to use muscle relaxants we were only covering up a light anesthetic and risked recall. While I do agree taht the incidence of recall is higher when relaxants are used, I highly doubt a 74yo patient who was on 2%+ of sevoflurane plus a remifentanyl infusion who had a low BP has any significant chance of recall. I felt the problem was the fact that surgeon was manipulating the airway and the MAC needle to blunt intubation is closer to 1.3...
So does anyone else think that this 74yo cardiac patient was lightly anesthetized or that the magical solution was turning on the nitrous? Forgot to mention that the CRNA was pregnant (not sure how much this facotrs into anything, but why risk it). I dunno, just never been a fan of nitrous, and it seems like more recent articles are showing that outcomes are poorer with its use. Just feeling a little bad, cause this anesthesiologist sort of dressed me down in front of a couple colleagues, as if I had never read about the miracle drug known as nitrous...
So supervising a total laryngectomy on a 74yo patient with a cardiac history. CRNA had him on a good amount of volatile but patient kept "moving" (I think it was more bucking do to the airway manipulation by the surgeon). Despite this apparent bucking this patient's BP which started in the 150/90s was hovering in the 80-90s systolics with MAPs dipping into the 60s. Added a remifentanyl infusion in the background to help try to blunt the stimuli, but CRNA said that he still occasionally was bucking. And again despite this his BP kept dipping. Oh and of course the surgeon was monitoring the patient, so for the first half of the surgery we couldn't use muscle relaxants. So the record (like a lot of ENT cases with varying amounts of stimuli throughout the case, looked like a rollercoaster ride)
So I get relieved for the day around 4pm and give my signout to the next anesthesiologist. And he looks at the record and says what's up with the waves. I tell him about the BP and the bucking. And he just says, "Why didn't you just start nitrous!?" the patient is clearly not anesthetized. He then goes on about how properly anesthetized patients don't move, and that when the surgeon was done monitoring and we were allowed to use muscle relaxants we were only covering up a light anesthetic and risked recall. While I do agree taht the incidence of recall is higher when relaxants are used, I highly doubt a 74yo patient who was on 2%+ of sevoflurane plus a remifentanyl infusion who had a low BP has any significant chance of recall. I felt the problem was the fact that surgeon was manipulating the airway and the MAC needle to blunt intubation is closer to 1.3...
So does anyone else think that this 74yo cardiac patient was lightly anesthetized or that the magical solution was turning on the nitrous? Forgot to mention that the CRNA was pregnant (not sure how much this facotrs into anything, but why risk it). I dunno, just never been a fan of nitrous, and it seems like more recent articles are showing that outcomes are poorer with its use. Just feeling a little bad, cause this anesthesiologist sort of dressed me down in front of a couple colleagues, as if I had never read about the miracle drug known as nitrous...