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anything wrong with this case scenario?

Discussion in 'Anesthesiology' started by CremeSickle, May 8, 2007.

  1. This came up at M&M recently.....

    66 y/o male in to have an Ex Lap done. Pt has been NPO X 2 days yet has been N/V for the last 12-24 hours.

    Hx: GERD, CVA, intractable abd pain.

    Plan by junior resident:

    RSI with lido, prop, fent, suxx
    GA sevo & Nitrous
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  3. jetproppilot

    jetproppilot Turboprop Driver 10+ Year Member

    Mar 12, 2005
    level at FL210

    Good plan.

    Upper-motor-neuron injury not a problem for the sux part.

    Academic dudes will argue-til-they-have-to-shave-again about the nitrous, bowel distention, blah blah blah.

    If thats an issue, then its not the issue.

    Its the surgeon taking too long thats the issue.

    An ELAP where N20 becomes an issue means the surgeon needs to go into psychiatry.
  4. zippy2u

    zippy2u Senior Member 5+ Year Member

    Feb 19, 2005
    Use Zem rather than the sux. Ya goin' to use a NDMR after the sux anyway, why not use 1 agent rather than 2--- the bean counters will appreciate it. Regards, ---Zip
  5. rmh149

    rmh149 2+ Year Member

    Apr 9, 2007
    Medications currently taking?
    Labs (chem, cbc, coags), anything impressive?
    Any details on the CVA? Any prolonged immobilization? Is there a possibility that the patient is susceptable to succinylcholine-induced hyperkalemia?
  6. Well you guys pegged the arguments right off.

    The attending told the CA1 that he was an "idiot" for wanting to give the suxx to a pt with an upper motor neuron injury. He even pulled out the packet insert which actually says that. The bad thing was the CA1 didnt know CVA was an upper motor neuron injury.

    In anycase, I did a full lit search and cant find any cases where a CVA causes a hyperkalemia issue. Not one. Yet, on the suxx packet insert it does mention upper motor neuron injury. I dont get it?

    I guess i can see if the pt had full paralysis on one side and ended with some muscle wasting etc, but even then, why isnt it mentioned more in the literature? Does this really matter? Ive done a couple of RSIs with pts who had old CVAs and used suxx everytime. Was this wrong?? Or is this all about a medico-legal scare related to what it says on the packet insert?

    The Nitrous is another biggie. The attending asked the CA1 why use nitrous. As most know, nitrous has proven to make no difference in "blowing up the bowel" unless used for HOURS AND HOURS. It really isnt the issue some people (and books) make you believe it is. However, the attending near hit the ceiling when he came back and the flows were running 1/1 o2/nitrous.

    What do you think? Is this just baseless concern or am i missing something?

    rmh: i see what yer saying about Zem but to me that isnt a true RSI (personal preference i know). Suxx does it faster (< 60 seconds) while rocc is 60-90 at best even at > 1mg/kg doses. And then i use Vecc. I think the suxx and vecc combined is much cheaper than the rocc isnt it?

    The labs wernt mentioned at all so i assume they were normal and no other reason to believe that the pt was at risk for suxx related hyperK. AFAIK he has mild weakness on right side from the CVA which happened a year prior.
  7. militarymd

    militarymd SDN Angel 10+ Year Member

    Dec 17, 2003
    Sounds like a pretty funny attending.

    Those are THEORETICAL concerns....which may an issue in a very minor percentage of cases....

    Sux ALMOST always OK....except for the case reports.

    Nitrous ALMOST always OK (although I see no use for it anymore with ready availability of sevo/des)....except for the case reports.
  8. zippy2u

    zippy2u Senior Member 5+ Year Member

    Feb 19, 2005
    Creme, I rarely use sux because of the potential problems associated with it. You want to minimize potential problems. CVA and sux is a potential problem. Extensive abdominal disorder and sux is a potential HA. You're prolly at an academic institution where nothing gets done quickly. The guy prolly has a NGT in and if not slip one in prior to induction and hook it to continuous suction. You want cheap, I'll give ya cheap. Bang in 1mg of vec, 2cc of fent, Stick o' STP and the other 9mgs. of vec in that order. You'll be able to intubate in less than 60 secs. Throw him on forane and call it a day. Keep him with 1/4 twitches and intermittent suction via NGT and nitrous shouldn't be a problem. I mentioned using zem 'cause I'm inherently a lazy a$$ from the 90s and "don't want to get a blister on my finger" mixing powdered vec. Make sure ya tell the surgery resident(in a way so the attending surgeon doesn't hear) that he better stay in the academic world because he's too slow for the private sector. Regards, ----Zip
  9. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 2, 2006
    The South

    This attending is obviously not fit to be a teacher, but there are many of them out there.

