Use of the Stethescope in the OR

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

militarymd

SDN Angel
20+ Year Member
Joined
Dec 17, 2003
Messages
5,886
Reaction score
22
Here is the clinical situation I was in the other day....see what everyone thinks.

An experienced crna is in the OR with 2 experienced surgeons doing a lap nissen what is quite challenging. Patient is a 60 year old with htn and reflux....otherwise healthy.

This is not my room, the anesthesiologist is a LT that both the crna and the surgeons did not trust, so they decide to call me into the room.

On coming into the OR, I note that the pulse ox reads 83% to 86% with a good wave form. The hr is 80 bpm and bp is 130/80.

I'm told by the surgeon that they think they may have entered the chest, and the crna says there is decreased breath sounds on the left.

My answer was, "go ahead and put in a chest tube on the left"

The surgeon asks me to please listen to the chest before he does that. My answer was decreased breath sounds doesn't necessarily mean a pneumo...other things like mucus plugs, lobar collapse, etc. can cause decreased breath sounds, and presence of breath sounds does not rule out pneumo either especially in this clinical situation.

I wasn't too concerned with a sat of mid 80's with good hemodynamics, so I told the surgeon that if he really wanted a diagnosis prior to putting in a chest tube, then we need to fluoro the chest.

He said get the fluoro in....then in the middle of it he changed his mind, and put in the chest tube.

There was no gush of air, but there was space in the pleura, and the sats took 15 more minutes to return to 95% on 100% fio2.

So what does everyone think of the stethescope in the OR....I know what they teach you, but I've found that the stethescope may help, but definitly not all the time.

Members don't see this ad.
 
ideally you should auscultate after intubation.. regardless.. does that happen? NO! why? because I mis place many of my stethoscopes and the stethoscopes in the room suck...


you never know when the tube is in the mainstem or riding the carina.. w/o a stethoscope//
 
davvid2700 said:
ideally you should auscultate after intubation.. regardless.. does that happen? NO! why? because I mis place many of my stethoscopes and the stethoscopes in the room suck...


you never know when the tube is in the mainstem or riding the carina.. w/o a stethoscope//

I check tube position by feeling the cuff of the ETT in the sternal notch. The pilot balloon and the cuff are connected, so if you partially compress the pilot balloon while blotting the cuff of the ETT...you can feel it the pilot balloon going up and down.

I move the ETT around until I feel the cuff of the ETT in the sternal notch.....There are studies published (cadaveric) that confirm that bronchial intubation is very unlikely when the cuff is in the sternal notch position.

So, I almost never listen after intubation if I have capnography in the OR.

However, my question is about decreased breath sounds after a case has started in the above scenario.
 
Members don't see this ad :)
There are a couple of things that come to mind here. When I intubate I watch the cuff go just past the cords and then I stop. I then look for bilateral chest rise. I don't listen unless I am unsure of something.

In this case the tube may have been in the trachea at the start of the case but as the abd. was insuflated the tube may have moved into a mainstem. If the CRNA had listened beforehand and then once the sats fell s/he could have clued in to some changes in breath sounds even if they are bilateral. Was the HR in the 80's before the problem? Tube on the carina, very stimulating.

Secondly, this is a reflux pt. Was the stomach empty, OGtube? As we all know there can still be some aspiration with an ETT in place. As the intraabdominal pressure increased the pt may have had some reflux. This would have been slow to respond.

I suspect it was a pneumo of some size (small or not) since the surgeon went ahead and placed a CT and the sats improved although slowly. If he suspected he might have entered the chest, then he did. During insuflation it is more difficult to recruit atelectatic lung. It will take a little time as in this case.

Now, if this is not what you are asking, I have to assume you want stethoscope opinions. I think the stethoscope is a good tool for the OR if used often. I don't think it is that easy to diagnose problems after they occur in some circumstances. If you listen up front then you can tell if the sounds have changed. Sure you can hear one-sided BS, wheezing, etc. But are they diminished from previous? I don't know cause I didn't listen earlier.
 
I swear I learn more from this board (or at the very least the motivation to learn more) than anywhere else. It gets the brain churning.

Good post. I listen to the chest if i see peaks comming up with no obvious immediate explination. Sometimes I'll catch a wheeze, or decreased unilat BS after some sort of tburg, but more often than not its at the end of the case when pt is light and they are chompen on the tube (I put bite block in now), BTW I love this field.

Sternal notch is at t2 vertebrae which is what, a few cm above the carina (t4'ish?) and a good 12 cm below cords? Hook it up MMD.

We have these dots (from the manufacturer) on our ETT's which are about 6 cm proximal to the tip. We were told that if you visualize this dot just going past cords that your position will always be dead on. No pun intended.

On another note what do you guys think of extubating "deep." Pt spontaneous breathing with reg respiratory pattern and decent tv's 3-4 cc/kg but otherwise a little deeper than mac awake.

MY apologies for the rambles but I'm a little hung over (giggle) and I gotta roll to the burbs to hang with the folks for a day of chillin.
 
Noyac said:
In this case the tube may have been in the trachea at the start of the case but as the abd. was insuflated the tube may have moved into a mainstem.


Tube position was the first thing that I checked.

Post-op CXR revealed significant LLL atelectasis....I suspect the main cause of the hypoxia.

I just found it odd that the surgeon wanted me to listen to the lungs before placing the chest tube, when I felt that physical examination is less than revealing.
 
militarymd said:
Here is the clinical situation I was in the other day....see what everyone thinks.

