A new case

[Planktonmd]

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35 Y/O, 2 hours post partum, now has retained placenta and hemorrhaging massively.
Took her to the OR, Induced GA, RSI, Ketamine + Sux, ETT.
replaced volume, OB extracted placenta, everything looking good except no return of twitches. and no spontaneous breathing.
Battery in nerve stimulator is good 🙂
60 minutes later still no twitches, what now?

 

[VentdependenT]

start the versed and fentanyl and check twitches every 15 min until the sux gets metabolized by her MUTANT PSEUDOCHOLINESTERASE.

If this was purely a central mediated phenomena then I would expect there to be twitches.

 

[Fastrach]

Had one of my attendings mention he once gave FFP for a pseudocholinesterase deficiency case... worked like Money - pt woke up like lightning. Anyone else heard of/tried it? Makes sense.

 

[Gern Blansten]

Had one of my attendings mention he once gave FFP for a pseudocholinesterase deficiency case... worked like Money - pt woke up like lightning. Anyone else heard of/tried it? Makes sense.

As it stands now, the use of FFP has some strict guidelines(can be found in Big Miller) and this is not one of them. If this is truly pseudocholinesterase deficiency, time is the only thing you need. No real harm done. Probably not worth introducing additional risk of giving FFP to a patient who will be back to normal without treatment within an hour or so. I don't doubt that it would work, but probably not a great idea. I would be interested in hearing other opinions.

 

[Planktonmd]

Well,
I waited, and 90 minutes later the twitches started to return, then she started breathing, and at 120 minutes she had good airway reflexes and was moving a good tidal volume.
I extubated her, and took her to recovery.
She still had generalized skeletal muscle weakness, but was ok otherwise.
I sent her to the ICU over night.
6 hours later I get called again because she now has a huge hematoma in the vagina that is causing severe pain and a compartment syndrome of her external genitalia. She needded I & D.
She still had obvious skeletal muscles weakness, can barely lift her head of the pillow.
She is now coagulopathic: PT= 16, PTT= 40, Platelets = 80,000.
She was still NPO.
I forgot to mention that her intubation was not very easy earlier.
What is the anesthetic plan?

 

[The_Sensei]

I forgot to mention that her intubation was not very easy earlier.
What is the anesthetic plan?

OR-->Etomidate, Zemuron, ETT

You intubated her once before, you can do it again. If you are really concerned, do it awake.

Peace

 

[zippy2u]

OR--> propofol and then LMA with Sevo. Get a couple of antiemetics on board and dump in rec. rm. Next! ___Zip

 

[VentdependenT]

Well,
I waited, and 90 minutes later the twitches started to return, then she started breathing, and at 120 minutes she had good airway reflexes and was moving a good tidal volume.
I extubated her, and took her to recovery.
She still had generalized skeletal muscle weakness, but was ok otherwise.
I sent her to the ICU over night.
6 hours later I get called again because she now has a huge hematoma in the vagina that is causing severe pain and a compartment syndrome of her external genitalia. She needded I & D.
She still had obvious skeletal muscles weakness, can barely lift her head of the pillow.
She is now coagulopathic: PT= 16, PTT= 40, Platelets = 80,000.
She was still NPO.
I forgot to mention that her intubation was not very easy earlier.
What is the anesthetic plan?

LMA. Or Proseal if you wanna suck out the gut for some reason.

If you are thinking another ICU stay for ventilatory support then you gotta tube her. If you gotta tube her you did it once so go for it IF SHE WAS EASY TO VENTILATE PRIOR....have a fiberoptic around just in case things are swollen around there now and somebody who knows how to PROPERLY ASSIST YOU (jaw thrust, tongue pull).

What the hell is she coagulopathic from? Retained products? Abruption?
She's gonna bleed like stink.

Check a CBC or I-stat H/H to have an idea of where youre at.

Get a couple of units of PRBC's and FFP upstairs before you let those OBGYNers go nuts on her. Drop a hespan in up front to buy you some time if need be.

 

[Planktonmd]

What the hell is she coagulopathic from? Retained products? Abruption?
She's gonna bleed like stink.

She had a low grade DIC with possibly some dilution.
H/H was already corrected.

 

[Noyac]

Well,
I waited, and 90 minutes later the twitches started to return, then she started breathing, and at 120 minutes she had good airway reflexes and was moving a good tidal volume.
I extubated her, and took her to recovery.

why did yo wait in the OR the whole time?

 

[The_Sensei]

why did yo wait in the OR the whole time?

I was thinking the same thing!

