asc aspiration

[thegasman]

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doing podiatry today at asc - pt is 65 yr old with htn and reflux ( took her nexium asymptomatic - got a pepcid per protocol), ankle block by surgeon with mac - get a call from crna. I go to the room and crna has yankauer full of green bilious fluid, says patient started throwing up. We RSI. He suctions OP and sees the same stuff coming from the cords. Suction Ett. Yep same green stuff. Sats 94% GIve peep, O2, sevo. Pt is stable, surgeon finishes case. Peep and O2 weaned and tolerates ok. L side sounds coarse on exam and diminished at base. Extubated to 100% NRB, Sats 100 in recovery. CXR shows LLL infiltrate per rads. Pt sats 94-97 on 2-4L but wean to ra and sats 88-92%. 330pm on fri. Now what.

 

[DrBrown]

gotta at least do overnight obs with pulse ox monitor an supplemental O2 in my opinion. This will probably be ok but could get a bit worse before it gets better

 

[toughlife]

gotta at least do overnight obs with pulse ox monitor an supplemental O2 in my opinion. This will probably be ok but could get a bit worse before it gets better

Send her to the ER and have the med studs admit her.

 

[OB1🤙]

Send her to the ER and have the med studs admit her.

I mean, what other option do you really have?

 

[Planktonmd]

It's interesting that the CXR showed an infiltrate already!
Usually it takes a while for that to happen, do you have a previous CXR to compare with?
Low SPO2 and abnormal auscultation are good reasons to send her to the hospital.

 

[militarymd]

send her home.

EVERYONE has a LLL infiltrate after a MAC converted to GA....

EVERYONE who is on a vent in the unit has a LLL infiltrate.



Aspiration in the supine position usually leads to infiltrates in the superior segment of the RLL and RUL.

Obviously no acid pneumonitis...possiblity of infectious pneumonia developing in a couple of days....

Send her home and follow up as necessary.

 

[huktonfonix]

out of curiosity, why did you feel the patient needed to be intubated? Was the patient obtunded to the point of losing airway reflexes? If not the usual turn the head to the side and suction may have been enough. Otherwise once you abolish the reflexes for intubation you may have inreased their chances of aspirating.

 

[zippy2u]

Let me paint the big picture for ya gasman... 1530 on Friday at the ASC is a biggie! My ***** be wantin' to get home, period. Ain't got no time to babysit pt. in the PACU and wait to see how this situation evolves--could get worse before it gets better. You shouldn't have gotten a CXR at the ASC because you wanna turf this guy after his short stay in the PACU." Need a PCXR, chief, and ya can get one at the ER down the road. The other theme is you're dealin' with a "quasi" surgeon namely a podiatrist who typically doesn't know "shiit from shinow" which translates to you, as a gasdoc, can "out-muscle" him and you can do what ya want with the pt. and he will meekly follow your recs. So tell pt's driver to take him over to ER to get his PCXR(don't need the big gun paramedics, ambulance and all that hysteria), call up the ER doc and tell him your spiel about the pt and he'll take it from there. I'll have a straight double shot of Wild Turkey waitin' for ya at 1700 at the bar and even Ice Cube it on the jukebox with "Today Was A Good Day." Regards, ---Zippy

 

[Planktonmd]

Let me paint the big picture for ya gasman... 1530 on Friday at the ASC is a biggie! My ***** be wantin' to get home, period. Ain't got no time to babysit pt. in the PACU and wait to see how this situation evolves--could get worse before it gets better. You shouldn't have gotten a CXR at the ASC because you wanna turf this guy after his short stay in the PACU." Need a PCXR, chief, and ya can get one at the ER down the road. The other theme is you're dealin' with a "quasi" surgeon namely a podiatrist who typically doesn't know "shiit from shinow" which translates to you, as a gasdoc, can "out-muscle" him and you can do what ya want with the pt. and he will meekly follow your recs. So tell pt's driver to take him over to ER to get his PCXR(don't need the big gun paramedics, ambulance and all that hysteria), call up the ER doc and tell him your spiel about the pt and he'll take it from there. I'll have a straight double shot of Wild Turkey waitin' for ya at 1700 at the bar and even Ice Cube it on the jukebox with "Today Was A Good Day." Regards, ---Zippy

Well said (as usual).

