ASC Case

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narcusprince

narcusprince

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So I have been on an ASC rotation for the last month. I really like the pace lots of blocks, lots of healthy patients. Their is something I have noticed in the last month is their is a fair amount of psychopathology amongst healthy patients that can slow the pace of an ASC. My question for practitioners is do you routinely screen for psychiatric issues IE PTSD, history of psycho trauma? Last week we had a case of a patient in their 20's with history of loss of pregnancy and what only we could conjecture as some history of trauma or abuse, whom had terrible emergence delirium. It was very bizarre agent was off bp was normal, O2 sat was normal, EKG NSR, RR 16, whom kept saying we were trying to kill her pulling at lines for roughly 30 minutes post LMA removal and 2 hrs in postop. Background on the case patient was having a turbinetectomy, done under LMA 200mg of propofol, 50mcg of fentanyl, 10mg of decadron up front, 2mg of versed once in OR, also some sevo. I gave an additional 50mcg after she was spontaneous during the procedure which was bizarre because it made her apneic for roughly 10 minutes(placed her on PCV) once respirations resumed she was normal. LMA out Sevo at 0% pt swallowing opens mouth LMA out. The problem is these cases eat up resources at an ASC and probably she should not have been done at an ASC. How can we screen for these patients?
 
Emergence delirium is fairly common in kids. If it's really bad I'll sometimes give a bit of propofol in the PACU or reverse the pre op midazolam with flumazenil. Sometimes that works. The post op nurses usually just treat it with some morphine. It chills them out until they get through it.
Why did you give 10 of decadron? I use 0.1mg/kg up to 4mg for routine PONV prophylaxis. 1/2 mg/kg up to 10 for peds airway cases or T&As. I know decadron can cause confusion and hallucinations, though I'm not sure if it can with a single moderate dose.
When I had a lot of PTSD marines back from Iraq I would dope them up intraop with generous morphine doses. That always worked. That might not be the way to go for a rapid ASC day though.😉
I'm interested in other opinions.

BTW, did I read right that you kept her in the OR for an additional 30 min post op? If she was thrashing around and not hypoxic, hypercarbic, etc. I would have put her back down with titrated propofol and let her emerge in the PACU. I have do that to kids from time to time. A bit of propofol to calm down after extubation and some more morphine, then off to the PACU. +/- an oral or nasal airway.
 
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No real pre-screening. Sort of take it as it comes... the vast vast majority of patients with a history of mental illness do just fine. Seems to happen to young and old patients the most... i had a 22 yo in the recovery room last week after a knee-scope that swore he was eating a T-bone steak for about 20 minutes.

Btw, you'd be surprised what 10mg of decadron can do to people sometimes.
 
IlDestriero said:
Why did you give 10 of decadron?
Click to expand...

Lots of our ENTs and OMFS'ers request it for their airway surgeries, just for the anti-inflammatory effects. When I get cornered into doing sedations for wisdom teeth extractions (blegh) they always want 10 mg of it too for the same reason. PONV prophylaxis is just a side benefit.


IlDestriero said:
When I had a lot of PTSD marines back from Iraq I would dope them up intraop with generous morphine doses. That always worked. That might not be the way to go for a rapid ASC day though.😉
I'm interested in other opinions.
Click to expand...

I am a huge fan of droperidol in young burly males, especially that population.
 
The 10mg of Decadron was for anti-inflammatory. Interestingly enough all of the patients at the ASC are given 10mg of decahedron if they have a history of PONV. I like to use 0.1mg/kg for PONV max of 6 and 0.5mg/kg max of 10mg for anti-inflammatory. What I would like to use is Precedex in patients that have history of emergence delirium and PTSD start it during the case and have the get turned off in PACU once the nurses have the patient within their aldrette score. Hopefully the .mil will allow me the freedom to use what I want.
 
pgg said:
Lots of our ENTs and OMFS'ers request it for their airway surgeries, just for the anti-inflammatory effects. When I get cornered into doing sedations for wisdom teeth extractions (blegh) they always want 10 mg of it too for the same reason. PONV prophylaxis is just a side benefit.




I am a huge fan of droperidol in young burly males, especially that population.
Click to expand...

