ACLS----circulation, a/w, breathing

[PinchandBurn]

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Given the new ACLS guidelines how are you running codes in the OR.

If one was a 'lay person', I get it, the new paradign is do Compressions, (defib ASAP), then secure away and do breathing,etc.

Now...let's suppose you are in the OR as an anesthesiologist. Assume for whatever reason the patient is not intubated (maybe you are doing a MAC case or a regional). You see the patient is non responsive, pulseless, and there's VFIB or VTACH or some other dysrhthmia.

1) Are you going to do resuscitative interventions for Circulation first--ie chest compressions/CPR, give epi, fluids, etc.

2) Will you secure the a/w first?

I think most of us would be doing a lot of this simultaneously, unquestionably. However, for medical-legal reasons would you attend to the circulation issues first as that is what the new ACLS guidelines state. I ask this, because very recently we had a discussion and some attendings stated that if we do not address circulation first in 2012, then we are breeching the 'standard of care' in terms of ACLS. This applies not only for lay people but also intraoperatively.

They alluded to the fact that nowadays, during codes, people are documenting the timing of everything. So if an adverse event were to occur and defendent's attorney noticed that someone spent 2-3 min or whatever, trying to intubate/LMA the patient before doing compressions and/or administering IV meds, there would be some increased exposure.


This sort of goes against the traditional, "airway" comes first thinking. Thoughts??

 

[cchoukal]

If it were truly a VFib or PEA arrest, I would absolutely prioritize chest compressions and defib above airway, particularly if you have an adequate mask airway. This would also be true even if I suspected the PEA were caused by hypoxemia/hypercapnia. Your primary goal during the arrest is maintenance of cerebral perfusion and even in a hypercapnic/hypoxemic PEA, establishing adequate oxygenation and ventilation in the absense of a beating heart (or you beating on its behalf) will yield poor results. But as you intuite, these interventions would likely occur simultaneuosly. The exception to this would be if I had an inadequate mask airway or the patient was bleeding into the airway or vomiting. As a resident, ICU fellow, and intensivist, I've attended a lot of arrests, and I generally try to mask and intubate without interrupting CPR; this is often easier than you'd think.

The de-emphasis on "advanced" airway management has been occurring gradually for years, and I agree with this.

Next thing you know, they'll be suggesting we give vasodilators during the arrest. Oh wait, it's all the rage...

http://www.ncbi.nlm.nih.gov/pubmed?term=nitroprusside cardiac arrest

 

[Bertelman]

Given the new ACLS guidelines how are you running codes in the OR.

If one was a 'lay person', I get it, the new paradign is do Compressions, (defib ASAP), then secure away and do breathing,etc.

Now...let's suppose you are in the OR as an anesthesiologist. Assume for whatever reason the patient is not intubated (maybe you are doing a MAC case or a regional). You see the patient is non responsive, pulseless, and there's VFIB or VTACH or some other dysrhthmia.

1) Are you going to do resuscitative interventions for Circulation first--ie chest compressions/CPR, give epi, fluids, etc.

2) Will you secure the a/w first?

I think most of us would be doing a lot of this simultaneously, unquestionably. However, for medical-legal reasons would you attend to the circulation issues first as that is what the new ACLS guidelines state. I ask this, because very recently we had a discussion and some attendings stated that if we do not address circulation first in 2012, then we are breeching the 'standard of care' in terms of ACLS. This applies not only for lay people but also intraoperatively.

They alluded to the fact that nowadays, during codes, people are documenting the timing of everything. So if an adverse event were to occur and defendent's attorney noticed that someone spent 2-3 min or whatever, trying to intubate/LMA the patient before doing compressions and/or administering IV meds, there would be some increased exposure.


This sort of goes against the traditional, "airway" comes first thinking. Thoughts??

ACLS is not "standard of care". Practically every guideline I have ever read maintains the physician's clinical judgment as worthy of superseding some prescribed sequence of events written by a committee of old people at a weekend meeting.

Besides, I've been in codes, and I've seen code documentation. Even on the floor or ED where there are like 20 people, documentation is shoddy. At the end of it all, someone is always confirming with someone else how many rounds of epi, etc. Documentation in an OR code is almost nonexistent, or all done post-hoc. The circulator is typically grabbing the defibrillator, and if you happen to have extra anesthesia personnel for assistance in the room, the patient has already bought a tube. 5 providers don't tend to gather to help out on a MAC case.

Bottom line, in an OR your differential for why someone has just coded is typically much narrower than finding someone unresponsive in the street, unless you happened to follow them from the cath lab to McDonald's. If you have any indication that an airway is more essential to resuscitating this patient than compressions, then by god stick a tube in him. Likewise, whether you are following the current or former ACLS protocol, if you've wasted 3 minutes establishing an airway while the patient is asystolic, YOU FAIL.