 

[mille125]

Let me paint the big picture for ya gasman... 1530 on Friday at the ASC is a biggie! My ***** be wantin' to get home, period. Ain't got no time to babysit pt. in the PACU and wait to see how this situation evolves--could get worse before it gets better. You shouldn't have gotten a CXR at the ASC because you wanna turf this guy after his short stay in the PACU." Need a PCXR, chief, and ya can get one at the ER down the road. The other theme is you're dealin' with a "quasi" surgeon namely a podiatrist who typically doesn't know "shiit from shinow" which translates to you, as a gasdoc, can "out-muscle" him and you can do what ya want with the pt. and he will meekly follow your recs. So tell pt's driver to take him over to ER to get his PCXR(don't need the big gun paramedics, ambulance and all that hysteria), call up the ER doc and tell him your spiel about the pt and he'll take it from there. I'll have a straight double shot of Wild Turkey waitin' for ya at 1700 at the bar and even Ice Cube it on the jukebox with "Today Was A Good Day." Regards, ---Zippy

OP was not wrong to get the CXR. However, since you are in the ASC this patient will need to go to the ER and you should make arrangements. If you were in the hospital, patient would be admitted to the surgeon's service (with a medical consult I hope).

 

[thegasman]

interesting mil is the only one who wants to send her home. And we tubed her because the crna had already done the turn and suction deal and green juices continued to appear, sats had already decreased as well. Zippy is right about the 330 pm deal - this was a major factor. We all agreed to have her admitted for observation - her husband seemed relieved by this as he was nervous about taking her home. So called up the hospitalist and arranged admission. Interestingly Mil was probably right as by the time the ambulance arrived (430) to get her she was 97-98% on the 2L NC and looked better. Earlier in the day and she might have been able to go home. My theory on what happened is that crna is running 50 mcg/kg prop with 50%
n20 and pt got light and gagged on oa.

 

[Arch Guillotti]

My theory on what happened is that crna is running 50 mcg/kg prop with 50% n20 and pt got light and gagged on oa.

If the pt. has a block and prop is running, what is the nitrous for?

 

[thegasman]

If the pt. has a block and prop is running, what is the nitrous for?

Ankle blocks are hit or miss sometimes. And CRNA is good, if he wants to use some n20 I don't care - maybe it isn't how I would do a MAC but I don't micromanage.

 

[Planktonmd]

My theory on what happened is that crna is running 50 mcg/kg prop with 50%
n20 and pt got light and gagged on oa.

I thought you said you were doing MAC.
If you need Propofol and N2O then why not just do a proper GA with some sort of airway device?
The other thing here: You know for a fact that she aspirated (You saw bile coming out of the cords) and you already documented low SPO2 and abnormal lung auscultation, at this point you have to send her to the hospital because you have no other choice.
The fact that the SPO2 got better latter probably means that she had atelectasis that are improving but does not mean she is not going to develop aspiration pneumonia in 24 hours.

 

[militarymd]

Ankle blocks are hit or miss sometimes. And CRNA is good, if he wants to use some n20 I don't care - maybe it isn't how I would do a MAC but I don't micromanage.

sounds like the dude doesn't know how to do a ankle block....

and nothing causes more airway disasters than "light" generals.

although, like I said, this was a nothing burger....I would have booted her out the door to follow up with her primary care md.

 

[mille125]

send her home.

EVERYONE has a LLL infiltrate after a MAC converted to GA....

EVERYONE who is on a vent in the unit has a LLL infiltrate.



Aspiration in the supine position usually leads to infiltrates in the superior segment of the RLL and RUL.

Obviously no acid pneumonitis...possiblity of infectious pneumonia developing in a couple of days....

Send her home and follow up as necessary.

give me a break.......

 

[mille125]

I thought you said you were doing MAC.
If you need Propofol and N2O then why not just do a proper GA with some sort of airway device?
The other thing here: You know for a fact that she aspirated (You saw bile coming out of the cords) and you already documented low SPO2 and abnormal lung auscultation, at this point you have to send her to the hospital because you have no other choice.
The fact that the SPO2 got better latter probably means that she had atelectasis that are improving but does not mean she is not going to develop aspiration pneumonia in 24 hours.

i agree plankton...too many MAC case run as GA's...i dont understand it either...if you are going to have a GA put in an airway device

 

[militarymd]

give me a break.......

which part didn't you understand?

 

[treasurefull2]

which part didn't you understand?