 

[The_Sensei]

LMA. Or Proseal if you wanna suck out the gut for some reason.
If you gotta tube her you did it once so go for it IF SHE WAS EASY TO VENTILATE PRIOR....have a fiberoptic around just in case things are swollen around there now and somebody who knows how to PROPERLY ASSIST YOU (jaw thrust, tongue pull).

Sounds like Ganzouri has influenced this young grasshopper.......

 

[Planktonmd]

why did yo wait in the OR the whole time?

Well, the only place I could take her intubated at night would have been the ICU, and since I don't trust them and would have needed to stay there anyway, I chose to wait and see if I can extubate her first.

 

[Noyac]

Well, the only place I could take her intubated at night would have been the ICU, and since I don't trust them and would have needed to stay there anyway, I chose to wait and see if I can extubate her first.

What do you mean "you don't trust them"?

 

[Planktonmd]

What do you mean "you don't trust them"?

I actually think the first rule of anesthesia should be "Trust no one".
So if you want to make sure something will be done, you need to do it yourself.
This patient probably wouldn't have been extubated that early by ICU criteria.

 

[zippy2u]

Take her over to the PACU intubated on a t-piece once she starts breathing on her own. Load her up with versed and fentanyl. Whisper in her ear that she's weak from anesthesia and that when she's strong enough you'll pull the tube. Hang around the PACU for awhile and keep the PACU nurses informed as to what's going on. Go outside and smoke a couple of cigs and curse at the moon that ya still have to take call at your age. Regards---- Zippy

 

[VentdependenT]

Sounds like Ganzouri has influenced this young grasshopper.......

you know it baby

 

[Noyac]

I actually think the first rule of anesthesia should be "Trust no one".

I totally disagree. I may be cautious with many in my hospital but I ultimately trust almost all of them. Yes, I do practice different from some of them but the end result is still the same most of the time. For those that I don't trust, well I avoid them like the plague but you can't avoid a whole unit. In my institution she would have been intubated longer if brought to the ICU as well. But I don't avoid the ICU because of this. In this case I would not have brought her to the ICU b/c she doesn't need the ICU. Are you saying that you don't have a PACU at night? Or that you can't bring an intubated pt to the PACU at night? I don't understand this. That's crazy.

Another bit of info for you soon to be practitioners. If you bring a pt to the ICU unexpected in a private hospital, it will be an automatic Peer Review case. You don't want your cases to go to PROC. Of course you can explain it but I don't want to have to explain anything to a committee. I just don't want to be in that position.

 

[Planktonmd]

Take her over to the PACU intubated on a t-piece once she starts breathing on her own. Load her up with versed and fentanyl. Whisper in her ear that she's weak from anesthesia and that when she's strong enough you'll pull the tube. Hang around the PACU for awhile and keep the PACU nurses informed as to what's going on. Go outside and smoke a couple of cigs and curse at the moon that ya still have to take call at your age. Regards---- Zippy

Zippy,
PACU nurses for OB patients in our place are OB nurses, which means I won't be able to leave to smoke that Cig (although I quit smoking 5 years ago) and trust they won't kill the patient.
By the way I did the second anesthetic your way(Propofol + LMA).
My point of posting this case was to see how people would anesthesize this patient the second time, and I am glad I am not the only one out there who would put an LMA in this woman.

 

[Planktonmd]

Are you saying that you don't have a PACU at night? Or that you can't bring an intubated pt to the PACU at night? I don't understand this. That's crazy.

You got it right 🙂

 

[Planktonmd]

If you bring a pt to the ICU unexpected in a private hospital, it will be an automatic Peer Review case. You don't want your cases to go to PROC. Of course you can explain it but I don't want to have to explain anything to a committee. I just don't want to be in that position.

Yes

 

[zippy2u]

Reminds me of some of the circle jerk hospitals I used to gig some locums jobs at. OB on one floor and main OR on another. OB nurses sayin' "all we know about is birthin' babies, we don't know nuthin' about no c-sections." Come stat C-section time, they'd wheel the pt on an elevator down a couple of floors and the main OR nurses would take over, the OB nurses would scatter like flies and say "we gotta get back to birthin' our babies". As you can imagine, the main OR nurses held disdain for the OB nurses and the OB nurses were resistant to learn how to scrub for the c-sections. I just went with the flow as I was makin' my coin. I'd imagine a couple of stat c-section time delays and a sharp personal injury lawyer would get the bean counter CEO to get the nursing crew to "tighten up". Regards, ---Zip

 

[UTSouthwestern]

Another bit of info for you soon to be practitioners. If you bring a pt to the ICU unexpected in a private hospital, it will be an automatic Peer Review case. You don't want your cases to go to PROC. Of course you can explain it but I don't want to have to explain anything to a committee. I just don't want to be in that position.

