10% sheer terror

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Hmmmmm

Off hand:

37 yo 4'11" 255 lb ESRD, volume overloaded, female arrives emergently to the OR with a cath lab RCA dissection, 95% ostial LAD, 99% mid circ, ST's creeping up, on IABP now with a cold leg where the IABP is in place. She has no neck to speak of, is combative from the chest pain, treated with NTG, Versed, and morphine, and may have aspirated at the end of the cath by report. Did I mention she has a sugar of >600, likely DKA with ketones galore, and a wonderful K of 6.3? She has a venous femoral cordis that runs like a 22 gauge because it is packed in with the arterial sheath for the IABP and has a transvenous pacing wire in place for 3rd degree heart block due to the RCA dissection/occlusion.

She also received a kidney transplant that we've just given a dye load to.

Can't do an awake FOI because she is very combative, so I give her 10 mg of etomidate and Nimbex her, cric kit ready to go, grade 4 view with MAC 3, grade 3 with Miller 2 + cric pressure, have tech give a chest compression while I have the tube in hand and ram that sucker down when I see an air bubble emerge from among the fat lands.

Now need to put in an arterial line because the balloon will have to go and go soon. Nail the radial, feeling my oats now, thread the catheter in and get no visible waveform with a reading of 25 mm Hg. ****. Put in not one, but TWO brachial caths with the same result: Good flow, no visible waveform. IABP shows 115 augmented systolic.

Do you know why/what is happening? (Tune in tomorrow, or later today at least for the answer, but I suspect the Venty stud will know this immediately).

Finally bite the bullet and put in an essentially iliac a line as surgeon tells me that the caliber of her femoral is too small by angiogram to accomodate even a small bore arterial cath long term (Stick the femoral with 22 ga needle, thread a guidewire up, use C-arm to visualize guidewire "trail" and stick three inches up about an inch distal to the takeoff of the iliac and thread second wire and 6 inch cath).

Now need to place a cordis for PAC (mandatory at this facility). Neck is out of the question. She's had multiple accesses on both sides and both IJ's are noted to be tiny and may also have significant stenoses from previous accesses. R subclavian stick X 2. Get reasonable flow, wire goes in without unreasonable resistance, but cordis won't pass. Can't futz around for much longer (it has been now almost 45 minutes since arrival to the OR) so I maneuver for almost 5 minutes until I get the cordis to make some bizarre turn that allows it to go in under her thick clavicle. Swan goes in easily (about time something went in easy). Opening PAP 42/23, CVP 23. Unfortunately, as with the femoral cordis, the flow is like a 22 gauge at best through the side port, 20 gauge through the Swan's port. I hook up two extensions to the two brachial lines and arterial or not, they will be forced to accept fluid if necessary.

Two mg Bumex, insulin infusion, and a cloud of dust later, we're off.

Seven and a half hours later at 2 am she is in the ICU stable, FSG of 107 with a K of 4.3, and off pacing with three new coronary grafts and is extubated two days later. I go home and pass out for 12 hours straight. I don't remember driving home. That case was following a 4 hour elective multilevel spine fusion in the morning followed by an emergent 5 hour MVR/CABG for a patient with classic inferior wall infarct with P1, P2 flail and wide open MR.

This was just a recent case. I've seen worse this past summer.
 
UTSouthwestern said:
Hmmmmm

Off hand:

37 yo 4'11" 255 lb ESRD, volume overloaded, female arrives emergently to the OR with a cath lab RCA dissection, 95% ostial LAD, 99% mid circ, ST's creeping up, on IABP now with a cold leg where the IABP is in place. She has no neck to speak of, is combative from the chest pain, treated with NTG, Versed, and morphine, and may have aspirated at the end of the cath by report. Did I mention she has a sugar of >600, likely DKA with ketones galore, and a wonderful K of 6.3? She has a venous femoral cordis that runs like a 22 gauge because it is packed in with the arterial sheath for the IABP and has a transvenous pacing wire in place for 3rd degree heart block due to the RCA dissection/occlusion.