An experienced crna is in the OR with 2 experienced surgeons doing a lap nissen what is quite challenging. Patient is a 60 year old with htn and reflux....otherwise healthy.

This is not my room, the anesthesiologist is a LT that both the crna and the surgeons did not trust, so they decide to call me into the room.

On coming into the OR, I note that the pulse ox reads 83% to 86% with a good wave form. The hr is 80 bpm and bp is 130/80.

I'm told by the surgeon that they think they may have entered the chest, and the crna says there is decreased breath sounds on the left.

My answer was, "go ahead and put in a chest tube on the left"

The surgeon asks me to please listen to the chest before he does that. My answer was decreased breath sounds doesn't necessarily mean a pneumo...other things like mucus plugs, lobar collapse, etc. can cause decreased breath sounds, and presence of breath sounds does not rule out pneumo either especially in this clinical situation.

I wasn't too concerned with a sat of mid 80's with good hemodynamics, so I told the surgeon that if he really wanted a diagnosis prior to putting in a chest tube, then we need to fluoro the chest.

He said get the fluoro in....then in the middle of it he changed his mind, and put in the chest tube.

There was no gush of air, but there was space in the pleura, and the sats took 15 more minutes to return to 95% on 100% fio2.

So what does everyone think of the stethescope in the OR....I know what they teach you, but I've found that the stethescope may help, but definitly not all the time.

Not a bad move.

Easy for me to armchair quarterback since I read the post and thought about it for a while...totally different then being called to the room to fix something.

One thing I've done myself, though, is being lead down the wrong diagnostic path by someone's suggestion of what they think is wrong. If youve got time, quickly rule out all the easy stuff that they probably didnt think of before you get invasive.

I'm sure you addressed the easy stuff first. Tube down too far? Suction the tube? Did the pulse ox probe become malpositioned, now its sideways...enough to give a good waveform but with an erroneous reading? Etc. This stuff is easy and doesnt take long. If none of that works

One thing I wouldda asked them to do before the chest tube is deflate the belly temporarily (easily done) so you could aggressively ventilate with a few 1000 tidal volume breaths....since atelectasis is common in laparoscopic cases, especially long ones, that may have helped identify an intrapulmonary shunt secondary to lobar atelectasis. This would only take a minute to do.

It wouldve helped one way or the other. Sats come up? Great. Probably atelectasis. Go ahead and reinflate the belly.

Sats dont come up? Or did the situation get worse with aggressive ventilation (tension)? Chest tube.

I'm ambivalent on the stethescope. Yes, it cant hurt. But you can usually tell whats wrong without one.

Next time you put in a DLT, really concentrate on the patient's chest rise. Up and down. Up and down. Then put the Kelly clamp on, to occlude ventilation to one side, while concominantly watching the chest. Pretty dramatic difference. You dont need a stethescope to tell whether youre in the right spot or not.

PIPs up? Capnographic upslope? Bronchospasm

Its difficult to get a full auscultative assessment on a supine patient in a loud operating room, so youre almost forced to use other tools to as well.
 
Why not just get a stat portable x-ray, have the tech take it directly to radiologist for a "wet" reading. 5-10 minutes at most. Regards---- Zippy
 
zippy2u said:
Why not just get a stat portable x-ray, have the tech take it directly to radiologist for a "wet" reading. 5-10 minutes at most. Regards---- Zippy

Yeah, you could do that, Zipster, but I'd say fluro is quicker and easier.
 
zippy2u said:
Why not just get a stat portable x-ray, have the tech take it directly to radiologist for a "wet" reading. 5-10 minutes at most. Regards---- Zippy


I actually asked for fluoro in the OR, and I would have read it immediately. The x-ray tech was actually bringing the unit in at the time.

The surgeon asked what we should do, and because I didn't feel strongly about any specific course of action (patient stable)...I offered the following choices of action to him:

1) addtional diagnostic study >>>>> fluoroscopy for definitive diagnosis.

2) immediate therapy based on presumptive diagnosis >>>>> small bore chest tube on presumably affected side

3) do nothing and observe >>>>>> patient will either do better based on ventilator manipulations I do, or get worse when we revert to 1 or 2

The surgeon initallly opted for number 1, but then changed his mind to 2 before we got images.

And jet, I did all the simple stuff you mentioned already...actually the experienced crna did them already, and I just reverified with her to make sure they were done...including deflating the abdomen.
 
militarymd said:
I actually asked for fluoro in the OR, and I would have read it immediately. The x-ray tech was actually bringing the unit in at the time.

The surgeon asked what we should do, and because I didn't feel strongly about any specific course of action (patient stable)...I offered the following choices of action to him:

1) addtional diagnostic study >>>>> fluoroscopy for definitive diagnosis.

2) immediate therapy based on presumptive diagnosis >>>>> small bore chest tube on presumably affected side

3) do nothing and observe >>>>>> patient will either do better based on ventilator manipulations I do, or get worse when we revert to 1 or 2

The surgeon initallly opted for number 1, but then changed his mind to 2 before we got images.

And jet, I did all the simple stuff you mentioned already...actually the experienced crna did them already, and I just reverified with her to make sure they were done...including deflating the abdomen.


HHOOOHHHHHH....CONFUSCIOUS SAY HORY CRAP.. THEN SOUND LIKE SURGEON PUT TROCAR IN WRONG COMPARTMENT... :laugh:
 
Top