That's pretty harsh. I've taken patients to the ICU twice unexpectedly, but neither case ended up on PRC's. Coincidentally, both were pseudocholinesterase deficiency patients.

 

[zippy2u]

Plankton, sounds like your OB nurses are doin' double duty at the local surgery center. If ya brought an intubated pt.(or even a pt with a LMA in) into the PACU at some of these surgery centers the PACU nurses have a look of panic and terror on their faces. Serious brain drain goin' on with the RNs. I guess the smart ones become CRNAs or hook up with a doc and get that MRS. degree. Regards, -----Zip

 

[Noyac]

That's pretty harsh. I've taken patients to the ICU twice unexpectedly, but neither case ended up on PRC's. Coincidentally, both were pseudocholinesterase deficiency patients.

First, why take them to the ICU? All they need is a vent for 1-6hrs depending on the pseudocholinesterase makeup. Why not bring a vent to the PACU for the time needed?

Secondly, it is a trigger. When someone goes unexpectantly to the ICU it triggers a review. It is good medicine in my opinion. We review the circumstances and 90% of the time the people involved are commended for their actions. In other words, their actions were appropriate. In any case, we review any escalation of care (unexpected ICU admit), death within 24 hrs, readmit within 24 hrs. among others. If your not on PROC then you may not have any knowledge of the review. That is until they deem you at fault.

 

[UTSouthwestern]

First, why take them to the ICU? All they need is a vent for 1-6hrs depending on the pseudocholinesterase makeup. Why not bring a vent to the PACU for the time needed?

Secondly, it is a trigger. When someone goes unexpectantly to the ICU it triggers a review. It is good medicine in my opinion. We review the circumstances and 90% of the time the people involved are commended for their actions. In other words, their actions were appropriate. In any case, we review any escalation of care (unexpected ICU admit), death within 24 hrs, readmit within 24 hrs. among others. If your not on PROC then you may not have any knowledge of the review. That is until they deem you at fault.

The cases were at a hospital where if a patient is expected to be on the vent more than an hour, they are shunted straight to the ICU.

I am on the PROC now and when I checked on past cases related to the OR, mine were not on the list of cases reviewed (both cases happened more than six months ago and our docket is empty as of two weeks ago).

I agree that PROC is a good way to review appropriate medical care in unusual circumstances. It may have been the fact that I knew what was going on and their recovery proceeded as I had described to the pulmonologist on call those days in the ICU, that may have not triggered PROC.

 

[VentdependenT]

whats PROC?

 

[Noyac]

whats PROC?

Peer Review Committee.

Its a committee of physicians who's job it is to review cases that may or may not have had adverse outcomes. It is a good way of keeping tabs on physicians, nurses, midlevels and anyone involved in pt care. Not only does it review the practitioners but it also reviews the system. It is a great committee to be on if any of you get the chance.

 

[Intubate]

OR--> propofol and then LMA with Sevo. Get a couple of antiemetics on board and dump in rec. rm. Next! ___Zip

Am I the only one who thinks this is a horrible idea that falls well below the standard of care for a peripartum patient?

 

[zippy2u]

Intubate, sorry to offend your sensibilities and perhaps a poor choice of words. How about "transfer to" rather than "dump in". Regards, ----Zip

 

[Noyac]

Am I the only one who thinks this is a horrible idea that falls well below the standard of care for a peripartum patient?

No, I wouldn't have done it this way either. But I can't fault it all together. The case is so short and I've only seen one pt ever throw up in an LMA and she was NPO without a h/o GERD. I have seen a few cesarians done under LMA as well and they are a lot longer than this case. One of those cases I did as a CA-1 when I couldn't intubate the pt and neither could my attending. I usually just mask these retained products cases as well as D&C's.

 

[Intubate]

Intubate, sorry to offend your sensibilities and perhaps a poor choice of words. How about "transfer to" rather than "dump in". Regards, ----Zip

Its not your choice of words, its your anesthetic plan... I don't make all of my decisions based on possible litigation, but you could not defend yourself in court if this patient aspirated. No one would get up and say that an LMA is the standard airway management for emergency surgery on an immediately postpartum patient. I agree that her chance of aspiration is probably pretty low, but this plan is pretty much indefensible in my mind. You have to at least try to intubate the patient and get definitive airway control. If you can't, you can't. Follow the algorithm and put in the LMA.