She also received a kidney transplant that we've just given a dye load to.

Can't do an awake FOI because she is very combative, so I give her 10 mg of etomidate and Nimbex her, cric kit ready to go, grade 4 view with MAC 3, grade 3 with Miller 2 + cric pressure, have tech give a chest compression while I have the tube in hand and ram that sucker down when I see an air bubble emerge from among the fat lands.

Now need to put in an arterial line because the balloon will have to go and go soon. Nail the radial, feeling my oats now, thread the catheter in and get no visible waveform with a reading of 25 mm Hg. ****. Put in not one, but TWO brachial caths with the same result: Good flow, no visible waveform. IABP shows 115 augmented systolic.

Do you know why/what is happening? (Tune in tomorrow, or later today at least for the answer, but I suspect the Venty stud will know this immediately).

Finally bite the bullet and put in an essentially iliac a line as surgeon tells me that the caliber of her femoral is too small by angiogram to accomodate even a small bore arterial cath long term (Stick the femoral with 22 ga needle, thread a guidewire up, use C-arm to visualize guidewire "trail" and stick three inches up about an inch distal to the takeoff of the iliac and thread second wire and 6 inch cath).

Now need to place a cordis for PAC (mandatory at this facility). Neck is out of the question. She's had multiple accesses on both sides and both IJ's are noted to be tiny and may also have significant stenoses from previous accesses. R subclavian stick X 2. Get reasonable flow, wire goes in without unreasonable resistance, but cordis won't pass. Can't futz around for much longer (it has been now almost 45 minutes since arrival to the OR) so I maneuver for almost 5 minutes until I get the cordis to make some bizarre turn that allows it to go in under her thick clavicle. Swan goes in easily (about time something went in easy). Opening PAP 42/23, CVP 23. Unfortunately, as with the femoral cordis, the flow is like a 22 gauge at best through the side port, 20 gauge through the Swan's port. I hook up two extensions to the two brachial lines and arterial or not, they will be forced to accept fluid if necessary.

Two mg Bumex, insulin infusion, and a cloud of dust later, we're off.

Seven and a half hours later at 2 am she is in the ICU stable, FSG of 107 with a K of 4.3, and off pacing with three new coronary grafts and is extubated two days later. I go home and pass out for 12 hours straight. I don't remember driving home. That case was following a 4 hour elective multilevel spine fusion in the morning followed by an emergent 5 hour MVR/CABG for a patient with classic inferior wall infarct with P1, P2 flail and wide open MR.

This was just a recent case. I've seen worse this past summer.
Click to expand...

So, You were physically in the OR for 16.5 hours that day!
I hope they are paying you enough to do that and I hope you don't have to do that too frequently!
 
UTSouthwestern said:
Hmmmmm
4'11" 255 lb ESRD, volume overloaded, female arrives emergently to the OR with a cath lab RCA dissection, 95% ostial LAD, 99% mid circ, ST's creeping up, on IABP now with a cold leg where the IABP is in place. She has no neck to speak of, is combative from the chest pain, treated with NTG, Versed, and morphine, and may have aspirated at the end of the cath by report. Did I mention she has a sugar of >600, likely DKA with ketones galore, and a wonderful K of 6.3? She has a venous femoral cordis that runs like a 22 gauge because it is packed in with the arterial sheath for the IABP and has a transvenous pacing wire in place for 3rd degree heart block due to the RCA dissection/occlusion.

She also received a kidney transplant that we've just given a dye load to.
Click to expand...

Hmmm, are you sure she wasn't one of my medicine patients this last spring? hehe.
 
UTSouthwestern said:
Nail the radial, feeling my oats now, thread the catheter in and get no visible waveform with a reading of 25 mm Hg. ****. Put in not one, but TWO brachial caths with the same result: Good flow, no visible waveform. IABP shows 115 augmented systolic.