Sorry man, but even with my limited experience as a medical student, I would have to disagree with you...

Send her home? A 65yo person who just aspirated, and you really can't say which way she's going?

Send her to the hospital, if not for her well-being, at least to CYA...

 

[urge]

We are seeing more and more of this threads where pt craps out in an ASC. It seems like working in a standalone ASC is a pain the neck. They should have an agreement with a hospitalist nearby, so patients who didn't do that well can be taken care of, instead of being sent to the ER.

Anyway, the traditional teaching is to observe them for 4-6hrs to see if they deteriorate. They can be discharged by then if criteria are met.

 

[Planktonmd]

We are seeing more and more of this threads where pt craps out in an ASC. It seems like working in a standalone ASC is a pain the neck. They should have an agreement with a hospitalist nearby, so patients who didn't do that well can be taken care of, instead of being sent to the ER.

Anyway, the traditional teaching is to observe them for 4-6hrs to see if they deteriorate. They can be discharged by then if criteria are met.

Practicing anesthesia at an ASC is tricky and you need to always have a plan to get these patients in and out as fast and as safe as possible.
You also have to be a diplomat and make sure you don't annoy the surgeons too much because they could very easily take their business somewhere else or they might actually own the surgicenter and in both cases you lose.
Most of the times you are it, you are the medical director of the surgicenter when you are there and there is no one else.

 

[thegasman]

I thought you said you were doing MAC.
If you need Propofol and N2O then why not just do a proper GA with some sort of airway device?
.

Agree, this is not really a MAC - the term at my hospital is RAG (room air general)

 

[jwk]

Agree, this is not really a MAC - the term at my hospital is RAG (room air general)

It's not even that - it's a general anesthetic, period. If you're obtunded to the point of losing protective airway reflexes, again, it's a general anesthetic. Had your CRNA not been giving a light general anesthetic, they probably would have maintained their airway reflexes and not aspirated.

With a good ankle block, propofol and N2O is gross overkill. And again, the two together make a general anesthetic.

Oh - and a SaO2 of 94%? While puking? Hell, I'll bet mine would be 94% without anything on board - it's hard to puke and breathe deeply at the same time.

And if you're more concerned about making it out the door than taking care of the patient, then there are other issues. As urge indicated, 4-6 hrs, and if they're looking good, out they go. Looks like in your case, they were, in fact, ready for discharge by the time you shipped them off to the ER.

 

[mille125]

which part didn't you understand?

none of it...

 

[militarymd]

none of it...

well then , let me explain.

As a physician, if you order a test, you should know what you're looking for....in this particular case....radiographic evidence that would suggest aspiration.

In patients who aspirate while in a recumbent position, the most common sites of involvement are the posterior segments of the upper lobes and the apical segments of the lower lobes (Figure 1), whereas in patients who aspirate in an upright or semirecumbent position, the basal segments of the lower lobes are usually affected....from NEJM.

The finding that the op's patient had...LLL infiltrate...diagnosed by a radiologist...is a COMMON finding in patients who have recently been anesthetized or are on ventilators....

The OP's patient's post op clinical course is common EVEN in patients who did not have the "aspiration" event.

As a physician anesthesia provider we should be able to differentiate between those patients who have actually suffered an event that requires admission and consultation with an Intensivist/hospitalist versus those events that need nothing other than reassurance and discharge.

OR you can be a tube/needle jockey.

and tell CRNA's that they aren't as good a tube/needle jockey as you are because you have "MD" in your title.

 

[deleted126335]

.

 

[mille125]

well then , let me explain.

As a physician, if you order a test, you should know what you're looking for....in this particular case....radiographic evidence that would suggest aspiration.

In patients who aspirate while in a recumbent position, the most common sites of involvement are the posterior segments of the upper lobes and the apical segments of the lower lobes (Figure 1), whereas in patients who aspirate in an upright or semirecumbent position, the basal segments of the lower lobes are usually affected....from NEJM.

The finding that the op's patient had...LLL infiltrate...diagnosed by a radiologist...is a COMMON finding in patients who have recently been anesthetized or are on ventilators....

The OP's patient's post op clinical course is common EVEN in patients who did not have the "aspiration" event.

As a physician anesthesia provider we should be able to differentiate between those patients who have actually suffered an event that requires admission and consultation with an Intensivist/hospitalist versus those events that need nothing other than reassurance and discharge.