 

[PMPMD]

I would instruct the surgeon to begin compressions immediately. Then I would push the first round of epi (assuming PEA/asystole) and intubate if not already done.

My take home of the emphasis on C-A-B vs A-B-C is that you don't delay or interrupt compressions to secure an airway. The codes we run in the OR, which are witnessed, with monitors already placed, and attended immediately by multiple BLS and ACLS-trained personnel, are nothing like floor codes. As Bert mentioned, the differentials are also different. See Anesthesiology-Centric ACLS for a great description of how anesthesia codes differ.

 

[Idiopathic]

i feel like most of the codes i go to are primarily due to hypoxemic/hypercarbic respiratory failure, so I usually intubate while someone else does CPR, and I will have them pause if i need three seconds to get a tube in

 

[E Tom Idate]

The only way to fix vfib is electricity so light him up. Plus ACLS protocol says that defib is priority for witnessed arrest.

 

[pgg]

ACLS was built around
1) the unwitnessed arrest in the field
2) non-doctors who need specific protocols and checklists to follow
All the data backing up the algorithms is in a patient population and cicumstances very different from what happens in the OR

ACLS is a good starting place, and something you can do with a sense of purpose if you honestly don't know WTF just happened - but most of the time in the OR you're going to have a short list of pretty good ideas why the patient coded. In those cases, the ACLS guidelines are truly just guidelines.

Eg, an unwitnessed PEA arrest in ward room 234 during breakfast is very different than PEA in OR 3 after the new intern just made unsuccessful pass #6 on his subclavian line attempt, and my adherence to ACLS would be a lot less rigid ...

In your example (vfib / pulseless VT) I'd still go for compressions and shocks first but likely someone else is doing CPR and fetching the defibrillator while I'm intubating.

 

[Lee123]

If you read the references cited, pay attention to the fact that while not interrupting compressions to attempt to establish an airway (I believe they are assuming an anesthesiologist is not at the head of the bed) has a better chance of restoring circulation; however, neurological outcomes were poor if an airway is not established within 6-10 minutes. I don't remember the exact time, but the point I got is at some point you need to intubate if the patient is not breathing. Air exchange from compressions is not sufficient for the brain to survive; however, you will have a donor because the heart will be pumping blood.

 

[rsgillmd]

Given the new ACLS guidelines how are you running codes in the OR.

If one was a 'lay person', I get it, the new paradign is do Compressions, (defib ASAP), then secure away and do breathing,etc.

Now...let's suppose you are in the OR as an anesthesiologist. Assume for whatever reason the patient is not intubated (maybe you are doing a MAC case or a regional). You see the patient is non responsive, pulseless, and there's VFIB or VTACH or some other dysrhthmia.

1) Are you going to do resuscitative interventions for Circulation first--ie chest compressions/CPR, give epi, fluids, etc.

2) Will you secure the a/w first?

I think most of us would be doing a lot of this simultaneously, unquestionably. However, for medical-legal reasons would you attend to the circulation issues first as that is what the new ACLS guidelines state. I ask this, because very recently we had a discussion and some attendings stated that if we do not address circulation first in 2012, then we are breeching the 'standard of care' in terms of ACLS. This applies not only for lay people but also intraoperatively.

They alluded to the fact that nowadays, during codes, people are documenting the timing of everything. So if an adverse event were to occur and defendent's attorney noticed that someone spent 2-3 min or whatever, trying to intubate/LMA the patient before doing compressions and/or administering IV meds, there would be some increased exposure.


This sort of goes against the traditional, "airway" comes first thinking. Thoughts??

PInchandBurn, I'm assuming you are a fellow anesthesiologist. You have already answered your own question -- things will occur simultaneously. Barring the rare difficult airway, any of us can secure the airway much faster and reliably than your typical non-anesthesia provider.

So I'd probably say something loudly along the lines of: "The patient is in cardiac arrest. Dr. Surgeon begin chest compressions. Nurse Circulator call for help and grab the code cart.

We have premixed Epi (among other things) in my current institution in the anesthesia carts. So while I'm saying this out loud, I'll be simultaneously grabbing the Epi (assuming Vfib for this case for unknown reason) and injecting it.

Like you probably are as well, I am always ready for general anesthesia. So I will grab my laryngoscope and tube and intubate the patient rapidly. By then help should be starting to arrive to help with additional line placement (if necessary), ventilation, running differentials, etc. All of the above can be done before someone even has a chance to start recording times. If you go 2-3 minutes without at least successfully ventilating the patient, something is seriously wrong.