Do you know why/what is happening? (Now need to place a cordis for PAC (mandatory at this facility).

CVP 23.

Two mg Bumex
Click to expand...

Good job. Glad the pt did ok. I hope you had some help. I have a few comments:

1 I think you were hitting a vein. Did the pt have a pulse in that extremity?Compare 23 mmHg to CVP of 25 mmHg. Nothing better than being overloaded to make your veins pop out. Why didn't you try the other arm and went for the brachial? Could it be IABP? I don't think so. You should still have a pulse even if the ballon is opening on the subclavian. If unsure you could have set the balloon to 1:2 for a few seconds. If anything, I would be concerned about the possibility of an AV fistula in the same arm causing the flat trace. But, I don't think you would be sticking an arm with a fistula.

2 Do you rutinely give Bumex to the pump cases? Why did you give it here? Why not lasix?

3 What happens if you don't place a PAC? Just because everyone is used to PAC's in your setting does not make it a necessity. It can placed when the case is over for icu management.
 
I'm not sure if this counts as "terror," since it was prolonged, but it was a bad day in the OR:

40-somethingish guy, really nice, otherwise healthy, in for resection of a meningioma recurrence. After sending him off to sleepyland, we tried to hyperventilate to drive down the CO2, minimize cerberal swelling, etc. Hmm, the CO2 wouldn't go down... We had the vent going more or less at its maximum with >18L of minute ventilation, and this guy's CO2 wouldn't drop much below 40. Everything else was stable, drew some ABGs and labs, he wasn't acidotic, wasn't hyperkalemic, so we exchanged out the CO2 absorber. Then his HR and BP started going up, and so did his temperature... More ABGs and labs, still not acidotic, K is normal, CK is normal, there's no rigidity, surgeons are unhappy... My resident and attending (and a few other attendings) debated giving dantrolene but decided against it. Surgeons had to eventually do an unplanned frontal pole lobectomy in order to control the swelling/close. 11 hours later, we leave the OR to take him to radioloy and get a post-surgical scan. Diffuse SAH. When this guy eventually ends up in the PACU and gets extubated, he pukes ALL OVER (it was like we stopped at McDonalds for a burger on the way back from radiology or something) to the extent that one of the seasoned PACU nurses was retching in a garbage can (I've never seen anything like it). The next day his CK was >2000. From laying on the OR table all day the day before or from soemthing along the lines of MH? Who knows... I think someone needs a muscle bx, personally. BTW, the guy ended up being perfectly neurologically intact in the long run.
 
1st day as a resident I walked into the OR and the attending says

"ever intubate before?"

Me: "Yup, couple times"

Attending: "Ok, Go ahead" (pt sedated and paralyzed at that moment).

I may have stained my pants. Oh, and i tubed the goose.
 
Planktonmd said:
So, You were physically in the OR for 16.5 hours that day!
I hope they are paying you enough to do that and I hope you don't have to do that too frequently!
Click to expand...

Fortunately, rarely have to do that type of day, but it was a perfect storm of me being on first call and the emergencies coming in sequentially.
 
urge said:
Good job. Glad the pt did ok. I hope you had some help. I have a few comments:

1 I think you were hitting a vein. Did the pt have a pulse in that extremity?Compare 23 mmHg to CVP of 25 mmHg. Nothing better than being overloaded to make your veins pop out. Why didn't you try the other arm and went for the brachial? Could it be IABP? I don't think so. You should still have a pulse even if the ballon is opening on the subclavian. If unsure you could have set the balloon to 1:2 for a few seconds. If anything, I would be concerned about the possibility of an AV fistula in the same arm causing the flat trace. But, I don't think you would be sticking an arm with a fistula.

2 Do you rutinely give Bumex to the pump cases? Why did you give it here? Why not lasix?

3 What happens if you don't place a PAC? Just because everyone is used to PAC's in your setting does not make it a necessity. It can placed when the case is over for icu management.
Click to expand...


