Anesthesia Question for you guys/gals

[Noyac]

You do a case under GETA. The pt is slow to wake up. Lets say she had a TAH/BSO with a history of HTN, OSA, obesity and DM typeII. You manage to extubate her and get her to the PACU safely. She never really needs any pain meds. She got 250 fent and 5mg MS for the case (nothing spectacular). The floor calls you 4 hrs later and says she is really drowsy and difficult to arouse. What next? Whats on your mind?

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[militarymd]

for the attendings....or for the trainees?

 

[VolatileAgent]

hypercapnia. pseudocholinesterase deficiency. exquisite sensitivity to narcs. cva. undiagnosed cardiac event.

why is it always anesthesia's fault?

 

[zippy2u]

Hypoglycemia ---Zip

 

[VolatileAgent]

hyperglycemia.

 

[militarymd]

OSA

PPOCD

HHNC

Inadequate NMB reversal.

 

[cubs3canes]

OSA

PPOCD

HHNC

Inadequate NMB reversal.

Not to be really dumb, but I only understand the last acronym. Please help all of you lords of gas.

 

[aredoubleyou]

Not to be really dumb, but I only undetstand the last acronym. Please help all of you lords of gas.

Lemme take a guess

obstructive sleep apnea
prolonged postop cognitive dysfunction
hyperosmolar hyperglycemic non-ketoacidotic coma

 

[Noyac]

As you already know, Mil, I like to give the trainees a chance first.
I think they have had enough time by now, though.

The differencials are good but what I was trying to get at was, what is your stepwise approach?

1) pseudocholinesterase def and inadequate NMB reversal would be very unlikely since the pt has been on the floor for 4 hrs and is not coding or desat'ing.

Its really late so I will cont. later.

 

[Idiopathic]

Narcan/Romazicon, vitals, quick neuro check, accu-check.

How about this...chronic OSA px, given high FiO2, decreased respiratory drive -> decreased effort. She's probably reliant on a hypoxic drive mechanism if her OSA is bad enough.

I like it.

 

[jwk]

Without knowing the respiratory rate...

Too much narcs - slow to arouse at the end of the case, and nurses giving too much on the floor (or the family pushes the button on the PCA every time the patient moans).

Narcan.

 

[dogbone65]

4 hours post-op; obese female that is lethargic/obtunded. She is having re-distribution of the fent from all that fat and needs narcan.

 

[Noyac]

Think you guys are on to it. I don't know exactly what the cause is but here is the scenario. I did a TAH/BSO on an obese female under GETA ( she refused spinal ) with Des, Fent 250mcg, MS 4mg, and some anti emetics (reglan, kyril). She woke up slowly (all fent was up front) with poor tidal volumes. i watched her in the OR for about 5 minutes and took her to PACU. Sats were 91% pre-op awake and they were 92-95% on FM 5LPM. She went to the floor 1 hr later and 4 hrs later the floor nurse says she still isn't waking uop much. I am thinking she is getting narcs for pain but she has had nothing since the PACu were she got 4 mg MS. I check her pupils which are not pinpoint, she arouses when I speak to her but is very lethargic. No real pain to speak of. I was going to give small doses of narcan but after seeing her i didn't think that narcs was the culprit.

I left the room a little confused but I put her on a pulse ox and otherwise did nothing. i told the nurse to kep a close eye on her (now thats good doctorin for you ). I am thinking OSA is the culprit. You guys are right also about checking Na level, CBG, CO2 etc. I was not impressed however with her symptoms. I thought this was an unusual case that could be discussed.

 

[Idiopathic]

If this is someone who is chronically hypoxemic (~90% on RA) I think that its very likely that she has developed the dreaded "hypoxic drive" and any big O2 supplement such as would happen during and after a GETA will suppress that. It would be interesting to see her tidal volumes and RR, etc, I bet all are diminished, but probably not due to narcs.

 

[VolatileAgent]

did you get a blood gas? if so, what was it?

 

[militarymd]

If this is someone who is chronically hypoxemic (~90% on RA) I think that its very likely that she has developed the dreaded "hypoxic drive" and any big O2 supplement such as would happen during and after a GETA will suppress that. It would be interesting to see her tidal volumes and RR, etc, I bet all are diminished, but probably not due to narcs.

I hope they're still not teaching that "hypoxic drive" dribble.

ATS guidlines on treatment of COPD....read it.

 

[Idiopathic]

I hope they're still not teaching that "hypoxic drive" dribble.

ATS guidlines on treatment of COPD....read it.

Well, the big pretty physiology text I used teaches it.

So the ATS guidelines are pretty straightforward but dont help us much on this case. No acute distress, no wheezing, just lethargy/poor inspiratory effort, right? This doesnt sound like a woman who needs acute bronchodilators. Sound like an AECOPD to you? Sounds more like decreased drive, either d/t narcs, CVA/central apnea, NMB problem or (yes, i said it) loss of hypoxic drive.

Disclaimer: only an intern-to-be, but not afraid to offer an opinion.

 

[militarymd]

Well, the big pretty physiology text I used teaches it.

So the ATS guidelines are pretty straightforward but dont help us much on this case. No acute distress, no wheezing, just lethargy/poor inspiratory effort, right? This doesnt sound like a woman who needs acute bronchodilators. Sound like an AECOPD to you? Sounds more like decreased drive, either d/t narcs, CVA/central apnea, NMB problem or (yes, i said it) loss of hypoxic drive.

Disclaimer: only an intern-to-be, but not afraid to offer an opinion.

Absolute dribble.

That term came out of COPD patients who when given Oxygen responds with increased CO2.....absolutely not applicable in this scenario.....not only does it not apply......LOSS OF HYPOXIC DRIVE is simple wrong.......has been disproven....and published....reference is in the ATS guidleines..

If I were still an academic attending, I would spend the time to find that reference.

 

[jetproppilot]

You do a case under GETA. The pt is slow to wake up. Lets say she had a TAH/BSO with a history of HTN, OSA, obesity and DM typeII. You manage to extubate her and get her to the PACU safely. She never really needs any pain meds. She got 250 fent and 5mg MS for the case (nothing spectacular). The floor calls you 4 hrs later and says she is really drowsy and difficult to arouse. What next? Whats on your mind?

OSA is the likely culprit.

If their CO2 is too high post-op they'll downward spiral.

OSA pt too sleepy in the PACU?

CPAP'em 'til they awaken more.

 

[UTSouthwestern]

Reglan side effect (drowsiness, lassitude, fatigue, confusion, decreased mentation, etc.). Seen it before twice.

 

[Noyac]

Reglan side effect (drowsiness, lassitude, fatigue, confusion, decreased mentation, etc.). Seen it before twice.

Totally agree. It was on my diff dx when I saw her. So what do you do about it? I did nothing b/c I didn't fell like she was in jeopardy.

Jet, I like hte CPAP idea. I didn't think to do that..

 

[militarymd]

medical therapy includes:

dopram
caffeine
progesterone

 

[UTSouthwestern]

medical therapy includes:

dopram
caffeine
progesterone

Caffeine. Cheapest and easiest solution.

 

[Noyac]

How much caffiene? 50 mg IV?

 

[UTSouthwestern]

How much caffiene? 50 mg IV?

2-10 mg/kg depending on age, risk factors, etc.

 

[meddog1]

Without knowing the respiratory rate...

Too much narcs - slow to arouse at the end of the case, and nurses giving too much on the floor (or the family pushes the button on the PCA every time the patient moans).

Narcan.

I have seen this scenario too many times!