The navy pharmacists took droperidol away from me. It was great.
I stopped using it routinely BTW after I got it for intractable nausea and vomiting while on vacation. The ED MD asked if I wanted it as he had good success with it. Big F'ing mistake. I was unhappily dissociated for 2-3 hours. Never again. I don't even like to be drunk.
 
narcusprince said:
Hopefully the .mil will allow me the freedom to use what I want.
Click to expand...

You have no idea how hilarious that is, but you will soon.

I can't speak to your soon-to-be home's PACU, but at the mothership, the nurses would freak out if you came rolling back with anything running, and instructions on when to titrate or turn it off.
 
narcusprince said:
The 10mg of Decadron was for anti-inflammatory. Interestingly enough all of the patients at the ASC are given 10mg of decahedron if they have a history of PONV. I like to use 0.1mg/kg for PONV max of 6 and 0.5mg/kg max of 10mg for anti-inflammatory. What I would like to use is Precedex in patients that have history of emergence delirium and PTSD start it during the case and have the get turned off in PACU once the nurses have the patient within their aldrette score. Hopefully the .mil will allow me the freedom to use what I want.
Click to expand...

yes clearly you are concerned about conserving resources 😉

why the versed if you are already in the OR?
 
IlDestriero said:
Emergence delirium is fairly common in kids. If it's really bad I'll sometimes give a bit of propofol in the PACU or reverse the pre op midazolam with flumazenil. Sometimes that works. The post op nurses usually just treat it with some morphine. It chills them out until they get through it.
Why did you give 10 of decadron? I use 0.1mg/kg up to 4mg for routine PONV prophylaxis. 1/2 mg/kg up to 10 for peds airway cases or T&As. I know decadron can cause confusion and hallucinations, though I'm not sure if it can with a single moderate dose.
When I had a lot of PTSD marines back from Iraq I would dope them up intraop with generous morphine doses. That always worked. That might not be the way to go for a rapid ASC day though.😉
I'm interested in other opinions.

BTW, did I read right that you kept her in the OR for an additional 30 min post op? If she was thrashing around and not hypoxic, hypercarbic, etc. I would have put her back down with titrated propofol and let her emerge in the PACU. I have do that to kids from time to time. A bit of propofol to calm down after extubation and some more morphine, then off to the PACU. +/- an oral or nasal airway.
Click to expand...

how much flumazenil? does it work well?

i've never given it. i usually give fentanyl alone for the ride into the room and try to stay away from the midaz unless a patient is obviously decompensating because i think it really interferes with the wake-ups and pacu discharges...
 
Robert Loblaw said:
how much flumazenil? does it work well?

i've never given it. i usually give fentanyl alone for the ride into the room and try to stay away from the midaz unless a patient is obviously decompensating because i think it really interferes with the wake-ups and pacu discharges...
Click to expand...

The appropriately named Antilirium (physostigmine) also works wonders.
 
IlDestriero said:
The navy pharmacists took droperidol away from me. It was great.
I stopped using it routinely BTW after I got it for intractable nausea and vomiting while on vacation. The ED MD asked if I wanted it as he had good success with it. Big F'ing mistake. I was unhappily dissociated for 2-3 hours. Never again. I don't even like to be drunk.
Click to expand...

He offered it to you solo? 🙁 Without versed, etc? My chief once was booked for a colonoscopy. He offered himself as a guinea pig, wanting preop droperidol without anything else yet on board in the holding room. A few minutes later he removed his own IV, and walked out, refusing to stay. A few days later he said he was internally screaming while looking perfectly calm.

I hate to see the USN take it off the formulary. A little whiff of droperidol works wonders when waking up young burly Marines who are full of PTSD or too much testosterone.
 
IlDestriero said:
The navy pharmacists took droperidol away from me. It was great.
Click to expand...

Funny, the only place I have droperidol now is at the Navy joint.


trinityalumnus said:
He offered it to you solo? Without versed, etc? My chief once was booked for a colonoscopy. He offered himself as a guinea pig, wanting preop droperidol without anything else yet on board in the holding room. A few minutes later he removed his own IV, and walked out, refusing to stay. A few days later he said he was internally screaming while looking perfectly calm.
Click to expand...

