a quick case scenario to discuss..

[RussianJoo]

an anesthesia resident is getting a sebaceous cyst removed from his back, and wants to do it under local only, the surgeon feels like it might be deep and wants at least conscious sedation, but then agrees to do whatever the anesthesiologist is willing to do. What would you do? allow for local only? Conscious sedation? or GA and intubate cause the patient is going to be prone for the case.

The patient is in his late 20's healthy, no GERD, none smoker, so ASA 1...

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[Planktonmd]

an anesthesia resident is getting a sebaceous cyst removed from his back, and wants to do it under local only, the surgeon feels like it might be deep and wants at least conscious sedation, but then agrees to do whatever the anesthesiologist is willing to do. What would you do? allow for local only? Conscious sedation? or GA and intubate cause the patient is going to be prone for the case.

The patient is in his late 20's healthy, no GERD, none smoker, so ASA 1...

I would do what ever the patient wants as long as the patient is smart enough and understands that he is going to have to tolerate some pain and discomfort. He should also agree that if he decides to act like a pu$sy in the middle of the case then there is nothing I can do for him.

 

[psychbender]

an anesthesia resident is getting a sebaceous cyst removed from his back, and wants to do it under local only, the surgeon feels like it might be deep and wants at least conscious sedation, but then agrees to do whatever the anesthesiologist is willing to do. What would you do? allow for local only? Conscious sedation? or GA and intubate cause the patient is going to be prone for the case.

The patient is in his late 20's healthy, no GERD, none smoker, so ASA 1...

I actually did a very similar case like this last week, only it was a lipoma, and the patient was definitely not an anesthesia resident. In an otherwise healthy, ASA-1 patient, for a procedure such as this, you can certainly go prone without an ETT. Start the IV in holding, and discuss with pt that if he cannot tolerate simply local, then either the procedure will need to be aborted, or he will have to accept some amount of sedation. Standard ASA monitors in OR, facemask O2 (with ETCO2 line running into the side, secured under a nostril. Have him roll over, with his face resting on one of those pillows used for prone cases. Let the surgeons go.

If the patient decides that he cannot tolerate it, then give a small propofol bolus (0.5-1mg/kg), and start a low-dose propofol drip (20-40mcg/kg/min), and titrate to effect (with supplemental boluses, if needed). That's a fairly low level of sedation, and the stimulation will likely keep him breathing, while gravity assists with preventing obstruction.

 

[Bertelman]

I actually did a very similar case like this last week...

Me too. Excision of melanoma plus ax dissection for nodes. She was convinced anesthesia had caused some behavioral disturbances which lasted nearly a year. Wanted to be awake, no sedatives. Explained the poor likelihood she would endure the ax nodes w/o something. Liberal propofol infusion.

"Wow, this hurts much more than I thought it would.".

Yeah.

Another satisfied customer. Another story to tell.

 

[gaspasser2004]

I would do what ever the patient wants as long as the patient is smart enough and understands that he is going to have to tolerate some pain and discomfort. He should also agree that if he decides to act like a pu$sy in the middle of the case then there is nothing I can do for him.

...............................

 

[Idiopathic]

plenty of invasive procedures are done prone with light sedation, especially on healthy people

 

[RussianJoo]

cool thanks guys.. yeah what we did was 1mg of versed in the holding area, another before the case, some propofol while the surgeon was injecting the local and that was it.. went very smootly the pt. didn't move, didn't complain. The pt's main reason for lack of sedation was that he didn't have anyone to give him a ride home after and he didn't want to stay too long in the PACU...

 

[Idiopathic]

Hmm, I still would have made him get a ride, I think.

 

[sevoflurane]

You gave anesthesia to yourself?

Where ya been Dawg?

Did you see Anderson Silva get his ass beat? He got lucky with that one.....

 

[RussianJoo]

You gave anesthesia to yourself?

come on, we all know it's against TOS to ask medical questions or advice about yourself on SDN.

 

[epidural man]

for prone sedation (or any sedation really) propamine, or ketofol (however you like to call it) is great.

I have done an unblocked arm (he was block distally) with a tourniquet with propamine - and I would think a tourniquet would hurt! It worked well. There is something magical about that drug combination.

Anyone remember that plastic surgeon anesthesiologist that a few years back - on this forum - claimed he invented that technique? HAHAHA!

 

[sevoflurane]

ketafol + magnesium even better.

http://bja.oxfordjournals.org/content/96/2/247.full

http://www.anesthesia-analgesia.org/content/92/5/1182.full

 

[amyl]

for these cases, we do a propofol alfentanil infusion -- general w/o the tube. titrate to respiratory rate. in a healthy normal person prone it goes well.

 

[Arch Guillotti]

cool thanks guys.. yeah what we did was 1mg of versed in the holding area, another before the case, some propofol while the surgeon was injecting the local and that was it.. went very smootly the pt. didn't move, didn't complain. The pt's main reason for lack of sedation was that he didn't have anyone to give him a ride home after and he didn't want to stay too long in the PACU...

I am very surprised the patient was allowed to drive home after 2 mg of versed. I realize that this may be a trivial amount but every PACU set of d/c orders I have ever seen clearly states that the pt. should not drive, make important decisions, etc for 24 hours no matter how minor or trivial the sedation.

 

[lobelsteve]

I ha a patient who refused conscious sedation in an ASC for a pedicle screw removal out of C4. Did it under local. She insisted on a meditation CD play on the OR stereo. She was a rock star, I was cringing with each turn of the screw.

