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Someone needs to proofread his profile...
3 year old boy dies during dental procedure
Started by sevo00
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What a weak sauce murse. If he needs to make this tragedy about himself, he has proven he is insecure. Fact.
Also. Anesthesiologists have way more training than CRNAs. He is not my equal. Fact.
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I love this.
HIs idea that all you have to do to be equal is BELIEVE you are equal reminds me of this SHOCKING news story I saw a few years ago.
AANA: 'Despite Having Much Less Training CRNAs Also Equivalent to Neurosurgeons, Fighter Pilots, and LeBron James' | GomerBlog
"Where is the research proving CRNA’s can't fly jets as well as fighter pilots? I haven’t seen it so we should be allowed to independently fly jets, drop bombs and stuff.
gomerblog.com
It’s almost always laryngospasm hypoxia bradycardia death!
Kansas mother hopes for answers after 3-year-old son dies after dental procedure, dentistry releases statement
A Kansas mother is sharing her family’s tragedy and looking for answers after her 3-year-old son died following a dental procedure in Wichita on Tuesday.www.ksn.com
Just saw this on the news. Sad. According to the article the Dental office uses a solo CRNA group to administer anesthesia during their cases.
Being an MD doesn’t necessarily prevent hypoxia.
A few years ago a board certified pediatric anesthesiologist had this happen in SW Washington.
Sublingual IM sux might bail you out.
If your not there it won’t happen to you!
Arch Guillotti
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Why give it sublingual?
Faster onset
Not really "sublingual" in the sense we usually mean with that word (e.g. sublingual NTG or Zofran), but injecting it into the highly vascular tissue under the tongue. I had a peds attending in residency who advised giving IM succ in that location for faster onset.
Seems reasonable.
Seems reasonable.
Arch Guillotti
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I get that part.
I wouldn’t do it in a million years though.
4 mg/kg in the deltoid. And atropine.
The dentist is mucking around in the mouth. The bed is away from you. An ET tube may be in the way. You could cause bleeding. No way I am skipping the tried and true in an emergency.
My thought exactly.
Did find this little gem for those who are interested.
Intra-lingual succinylcholine for the treatment of adult laryngospasm in the absence of IV access
If 200 mg of suxamethonium is the same as 200 mg succinylcholine, that was 10 ml injected into that ladies tongue. Seems like that much volume my hurt your ventilation but I have never tried it.
If you have an ETT you really shouldn’t need sux!
Better absorption means you need less volume.
A syringe ready to go can save the kid and you.
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Good point.
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Arch Guillotti
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One would think it is impossible to laryngospasm with an ET tube in place.
Isn’t that obvious?
Arch Guillotti
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I have had CRNA's confuse laryngospasm with bronchospasm.
I’ll defer to you your the verified expert!
One pedi center we cover is asking us to refrain from drawing up the sux, unless needed in an emergency 🤔
Thoughts?
Thoughts?
F that noise. Draw that **** up for every case. You really just need one drawn up for the whole day.
They want to be that cheap over one syringe wasted? F that. Tell them if they really want to be cheap they can save the vial in the fridge till it runs out.
Give me a damn break.
Absolutely. If I'm doing kids that day the first thing I do is draw up a vial of sux into a full 5 cc, a full 3 cc, and the rest into another 3 cc and load them each up with 25 ga needles. Then I draw up an atropine. This is just baseline, bare minimum cost of doing kids. Anyone that wants to save money by stopping this practice can go you-know what.
Prefilled syringes for the win.
Tell your pharmacy to do the right thing, get with the current century, and stock them.
I never draw up succ because the factory does it for me.
Maybe you should start telling them which patients should be getting procedures/surgery done and see how they like it. People need to stay in their lane.
If you desperately need paralysis, you can put a 25 g on a syringe with a paralytic in it and enter the skin and advance toward any vessel that is standing out while aspirating. As soon as you aspirate blood , inject. If you have steady hands, this will work, and probably more reliably than trying to start an IV really fast. In a life or death airway emergency with no access, you just need to get the paralytic into circulation, you don’t need to establish an IV.
I’ve done this once before for a thoracic case that had a confluence of really bad luck on induction. I injected 100 of rocuronium into a prominent EJ .