OR you can be a tube/needle jockey.

and tell CRNA's that they aren't as good a tube/needle jockey as you are because you have "MD" in your title.

Because you do have an MD in your title, you should know what the proper disposition is for a particular patient. The only thing that I am arguing against in your long elegant soliloquy is your decision to send this patient home. I think that this shows reckless abandon and puts the patient at risk. You are making a classic mistake by "zeroing in" on an isolated diagnostic test and are missing the forest for the trees. The xray shows a LLL infiltrate. I dont argue with that or with your statements that "this finding can be seen in anesthetized patients". Removal of green bilious fluid and postop sats of 88-92% at the time of discharge are not "findings commonly seen in anesthetized patients". From the ASC this person needs to be a direct admit to the hospital or sent to the ER. Observation is likely necessary. If this patient died at home, you would be liable for the cavalier approach. I find the CRNA comparison interesting because your decision making in this case more closely resembles their level of training.

 

[radslooking]

im not a gas man, but i'd tend to agree with mille on this one. it's too bad its 330 at an asc if you had a few more hours you'd probably be able to tell they'd be ok. but betting your chips on the fact that a lll pneumonia is an incidental finding is a little dangerous, even if it is common to be seen in anesthetized patients. You are betting quite a bit on which way that bile flowed, right or left. I don't think i'd take that bet, even if it's usually right. 98 times out of a hundred you may be allright, or that patient comes back in before he gets too bad. but what if he's stubborn and sticks it out till he's got a multilobar pneumonia and in rough shape? i dunno. just seems too risky for me.

 

[militarymd]

one approach:

- patient has an "aspiration" event ...NO EVIDENCE of acid pneumonitis
- order x-ray
- turf


my approach:
- patient has an "aspriation" event
- review clinical data
- normal cxr
- normal post op course
- no evidence of acid pneumonitis
- discharge with f/u directions

 

[Planktonmd]

my approach:
- patient has an "aspiration" event

Yes and you saw bile coming out of the cords.

- review clinical data

What clinical data?

- normal cxr

CXR was not normal and you are basing your conclusions on that if it's not in the expected location then it's not aspiration pneumonia. Unfortunately aspiration pneumonia can be anywhere in the lungs and like everything in medicine it doesn't always happen the way it should because if it did then anyone could practice medicine.
The only thing that argues against aspiration is that it was too early but even that is not a concrete rule.

- normal post op course

She was hypoxic and had abnormal chest auscultation.

- no evidence of acid pneumonitis

No evidence of MASSIVE acid pneumonitis.

- discharge with f/u directions

 

[militarymd]

You can say everything and anything that you want.

I can only tell you that I spent 5 years in an academic program as a sole intensivist in the department who got consulted on cases like this routinely.

I run a M&M on this once a year for resident benefit and also to train new attendings....military programs get lots of new attendings when they PCS.

This patient would go home....I did it for 5 years...and I would continue to send them home.

The difference between you and me is that I actually have experience taking care of these patients AFTER their surgery and followed up on these type of patients...yes some of them may develop an infectious pneumonia, but you know what????? You don't admit EVERY SINGLE patient with a pneumonia.

As for hypoxia....if you havn't seen this level of hypoxia post op, then you havn't done enough cases.

 

[Planktonmd]

You can say everything and anything that you want.

I can only tell you that I spent 5 years in an academic program as a sole intensivist in the department who got consulted on cases like this routinely.

I run a M&M on this once a year for resident benefit and also to train new attendings....military programs get lots of new attendings when they PCS.

This patient would go home....I did it for 5 years...and I would continue to send them home.

The difference between you and me is that I actually have experience taking care of these patients AFTER their surgery and followed up on these type of patients...yes some of them may develop an infectious pneumonia, but you know what????? You don't admit EVERY SINGLE patient with a pneumonia.

As for hypoxia....if you havn't seen this level of hypoxia post op, then you havn't done enough cases.

OK,
Good for you.

 

[mille125]

Military,


Arguing with you is like trying to convince a schizophrenic that their hallucinations are not real. I guess that we will need to agree to disagree on this issue. I should inform you that I have also seen the "other side". I have been repeatedly asked to consult with attorneys on cases involving anesthesiologists that end up in court. Let me inform you that if this case ended up in court, you would be in serious trouble. You seem to like to roll the dice. I hope that for your sake and for your patient's sake that lady luck stays with you.