weirdo case today

[amyl]

second case of the day is a revision of ankle screws. 20-something year old ASA I going in for her third revision. attending wants to do a popliteal block but the patient says no, her post-op pain has never been that bad and she is afraid of needles. surgeons estimate an hour. resident and i are thinking LMA, propofol. we get into the room and our attending says why don't we just do a mask induction and bag her. huh? okay. sevo. fentanyl. he said it was a learning exercise for us. i figured i have to do a week of peds coming up so this would be a good trial run for me. had the sevo high + nitrous to induce her and kept both for the whole case. she did pretty well, a little tachycardic toward the end which made us push a little more fentanyl that was probably ideal. anyways, almost three hours of bagging her later she wakes up...kind of.... she was disoriented for sure so probably a little hypercarbic...? anyways, thought it was a weird approach so i thought i would share....

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[2ndyear]

I hope to god you used the mask straps for that one! Real tired hands if you didn't. Mask inductions in adults are fun. No pain on injection, they cooperate real well (unlike a lot of kids).

 

[CremeSickle]

ah the wonders of fentanyl

Thats what beta blockers are for Fent at the end of the case WAS the learning experience

 

[amyl]

i didn't want to treat the numbers.... she was getting tachy because of pain...but we should have gone with toradol in hind sight... she still complained of pain in the pacu even with the fentanyl.

 

[CanGas]

Ankle screws? I assume they were likely using a tourniquet correct? Though I hope it was not up for the whole 180 min.

It's not unusual beyond 60-90 min of tourniquet time to start getting tachycardia and hypertension from the tourniquet ischemia. This pain can be quite resistant to narcotics and if you snow them well enough that they no longer react, when the tourniquet goes down and the pain goes away you may have dug yourself a great deep narcotic hole to get out of. B-blockers in those cases are useful when you feel you have appropriately covered the surgical pain with enough narcotics.

As for masking for 3hrs. Aren't you glad we work now in the days of LMA's, Propofol, ETCO2/SAT/ET agent monitors among others?

 

[Fastrach]

WTF.... 3hrs?!? At any point in that stretch of time was Narcan mentioned??

 

[amyl]

no tourniquet after first 60 min.

 

[VentdependenT]

second case of the day is a revision of ankle screws. 20-something year old ASA I going in for her third revision. attending wants to do a popliteal block but the patient says no, her post-op pain has never been that bad and she is afraid of needles. surgeons estimate an hour. resident and i are thinking LMA, propofol. we get into the room and our attending says why don't we just do a mask induction and bag her. huh? okay. sevo. fentanyl. he said it was a learning exercise for us. i figured i have to do a week of peds coming up so this would be a good trial run for me. had the sevo high + nitrous to induce her and kept both for the whole case. she did pretty well, a little tachycardic toward the end which made us push a little more fentanyl that was probably ideal. anyways, almost three hours of bagging her later she wakes up...kind of.... she was disoriented for sure so probably a little hypercarbic...? anyways, thought it was a weird approach so i thought i would share....

How bad did your hand hurt afterwards?

You can mask people like they did back in the pre Iso days. Same as leaving a LMA in or a Oral/nasal airway.

Did you also)
Have a precordial stethascope on with no EKG leads?
Check patient temperature per rectum?
Leave the pulse ox off and asses perfusion through patient color?
Manually inflate the sphygmomanometer every 3 minutes with a stethascope on the A/C fossa WHILE you are masking?
Have a metal needle in the vein with your IV fluids running versus a new-fangled IV catheter?
Twang your copper kettle with every heartbeat?