I’ve also given intra arterial rocuronium during a cardiac induction once in my career. Through a preinduction arterial line intentionally. Had no other choice
I realize kids don’t get preinduction arterial lines, just bringing it up in case any one is faced with this situation some time and forgets that the arterial line is technically vascular access
I’ve done this once before for a thoracic case that had a confluence of really bad luck on induction. I injected 100 of rocuronium into a prominent EJ .
I’ve also given intra arterial rocuronium during a cardiac induction once in my career. Through a preinduction arterial line intentionally. Had no other choice
I realize kids don’t get preinduction arterial lines, just bringing it up in case any one is faced with this situation some time and forgets that the arterial line is technically vascular access
Yikes… don’t leave us hanging, would love to hear the whole story for both of those
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Why?
To paralyze for a cardiac induction
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What was wrong with the vein?
D
deleted126335
Lone IV infiltrated giving induction drugs?
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Straight IA rocuronium - more cardiac stable than propofol or etomidate
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I dunno about your setup but there is pretty much always an ultrasound in the cardiothoracic room or right outside it where I'm at. In those situations I'm gonna put an 18g needle on the roc syringe, U/S on neck, inject directly into IJ.
Makes the artery stiffer and better for the bypass
Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies
Unintentional intra-arterial injection of medication, either iatrogenic or self-administered, is a source of considerable morbidity. Normal vascular anatomical proximity, aberrant vasculature, procedurally difficult situations, and medical personnel error all contribute to unintentional...
www.mayoclinicproceedings.org
According to this review, IA injection of atracurium and tubocurarine resulted in ischemic appearance of the limb and gangrene, respectively. Not sure about rocuronium or sux, but you’d have to convince me that intentional IA administration is preferable to IM sux in the “CICV IV blew on induction” scenario, even with the sat dropping and the patient bradying down… I think I’d still reach for IM sux and an LMA (vs US and needle into the IJ as mentioned above, depending on resources available).
IM sux. i need my hands free than trying to be creative in this scenario
D
deleted697127
Lol. Credibility on hold until more details provided.
Always read/heard about sublingual/IM sux, etc. In many many years of practice have never had to give it. The obvious scenario is while doing an inhalational induction you get a laryngospasm and would need it then. Or if you lose the IV and have laryngosasm. I have heard of some trying to do cases with manipulation of airway and no IV…Bad Idea!!! Why I mentioned not doing these cases without IV!!! For those who have done enough peds know that getting a good IV in some of these kids can be challenging. Especially some of the more cherubic ones! I can envision a busy dental practice opting to go ahead with a case without the benefit of a good functioning IV???
Ive given it several times; always with a peds inhalational induction. If I can’t find a vein, they get woken up and they go home. It has happened to me a couple of times.
Intra-arterial injection of some drugs is associated with terrible injury. I don't know which are safe and unsafe. I'm not sure anyone does.
Promethazine is well known for causing phlebitis and GIS will return a horror show of black hands from extravasation and especially accidental arterial injection. NMBDs sting a lot (way more than propofol) so I'd be extra wary of giving roc through a radial a-line.
I'd wager that those of us who trained before ultrasound became standard of care for IJ central lines could hit that with a 23 g needle on a syringe reliably and quickly. From time to time, I'll draw intraop labs that way if the arms are tucked or the peripheral veins suck. I've never directly injected drugs that way but think I'd do that before I put something into an arterial line.
Promethazine is well known for causing phlebitis and GIS will return a horror show of black hands from extravasation and especially accidental arterial injection. NMBDs sting a lot (way more than propofol) so I'd be extra wary of giving roc through a radial a-line.
I'd wager that those of us who trained before ultrasound became standard of care for IJ central lines could hit that with a 23 g needle on a syringe reliably and quickly. From time to time, I'll draw intraop labs that way if the arms are tucked or the peripheral veins suck. I've never directly injected drugs that way but think I'd do that before I put something into an arterial line.
For those of you who have tried not so conventional way of injecting sux. Can you elucidate your thinking process?
Not criticizing, just want to understand a little more, since you have two of the established methods of delivering medications, why deviate, especially presumably during an emergency?
Not criticizing, just want to understand a little more, since you have two of the established methods of delivering medications, why deviate, especially presumably during an emergency?
Having been in a few emergency situations, I can attest to the fact that I don't think as clearly as I do normally and may not make the best decisions.
Could you elucidate further by what you mean? Doesn't Anesthesiology have a fair share of emergency situations when compared to other specialties?
I would venture to say, not as much as people think. I would think the ER would have a hell of a lot more than us. Life and death literally? I mean compared to psych sure.