As others have said, ACLS is guidelines only, not "standard of care." Think of it from a more common perspective. Your're preparing to come off bypass after a CABG. As the heart starts to warm, it goes into Vifb. The surgeon isn't necessarily attempting defibrillation right away. You certainly aren't pushing 1 mg of Epi. But from the strict viewpoint of ACLS, it's a VFib arrest. It is just a set of guidelines that we apply to our own situation. As others have said, they were designed for unwitnessed out of hospital arrests.

ACLS can be summed up as: Find the underlying cause and treat it. While you are trying to do that, here are some suggestions on what you can do if you see......

Regarding paperwork, I follow the simple and obvious advice of one of my attendings from residency: Take care of the patient, and the paperwork will take care of itself. Paperwork can always be filled in retrospectively if needed.

 

[PinchandBurn]

PInchandBurn, I'm assuming you are a fellow anesthesiologist. You have already answered your own question -- things will occur simultaneously. Barring the rare difficult airway, any of us can secure the airway much faster and reliably than your typical non-anesthesia provider.

So I'd probably say something loudly along the lines of: "The patient is in cardiac arrest. Dr. Surgeon begin chest compressions. Nurse Circulator call for help and grab the code cart.

We have premixed Epi (among other things) in my current institution in the anesthesia carts. So while I'm saying this out loud, I'll be simultaneously grabbing the Epi (assuming Vfib for this case for unknown reason) and injecting it.

Like you probably are as well, I am always ready for general anesthesia. So I will grab my laryngoscope and tube and intubate the patient rapidly. By then help should be starting to arrive to help with additional line placement (if necessary), ventilation, running differentials, etc. All of the above can be done before someone even has a chance to start recording times. If you go 2-3 minutes without at least successfully ventilating the patient, something is seriously wrong.

As others have said, ACLS is guidelines only, not "standard of care." Think of it from a more common perspective. Your're preparing to come off bypass after a CABG. As the heart starts to warm, it goes into Vifb. The surgeon isn't necessarily attempting defibrillation right away. You certainly aren't pushing 1 mg of Epi. But from the strict viewpoint of ACLS, it's a VFib arrest. It is just a set of guidelines that we apply to our own situation. As others have said, they were designed for unwitnessed out of hospital arrests.

ACLS can be summed up as: Find the underlying cause and treat it. While you are trying to do that, here are some suggestions on what you can do if you see......

Regarding paperwork, I follow the simple and obvious advice of one of my attendings from residency: Take care of the patient, and the paperwork will take care of itself. Paperwork can always be filled in retrospectively if needed.

RGS-

thanks. If I recall, you practice in Canda correct? I totally understand that we are always doing these things concurrently. NO question.

However, the discussion I got into was with other aneshteiologists and talking about 'risk exposure'. Sure we can say these are 'guidelines', but in the event of an adverse event, attorneys alwys grab ahold of these 'guidelines' and warp them into 'standard of care'.

So it's only in that context I was concerned about C-A-B versus A-B-C.

I hate to state it, but in this day and age we have to be cognizant of this sort of thing. Look at the other thread on here where family members are trying to 'sue docs' in new ways. It's ridiculous.

 

[Bertelman]

However, the discussion I got into was with other aneshteiologists and talking about 'risk exposure'. Sure we can say these are 'guidelines', but in the event of an adverse event, attorneys alwys grab ahold of these 'guidelines' and warp them into 'standard of care'.

So it's only in that context I was concerned about C-A-B versus A-B-C.

That's when you explain to the jury why it was, exactly, you chose to conduct your code in such a manner. And you rely on a quality defense lawyer to poke holes in that line of attack.

For my money, I will ultimately do what I think is the best care for my patient, and expect a good outcome which means I won't get sued. A patient can sue you for whatever they want, if you follow guidelines or not. I won't choose to follow a guideline I don't believe just to stave off a lawsuit which may be inevitable anyway.

If a lawyer is able to distort the application of a clinical guideline used out of context, they are able to distort practically any other truth. You aren't safe from that kind of lawyer in any circumstance.

 

[periopdoc]

It really becomes a question of documentation. I usually carefully document the first five or so minutes of the code with time annotations. With no disrespect, this is one area where I disagree with the concept of completely "letting the charting take care of itself" or "retrospective charting." It takes no time at all to jot down a time and a quick notation of the intervention. Things don't happen that fast in the code. By the time 5 minutes is up, I have specifically assigned a scribe and I call out times of interventions for them.

I typically would write something like this in real-time

1010 - V-fib, CPR
- Epi
1011 - ETT
1012 - 300j

etc. until my scribe takes over

I would then go back and write the retrospective note.

During sedation for carpal tunnel release, V-fib was noted on the monitor and the patient was found to be pulseless. I instructed the nursing staff to obtain and attach the defibrillator and asked surgeon Y to initiate compressions. I administered 1 mg of epi and proceeded to secure the airway. Upon arrival of the defibrillator, the pads were attached and the patient was successfully defibrillated with a single shock at 300 joules...