    First: It really doesn't matter if it's upper or lower neuron when you are talking about the hypothetical risk of hyperkalemia with sux, If there is muscle disuse of ANY ETIOLOGY for a prolonged period of time, then (theoritically) there could be muscle atrophy --> proliferation of ACH receptors --> possible hyperkalemia.
    That's it, it's simple.

    Second: You said that the CA1 did not know that a CVA was an upper neuron injury, I find this hard to believe, because we are talking about someone who finished medical school and did 1 year of internship, there must be a mistake here.
  10. Hey Plank.

    Well exactly. I dont want to say the attending is a bad teacher, honestly, he has been great to me. I think he is teaching academic anesthesiology as opposed to clinical anesthesiology in this case. The kicker is that he showed evidence (in the M&M after we all got the nitrous and suxx question wrong) that both were unacceptable in this situation. I would think that on boards his answers would be correct right?

    One of the other residents brought up the studies about nitrous and how low the risk was and the attending simply said "how long is the operation going to be?" well, noone can say 100% and the argument promptly ended.

    I brought up my inability to find any real evidence about suxx/CVA/HyperK issues and he asked if this could happen. I said yes, and then he asked what the insert said.. again the argument ended.

    Seems to me even tho clinically, it dosent matter he was right.

    Would you all agree?

    Well I think this poor fellow was just nervous after getting called an idiot in front of everyone in the OR. Im sure he knew, but was in shell shock.
  11. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 2, 2006
    The South
    Here is what I do in real life:

    1- If you had a CVA and have residual weakness of any kind you are not getting sux.
    2- If there is any notion of bowel obstruction no Nitrous.

    I do this because I practice in Florida and we have lawyers at every corner.

    I know that Jet and many others would disagree with my lawyer avoiding logic but that's ok :)

    On the other hand, for an attending to call a resident IDIOT in the OR for any reason, is unacceptable, and very unprofessional. it only shows that this guy has a small d ck syndrome.
  12. VentdependenT

    VentdependenT You didnt build thaT Physician Moderator Emeritus 10+ Year Member

    Oct 3, 2003
    I'd use Rocuronium for the RSI. Sux in someone with sepsis or severe abdominal infection is at a higher risk for hyperkalemia.

    Agree with the CVA and sux I suppose.

    Screw the nitrous arguement. You can use that stuff if you want. YES EVEN FOR LAPROSCOPIC CASES. As long as there is a pressure regulator, which all those little machines have to keep the insufflation pressure constant, then there is no problem.

    If I'm using nitrous, which we use a lot of downtown then I run it one to one.
  13. thanks for the advice!
  14. Mman

    Mman Senior Member 10+ Year Member

    Mar 22, 2005
    A couple things that I wonder about...

    CVA? When was it? What were the symptoms? Was it somebody that had some speech disturbances in Wernicke's area for 3 days and never had motor symptoms of any kind? Was it somebody that has been dragging their right leg for the last 6 months because of the CVA? Not every CVA involves motor neurons in the first place.

    Nitrous? I wouldn't give it to this patient because they are already nauseous as hell and I'd like them to have as little nausea post op as possible.
  15. JackPB

    JackPB Fire, and lots of it! 5+ Year Member

    Nov 15, 2005
    I'd make sure the patient had good NG tube decompression before doing anything. However, I would remove the NGT before the RSI. Having an NGT in place distorts the anatomy for laryngoscopy, and it is easy enough to replace.

    Also, he is probably intravascularly dry as a bone. He'd need some aggressive fluid resuscitation before the RSI drops him. He doesn't sound like a man who would tolerate much hypotension.

    Why did this patient deserve an M&M? What happened?
  16. CVA was old and had minor one sided weakness nothing MAJOR.

    The M&M was a post op problem but as is standard Anesthesia is to blame. The stuff about the attending/CA1 we all heard through the grapevine and then the case was discussed as a group...
  17. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    I don't necessarily agree with this.
  18. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    I don't give sux to these pts. But then again I use maybe 3 bottles of sux a month. Zemuron exclusively.
  19. VentdependenT

    VentdependenT You didnt build thaT Physician Moderator Emeritus 10+ Year Member

    Oct 3, 2003

    Me either. Now that you have a conduit for puke to go through why would you remove it. Put that thing to suction and go for it.

    If anything I think a NGT HELPS with laryngoscopy. At least you know where the goose is and now you just need to go anterior to it.

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