IM has patients coding and deteriorating on the floors all day long. We try to avoid emergency situations by planning ahead and having backup plans as much as possible unless they come into the door already in a state of emergency.
If you are having bad emergencies happen to you constantly in this field you are either supervising a bunch of incompetent nurses, are yourself somewhat incompetent or doing nothing but high risk cases all day everyday IMO.
Might be another dumb question, but isn't anesthesia often on the code teams and airway call in many hospitals? I guess that's where I am getting it from.
This depends entirely on the practice setting. If you are working in a busy trauma center, you will be dealing with life or death situations on a regular basis. If you are in an ASC, not so much. Regardless, every anesthesiologists should feel competent dealing with an emergency, otherwise they have no business taking care of patients in the operating room, IMHO.
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I guess while I'm young and idealistic, that would be the kind of practice I would want for a career as an anesthesiologist or Anes/CCM, but could see it getting old and stressful as I get older......
D
deleted697127
This is true but these are rare events and as an individual you’re only rarely the one responsible for responding. This is usually managed by whoever is your floor manager, holding the call pager, or happens to be free at the moment. If everyone is tied up, it usually then falls to ED or ICU. If you are in an Md only practice, you are not expected to leave your OR to respond to codes unless maybe it’s in the PACU which is an extremely rare event.
In any event, it’s usually less stressful to be responding to someone else’s disaster than one you created for yourself cutting corners. 300 lb SBO who aspirated on the floor and are coding are stressful but thankfully most codes are easy airways. As Choco said, it is our job to anticipate and prevent emergencies from happening. For example, if you lose blood quickly during a partial nephrectomy or whipple. Usually i will have a free flowing 16 and be able to easily keep up. This is definitely a surgical emergency but with adequate access, all it really takes from me is getting blood in the room and squeezing it in.
I was mainly asking why do intra-lingual or IA injection.
I certainly have been in situations, coming out of it, wondered what the f just happened. Had a few just recently, sorry to say. I guess I am just drilled by attendings in training, I wouldn’t have thought of injecting sux other than IV or IM. But I suppose if IA is the only access, when push comes to shove, I may have used it ?
@NicMouse64 just like everyone else said, we should “rarely” get ourselves into a bind that we need to start coding a patient unprepared. Even in ICU, most of the time everyone knows it’s coming. Perhaps the family is not ready, or the family meeting hasn’t happened yet. I still remember one meeting, basically the attending just said, we already maxed out on 3 pressors, we will not start another one. We will perform CPR as you (family) and the patient’s wish. But there isn’t much we will do.
I certainly have been in situations, coming out of it, wondered what the f just happened. Had a few just recently, sorry to say. I guess I am just drilled by attendings in training, I wouldn’t have thought of injecting sux other than IV or IM. But I suppose if IA is the only access, when push comes to shove, I may have used it ?
@NicMouse64 just like everyone else said, we should “rarely” get ourselves into a bind that we need to start coding a patient unprepared. Even in ICU, most of the time everyone knows it’s coming. Perhaps the family is not ready, or the family meeting hasn’t happened yet. I still remember one meeting, basically the attending just said, we already maxed out on 3 pressors, we will not start another one. We will perform CPR as you (family) and the patient’s wish. But there isn’t much we will do.
D
deleted697535
Ah...
Ive had days of Type A's. 3 back to back was worst run. All 40-50% mortality on GERAADA. arresting arriving
Ive had weeks averaging 10 units of blood product per case. Its no big deal
But i am definitely incompetent!
D
deleted697535
Ive wondered that myself.
For some strange reason, ive never 'solo' in any shape or form had bad laryngospasm or cico or whatever. I dont know whether thats luck or no but ive never even come close to that situation.
When i was a resident I worked with one staff (who was very nice but in hindsight incredibly incompetent), and he had laryngospasm reasonably bad on 4 out of 4 cases in one day. He just did the wrong thing at the perfect ****storm wrong time... and boom spasm. Each time he would slightly differently **** it up. And he couldnt understand why
It was like dancing with a girl when you were kids man. You didnt know what you were doing but it was just rhythm, it didnt matter... Im sorry to say but this guy just hadnt any rhythm. And i dont know if you can teach that. You either have it or you dont. A 6th sense to pull that tube right now or else... Nope give more prop and wait til next time
You cant read about this stuff in a book. You just gotta go Luke Skywalker on it...