 

[militarymd]

Its not your choice of words, its your anesthetic plan... I don't make all of my decisions based on possible litigation, but you could not defend yourself in court if this patient aspirated. No one would get up and say that an LMA is the standard airway management for emergency surgery on an immediately postpartum patient. I agree that her chance of aspiration is probably pretty low, but this plan is pretty much indefensible in my mind. You have to at least try to intubate the patient and get definitive airway control. If you can't, you can't. Follow the algorithm and put in the LMA.

You do know that when you review cases of aspiration (and I've reviewed my fair share as M&M coordinator for years...and in the literature)...

Aspirations usually occur when you try to intubate, and it is difficult...and then you flail...and then try something else...

NOT...the smoothly placed LMA's.

 

[Planktonmd]

Its not your choice of words, its your anesthetic plan... I don't make all of my decisions based on possible litigation, but you could not defend yourself in court if this patient aspirated. No one would get up and say that an LMA is the standard airway management for emergency surgery on an immediately postpartum patient. I agree that her chance of aspiration is probably pretty low, but this plan is pretty much indefensible in my mind. You have to at least try to intubate the patient and get definitive airway control. If you can't, you can't. Follow the algorithm and put in the LMA.

I can't totally disagree with you, but in every case you as a physician have to put all the elements on the table, look at the whole picture, and use your best clinical judgement. You still can be sued, regardless of what you do.
The elements of this case are:
1- Post partum patient who is at least 8 hours NPO.
2- Residual muscle paralysis caused by pseudocholinesterase difficiencey.
3- Coagulopathy making regional less attractive.
4- Anterior larynx that was difficult to intubate even with Sux on board.
Now what are the options:
1- Do it by the book: Rapid sequence using Rocuronium and hope you can intubate, now assume the intubation was ok and she did not vomit on you either, do you know if you will be able to extubate her after the procedure? (since she already had muscle weakness), and will you feel good about having this poor woman on a vent for extended time?
2- Do an awake intubation and most likely cause her to vomit in the process with abolished airway reflexes (caused by your airway blocks).
3- Stick an LMA in, with a slim chance of vomiting, but most likely a smooth course of events.
Makes sense?

 

[urgewrx]

Sounds like you extubated her without meeting criteria. Now you are chasing your tail.

 

[urgewrx]

whats PROC?

Short for Proctologist.

 

[VentdependenT]

I can't totally disagree with you, but in every case you as a physician have to put all the elements on the table, look at the whole picture, and use your best clinical judgement. You still can be sued, regardless of what you do.
The elements of this case are:
1- Post partum patient who is at least 8 hours NPO.
2- Residual muscle paralysis caused by pseudocholinesterase difficiencey.
3- Coagulopathy making regional less attractive.
4- Anterior larynx that was difficult to intubate even with Sux on board.
Now what are the options:
1- Do it by the book: Rapid sequence using Rocuronium and hope you can intubate, now assume the intubation was ok and she did not vomit on you either, do you know if you will be able to extubate her after the procedure? (since she already had muscle weakness), and will you feel good about having this poor woman on a vent for extended time?
2- Do an awake intubation and most likely cause her to vomit in the process with abolished airway reflexes (caused by your airway blocks).
3- Stick an LMA in, with a slim chance of vomiting, but most likely a smooth course of events.
Makes sense?

you can always proseal it too. They arent perfect but its a good option.

I think that the LMA was fine for this case. If need be you could run the fiberoptic through the LMA and tube her if blood loss started getting outta control.

 

[Planktonmd]

Sounds like you extubated her without meeting criteria. Now you are chasing your tail.

What criteria?
If I am going to meet the "criteria" everytime I extubate someone I need to go work in academia.
She met my "Criteria" : Moving good tidal volume and had good airway reflexes before extubation.

 

[urgewrx]

What criteria?
If I am going to meet the "criteria" everytime I extubate someone I need to go work in academia.
She met my "Criteria" : Moving good tidal volume and had good airway reflexes before extubation.

You will sound real smart saying that in your court hearing after one of your patients is brain dead.

 

[Planktonmd]

You will sound real smart saying that in your court hearing after one of your patients is brain dead.

Well, last time I checked, this is a forum for physicians not lawyers.
And we practice "medicine" which goes beyond following concrete protocols, it actually involves using judgement.
My judgement was obviously correct because the patient did not go into respiratory failure and did not need to be re-intubated.
If we are going to just follow protocols blindly, then we will be practicing nursing.

 

[urgewrx]

Well, last time I checked, this is a forum for physicians not lawyers.
And we practice "medicine" which goes beyond following concrete protocols, it actually involves using judgement.
My judgement was obviously correct because the patient did not go into respiratory failure and did not need to be re-intubated.
If we are going to just follow protocols blindly, then we will be practicing nursing.