 

[Licoricestick]

Often the real issue with these sorts of cases is that the surgeons fail to appreciate that the presence of pain in the patient (excluding pain during administration of LA) indicates indequate local anaesthesia not failure of sedation.

Although I would also have advised the unnamed resident that he (or she) shouldn't drive home after sedation....

Prone is, however, a very good way of maintaining the airway - try it next time you have a friend who gets stupidly drunk (whilst you are not of course...hard to remember how well it worked otherwise).

 

[jwk]

I am very surprised the patient was allowed to drive home after 2 mg of versed. I realize that this may be a trivial amount but every PACU set of d/c orders I have ever seen clearly states that the pt. should not drive, make important decisions, etc for 24 hours no matter how minor or trivial the sedation.

Ditto - no documented ride home, no sedation.

 

[sigrhoillusion]

Dragging up a really is thread but... holy s**t... no way would someone be allowed to get any sedation on an outpatient procedure that didn't have a ride home.

This is like an insta-lawsuit if anything happens. we've had several patients come in without rides for small procedures, and the answer is either "sorry!" or "better find one". Don't care if the patient is a professional college student who pounds beers as a hobby. If they get 2mg Versed, go to Pacu, sing the alphabet backwards, but then get in a car accident on the way home (regardless of whose fault) guess who's getting blamed?

Anyone have any different opinions after 6 years?

 

[lobelsteve]

I have since removed an X-stop from L4-5 in the office under local. Patient selection is everything.

 

[sigrhoillusion]

I have since removed an X-stop from L4-5 in the office under local. Patient selection is everything.

Most invasive thing I've been a part of was a lower extremity neuroma excision under local cause the girl found out she was pregnant in pre-op. Lots of local, hand holding and I think some Enya in the background...

 

[deleted59964]

... Lots of local, hand holding and I think some Enya in the background...

enya ... that's cheating, might as well use sevo

 

[GhostTree]

Did a closed nasal fracture reduction with just local/afrin pledgets and local injected. Probably the worst part was the injection of local. But for me, the popping of bones with the butter knife made my teeth grate.

 

[Timeoutofmind]

I have since removed an X-stop from L4-5 in the office under local. Patient selection is everything.

Aren't u a pain doc? How r u removing xstops and pedicle screws? Can u even get credentialed for that stuff? Are surgeons cool with u touching their hardware? Why are you doing these cases with local no sedation?
I'm intrigued?!?!!

 

[lobelsteve]

Aren't u a pain doc?
Yes.

How r u removing xstops and pedicle screws?

Used needle drivers on the screw. 2.5mm hex head for x stop. Kelly, Kocher, 11 blade, battery cautery.

Can u even get credentialed for that stuff?

Yes in ASC.

Are surgeons cool with u touching their hardware?

Surgeon saw and declined in both cases, ssying hardware was loose, but not causing the problem.

Why are you doing these cases with local no sedation?

Because sedation was not wanted by the patient and LA really works. I have had crowns, root canals, wisdom tooth extractions done under local. The stuff works.


I'm intrigued?!?!!

I'm glad.

 

[propadope]

Most invasive thing I've been a part of was a lower extremity neuroma excision under local cause the girl found out she was pregnant in pre-op. Lots of local, hand holding and I think some Enya in the background...

Any nausea and vomiting from the Enya?

 

[deleted162650]

Any nausea and vomiting from the Enya?

The pt did OK but everyone else in the room was smart and took some prophylactic aprepitant

 

[pgg]

The pt did OK but everyone else in the room was smart and took some prophylactic aprepitant

Haldol would have been better.

 

[propadope]

The pt did OK but everyone else in the room was smart and took some prophylactic aprepitant

I have seen intractable N&V from Enya. Not pretty. The vomit flowed like the Orinoco

 

[deleted162650]

I have seen intractable N&V from Enya. Not pretty. The vomit flowed like the Orinoco

Who wants chowder!!

 

[Timeoutofmind]

Error

 

[Timeoutofmind]

Gutsy bro!

How did u know hardware was loose? Flex/ex films?

What if taking this stuff out destabilized the spine? Did u at least get the ok from the surgeon to remove it?

Also, did these interventions help the patients, was their pain reduced afterwards?

Thanks in advance.

 

[lobelsteve]

Gutsy bro!

How did u know hardware was loose? Flex/ex films?

Yes. C4 screw was posterior and halfway out. pain in neck over screw. Hardware block with 100 percent relief.

What if taking this stuff out destabilized the spine? Did u at least get the ok from the surgeon to remove it?

I asked surgeon to remove and he declined. he said nothing was wrong.
Also, did these interventions help the patients, was their pain reduced afterwards?

Pain better after hardware removal in both.


Thanks in advance.

 

[sigrhoillusion]

So patient had pain in neck where screw was. Screw was shown to be in improper position per imaging. Yet surgeon didn't think it was the issue...? That seems like a PCP who gives penicillin to treat pain from a football to the nuts...

 

[deleted162650]

So patient had pain in neck where screw was. Screw was shown to be in improper position per imaging. Yet surgeon didn't think it was the issue...? That seems like a PCP who gives penicillin to treat pain from a football to the nuts...

That's stupid. Everyone knows quinolones are the drug of choice for treating football related nut injuries.

 

[sigrhoillusion]

That's stupid. Everyone knows quinolones are the drug of choice for treating football related nut injuries.

Viagra single packs.

 

[Onefellswoop87]

Viagra single packs.

If he took that prior to the injury, might have deflected the football. Prevention > treatment