You win the cupie doll. The left arm had the "usable shunt" on/in this patient, the right arm was supposedly devoid of a USABLE shunt, however, when the patient was placed on nitro, the native artery-vein AV shunts opened up enough to cause an active shunting effect. Because the patient received dialysis on the left arm, it was never recorded that she had previously had two shunts on the right and whoever created the AV shunts in the right arm, left almost no scar/suture line to show them.

I almost never give a diuretic on hearts. This patient was not anuric but unresponsive to a total of 100 mg of lasix given over the past 4 hours. While both are loop diuretics, Bumex can still be beneficial in the lasix tolerant patient. This was not a pump case, by the way. It was done completely off pump. With 550 cc's of urine output over the time of the case and hemoconcentration of all of the salvaged blood, we were able to remove a significant amount of fluid from her (CVP 12 at the end of the case) and give her a better chance to survive this mess.

The PAC is not always a necessity and they can bite me if I decide not to put one in, but in this patient, with limited access sites, I wanted to have a cordis in place more than the PAC. I doubt a 2 L CVP cath would even run with that tight drop I had to cross to get the cordis in place.

Let's hear some more cases. You residents must have some interesting stuff by now in this fall time period.
 
Ferdie said:
I'm not sure if this counts as "terror," since it was prolonged, but it was a bad day in the OR:

40-somethingish guy, really nice, otherwise healthy, in for resection of a meningioma recurrence. After sending him off to sleepyland, we tried to hyperventilate to drive down the CO2, minimize cerberal swelling, etc. Hmm, the CO2 wouldn't go down... We had the vent going more or less at its maximum with >18L of minute ventilation, and this guy's CO2 wouldn't drop much below 40. Everything else was stable, drew some ABGs and labs, he wasn't acidotic, wasn't hyperkalemic, so we exchanged out the CO2 absorber. Then his HR and BP started going up, and so did his temperature... More ABGs and labs, still not acidotic, K is normal, CK is normal, there's no rigidity, surgeons are unhappy... My resident and attending (and a few other attendings) debated giving dantrolene but decided against it. Surgeons had to eventually do an unplanned frontal pole lobectomy in order to control the swelling/close. 11 hours later, we leave the OR to take him to radioloy and get a post-surgical scan. Diffuse SAH. When this guy eventually ends up in the PACU and gets extubated, he pukes ALL OVER (it was like we stopped at McDonalds for a burger on the way back from radiology or something) to the extent that one of the seasoned PACU nurses was retching in a garbage can (I've never seen anything like it). The next day his CK was >2000. From laying on the OR table all day the day before or from soemthing along the lines of MH? Who knows... I think someone needs a muscle bx, personally. BTW, the guy ended up being perfectly neurologically intact in the long run.
Click to expand...

We discussed this recently:
Unexplained hypermetabolic state under GA = MH until proven otherwise.
This means: you give Dantrolene, you don't wait for ABG or anything else, you just give Dantrolene and you treat as MH.
If the temperature starts risnig it is already too late.
The reason why the ABG did not show the expected metabolic acidosis is because you guys were hyperventilating this guy like there is no tomorrow which saved your rear end and his.
So the only right thing that was done here was unfortunately unintentional.
This is an exceptional oportunity for you as a student to see how people who are supposed to be experts can do very stupid things like wasting time on changing the CO2 absorber instead of treating the obvious MH.
and by the way lying down on the OR table for hours does not give you a CPK of 2000!
 
As always, UTSW wins.
Today, i tried my first opioid induction. Slammed in the alfenta (5000 then 2500) rather than titrating...

Pt apneic, eyes half mast but open.

Now rigid chest. Can't ventilate. sp02 75%

30 Propofol and 90 sux. Re PRE oxygenated and used planned glidescope intubation.

Not as sexy as UTSW but interesting for a little ca-1
 
Even after intern year? You must have done a transitional.

CremeSickle said:
1st day as a resident I walked into the OR and the attending says

"ever intubate before?"