You get the idea.

If you stick to quick facts in your real-time documentation, you can paint the scenario in your retrospective note in a manner that reflects reality. your liability concerns, and any judgement you made to deviate from the protocol.

In my example above, without explicitly explaining, I explained why we did not defibrillate first. It is obvious that the defib had to be retrieved and placed on the patient so we jumped ahead in the protocol. If I took the time to explain explicitly why we deviated, that might pique the interest of the defense lawyer/ jury. As it is, the answer to the question of why we deviated is there if someone wants to go looking for it, but it isn't a blatant "hey look at me we deviated from the protocol."

Hope that helps.

-pod

 

[rsgillmd]

RGS-

thanks. If I recall, you practice in Canda correct? I totally understand that we are always doing these things concurrently. NO question.

However, the discussion I got into was with other aneshteiologists and talking about 'risk exposure'. Sure we can say these are 'guidelines', but in the event of an adverse event, attorneys alwys grab ahold of these 'guidelines' and warp them into 'standard of care'.

So it's only in that context I was concerned about C-A-B versus A-B-C.

I hate to state it, but in this day and age we have to be cognizant of this sort of thing. Look at the other thread on here where family members are trying to 'sue docs' in new ways. It's ridiculous.

No. I practice in the U.S.A.

 

[rsgillmd]

It really becomes a question of documentation. I usually carefully document the first five or so minutes of the code with time annotations. With no disrespect, this is one area where I disagree with the concept of completely "letting the charting take care of itself" or "retrospective charting." It takes no time at all to jot down a time and a quick notation of the intervention. Things don't happen that fast in the code. By the time 5 minutes is up, I have specifically assigned a scribe and I call out times of interventions for them.

I typically would write something like this in real-time

1010 - V-fib, CPR
- Epi
1011 - ETT
1012 - 300j

etc. until my scribe takes over

I would then go back and write the retrospective note.

During sedation for carpal tunnel release, V-fib was noted on the monitor and the patient was found to be pulseless. I instructed the nursing staff to obtain and attach the defibrillator and asked surgeon Y to initiate compressions. I administered 1 mg of epi and proceeded to secure the airway. Upon arrival of the defibrillator, the pads were attached and the patient was successfully defibrillated with a single shock at 300 joules...

You get the idea.

If you stick to quick facts in your real-time documentation, you can paint the scenario in your retrospective note in a manner that reflects reality. your liability concerns, and any judgement you made to deviate from the protocol.

In my example above, without explicitly explaining, I explained why we did not defibrillate first. It is obvious that the defib had to be retrieved and placed on the patient so we jumped ahead in the protocol. If I took the time to explain explicitly why we deviated, that might pique the interest of the defense lawyer/ jury. As it is, the answer to the question of why we deviated is there if someone wants to go looking for it, but it isn't a blatant "hey look at me we deviated from the protocol."

Hope that helps.

-pod

No disrespect taken, and I agree with you. I am meticulous about my documentation. When things are stable, I keep up with it as much as possible. But I know I can always pull up vitals and chart them in retrospect if necessary. When we go to electronic charting, hopefully things will get easier.

I was painting the scenario where I was by myself, because the original poster seemed to be asking about a specific order in which I would do things. Things really happen simultaneously when you have multiple people. I remember being assigned the role of scribe several times when I was the most junior member of the team of people in a critical situation.

I was trying to say, I'll know from my monitor what time the code occurred. I know my sequence of events and how long it took to do them. This is easy to keep in mind until a scribe arrives and I can tell him/her, or my hands are free to write it myself. So my documentation would be the same as yours.

 

[rsgillmd]

That's when you explain to the jury why it was, exactly, you chose to conduct your code in such a manner. And you rely on a quality defense lawyer to poke holes in that line of attack.

For my money, I will ultimately do what I think is the best care for my patient, and expect a good outcome which means I won't get sued. A patient can sue you for whatever they want, if you follow guidelines or not. I won't choose to follow a guideline I don't believe just to stave off a lawsuit which may be inevitable anyway.

If a lawyer is able to distort the application of a clinical guideline used out of context, they are able to distort practically any other truth. You aren't safe from that kind of lawyer in any circumstance.

I agree. By the time things get to court, you are in a whole different world. Take care of the patient, and let your documentation reflect it.

 

[Narcotized]

So if an adverse event were to occur and defendent's attorney noticed that someone spent 2-3 min or whatever, trying to intubate/LMA the patient before doing compressions and/or administering IV meds, there would be some increased exposure.

Spending 2-3 minutes intubating/LMA never took priority over initiating compressions and meds, new or old guidelines.