It is obvious that you have some BS answer for everything. You practice medicine out there in the real world, where there are plenty of lawyers wanting to make a living out of you, not in this forum.

Protocols, or algorithms, exist for a reason. Mainly to protect patients from their practitioner's poor judgement, or stupidity. For example, extubating a "full stomach" patient, with a moderately difficult airway, even though still having residual muscle paralysis.

The fact that you got away with it does not mean that it was the right thing to do. If you want to distinguish your practice from nursing, I suggest you start doing better than this. I'll even help you out and educate you a little bit. A patient who cannot lift his head CANNOT protect his airway. The fact that someone can lift his head DOES NOT WARRANTY they can protect their airway. Lifting the head correlates with a 0.7 TOF, yet you need 0.9 TOF to protect your airway. If you want to learn some more read the papers on muscle relaxants by Kopman.

I don't want to hear more BS, please.

 

[Intubate]

You do know that when you review cases of aspiration (and I've reviewed my fair share as M&M coordinator for years...and in the literature)...

Aspirations usually occur when you try to intubate, and it is difficult...and then you flail...and then try something else...

NOT...the smoothly placed LMA's.

I understand this, but you just don't use an LMA in a full stomach or an aspiration risk patient if you're practicing good medicine. It blows my mind that this is even a conversation.

There are lots of things you can do your whole career and never experience the rare complications, but we have to try to avoid them. I once looked up case reports in the literature for neuraxial anesthesia in thrombocytopenic patients. I saw one report (this was years ago so I may be a little fuzzy) of a labor epidural in a pt with a plt count of 9 (nine!) thousand. Hey, if you don't hit a vessel, you're fine right? I won't be doing that, maybe you guys will.

 

[Planktonmd]

It is obvious that you have some BS answer for everything. You practice medicine out there in the real world, where there are plenty of lawyers wanting to make a living out of you, not in this forum.

Protocols, or algorithms, exist for a reason. Mainly to protect patients from their practitioner's poor judgement, or stupidity. For example, extubating a "full stomach" patient, with a moderately difficult airway, even though still having residual muscle paralysis.

The fact that you got away with it does not mean that it was the right thing to do. If you want to distinguish your practice from nursing, I suggest you start doing better than this. I'll even help you out and educate you a little bit. A patient who cannot lift his head CANNOT protect his airway. The fact that someone can lift his head DOES NOT WARRANTY they can protect their airway. Lifting the head correlates with a 0.7 TOF, yet you need 0.9 TOF to protect your airway. If you want to learn some more read the papers on muscle relaxants by Kopman.

I don't want to hear more BS, please.

This forum unfortunately is full of green newbies who read a few things and love to recite them at every occasion.
You sir are one of those.
The reason why i would post a case on an open forum like this is to hear other people's input, and to stimulate discussion.
It's nice when we act like physicians and not assume that we are smarter than every one else.
I am fully aware of all the arguments that a newbie like you would worry about and yes, i do have answers for all of them. Those answers are obviously higher than your level so I won't waste my time repeating them to you.

 

[urgewrx]

Its fascinating how guys like you are never wrong. And when you have nothing else to say you call "newb" and portray yourself as being at a "higher level". You are only fooling yourself.

 

[dhb]

urgewrx: you sound like those attendings that teach you nothing but DOGMA

 

[Planktonmd]

The pseudo-cholinesterase measurement, 24 hours later, came back 900 while the normal range is between 2900 - 7000.

 

[timtye78]

So, 'a' possible answer is supporting ventilation and oxygenation until the patient meets clinical extubation criteria.

Fascinating case. Thanks for telling us about it.

 

[Anesthesia1979]

Not saying anything was done wrong.... pt did well... that's what matters.

How I would've done it.
After recognizing pt is weak and probably has psuedo-defciency (good job), I take pt to ICU, propofol for 4 hours, come back and assess pt now off propofol and pull the snorkel if strong. If any skeletal weakness, I'm leaving the tube in.

If pt extubated and needs to go back to OR, then I would probably place Proseal or Fast-track and intubate through that without the paralytics.

 

[OBRules]

I am kind of disgusted with your attitudes towards nurses and doctors as well. I came to this site looking for intelligent discussion about hespan and instead am appalled by your cavalier attitude towards other professionals in the hospitals you work in.

 

[Planktonmd]

I am kind of disgusted with your attitudes towards nurses and doctors as well. I came to this site looking for intelligent discussion about hespan and instead am appalled by your cavalier attitude towards other professionals in the hospitals you work in.

😕
What?