Me: "Yup, couple times"

Attending: "Ok, Go ahead" (pt sedated and paralyzed at that moment).

I may have stained my pants. Oh, and i tubed the goose.
Click to expand...
 
Lowly intern here, but I've had a crazy month in the ICU.

Other day, 4am, just me and another intern on the unit floor, seniors admitting in the ER downstairs.

Dude with end stage liver disease and a hgb of 4 has been transfused all night..altered mental status due to uremic enceph, but he is protecting his airway enough.

Codes while simultaneously bleeding copiously from his rectum and mouth, where is he nearly projectile vomiting blood across the room, with sats dropping to the 70s. Stops projectile, and turns blue with blood pouring out of his mouth. No pulse, so my buddy and I (with now a roomful of freaked out nurses looking on) run the code, intubate him, and finally bring him back in time for our senior and the ER attending (covering difficult airways) walk into the room asking if we need help. Not too sexy, but dang sweet for a couple of interns by themselves. Too bad the guy died later that day on the interventional radiologists table, who are only good at coding procedures, not patients...
 
UTSouthwestern said:
3. Awake portions of spinal cord stimulator testing and placement. If you haven't done those yet, look forward to it. Prone patient not intubated, undergoing a thoracic/lumbar/thoracolumbar laminectomy then having to be awake for testing lead placement. Patient usually a narcotics nightmare preoperatively. You want to blast them with narcotics, but you have to be careful not to snocker them or get them so comfortable that the testing is useless. Precedex's alternative mechanism of action gives you a way to keep the patient comfortable in a titratable fashion.
Click to expand...


I have only done two of these, and both were consecutive cases. Both pt's were no virgins to opioids. First one youngish and went smoothly. Second one... not so much of either. He was uncomfortable and not being "cooperative". I gave him some fentanyl and a couple of small propofol boluses during the tunneling of the wires then.... Sh1t! Apneic, prone, and quickly decompensating. I screeched like a 3 year-old girl and my attending slid in a upside-down LMA. Pt had a good outcome and I was only out a pair of drawers. I learned may things that day – renewed respect for opioids, how difficult (if not impossible) it is to mask someone prone, and always have backup plan B & C ready to go.
 
Coastie said:
Lowly intern here, but I've had a crazy month in the ICU.

Other day, 4am, just me and another intern on the unit floor, seniors admitting in the ER downstairs.

Dude with end stage liver disease and a hgb of 4 has been transfused all night..altered mental status due to uremic enceph, but he is protecting his airway enough.

Codes while simultaneously bleeding copiously from his rectum and mouth, where is he nearly projectile vomiting blood across the room, with sats dropping to the 70s. Stops projectile, and turns blue with blood pouring out of his mouth. No pulse, so my buddy and I (with now a roomful of freaked out nurses looking on) run the code, intubate him, and finally bring him back in time for our senior and the ER attending (covering difficult airways) walk into the room asking if we need help. Not too sexy, but dang sweet for a couple of interns by themselves. Too bad the guy died later that day on the interventional radiologists table, who are only good at coding procedures, not patients...
Click to expand...


Don't miss those days at all.
 
CremeSickle said:
1st day as a resident I walked into the OR and the attending says

"ever intubate before?"

Me: "Yup, couple times"

Attending: "Ok, Go ahead" (pt sedated and paralyzed at that moment).

I may have stained my pants. Oh, and i tubed the goose.
Click to expand...

Coastie said:
Even after intern year? You must have done a transitional.
Click to expand...

or MEDICAL school???? you never did an anesthesia rotation?
 
I did an anesthesia rotation (which consisted of me watching mostly) and an intern year but I sucked at intubating. I bet i had missed 50% of the attempts I had made up until CA1. So I was trying to "set the bar low" as it were!
 
As an MS4 applying to Anesthesia, I have thoroughly enjoyed your stories. Please keep them coming. This is the stuff that makes me insanely giddy about joining the field. 😀
 
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