How much did they give him?


trinityalumnus said:
I hate to see the USN take it off the formulary. A little whiff of droperidol works wonders when waking up young burly Marines who are full of PTSD or too much testosterone.
Click to expand...

Amen to that.
 
Dex is good for PTSD, but patients tend to stay sedated in the PACU for hours. I would say maybe 10% of my Dex patients also require IV fluid boluses for post-op hypotension.
 
narcusprince said:
How can we screen for these patients?
Click to expand...

Probably in a way that's no more complicated than the history and physical you're doing already. The patient you're describing, you already screen her as high risk. So I would say feel free to prophylax. Some options I've done, with varying success:

-droperidol 1.25mg
-dexmedetomidine 0.2-0.5 mcg/kg
-midazolam 1-2mg
-benadryl 25-50mg
-propofol 10-20mg to effect
-opioids until they're teetering on ventilatory failure
-decadron in less than psychosis-inducing doses 😀
 
fakin' the funk said:
Probably in a way that's no more complicated than the history and physical you're doing already. The patient you're describing, you already screen her as high risk. So I would say feel free to prophylax. Some options I've done, with varying success:

-droperidol 1.25mg
-dexmedetomidine 0.2-0.5 mcg/kg
-midazolam 1-2mg
-benadryl 25-50mg
-propofol 10-20mg to effect
-opioids until they're teetering on ventilatory failure
-decadron in less than psychosis-inducing doses 😀
Click to expand...
Educate me what is a psychosis inducing dose and please include resources. All of the research I have done regarding steroid induced psychosis is long term use of steroids not just one dose. And she was not screened as high risk. 26 year old female for endoscopic sinus surgery otherwise healthy. Now she definitely his in the high risk category given her emergence delirium.
 
trinityalumnus said:
1/2 ml = 1.25 mg.
Click to expand...

.625mg is the most I'd ever give for PONV... Sometimes 1/2 that.
It's never my first line agent. I believe it's a pretty good drug... You have to have other agents on board to avoid some of it's dissociative properties. It's like giving IV ketamine w/o other meds running around. Just smoother synergism with other agents IMO.... but especially in the awake or emerging patient.
 
Yeah, drope and dope. 1 ml had 50 mcg of fentanyl and 2.5mg of of droperidol. Would use it for sedation for awake fiberoptic intubations. Sometimes worked beautifully. Sometimes made you hate the drug.
 
I have ready access to droperidol and have used it a few times in small doses for patients at high risk for PONV. Do you all ever give Zofran in addition, or does the risk of QT prolongation make the concurrent use of both drugs prohibitive?
 
Multifidus said:
I have ready access to droperidol and have used it a few times in small doses for patients at high risk for PONV. Do you all ever give Zofran in addition, or does the risk of QT prolongation make the concurrent use of both drugs prohibitive?
Click to expand...

Nearly everything we give prolongs the QT to some degree or other, but I believe that the overall risk of clinically significant QT prolongation from either/both of these drugs is low. I regularly give 4mg zofran in addition to 0.625mg droperidol in my high-risk PONVers (or young/crazy marines), and have never seen any noticeable QT prolongation in the OR or PACU. Admittedly, I am just a CA2, so that doesn't count for much, but none of my pro-droperidol staff who have the same practice have seen anything significant, either. I do not believe that this combination has ever been studied, so we unfortunately tread in the realm of logic and anecdote.
 
dr doze said:
Yeah, drope and dope. 1 ml had 50 mcg of fentanyl and 2.5mg of of droperidol. Would use it for sedation for awake fiberoptic intubations. Sometimes worked beautifully. Sometimes made you hate the drug.
Click to expand...

👍

Good to have some guys on this board with some old school experience.
 
The ASC center is staffed by older anesthesiologist and CRNA's so we have had an Innovar discussion throughout the month. FYI Dexamethasone psychosis part of the steroid psychosis is not a one time dose phenomena. Did an extensive literature search this weekend. No evidence that 1x dosing of steroids can induce psychosis. My new hypothesis is a paradoxical effect of the benzo's or factitious disorder. Good case.
 
I recall being told by one of my 'old timers' that When Fentanyl was first released (1960s) That concern for the abuse potential was so high it did not gain widespread use very rapidly. Innovar was developed bcause of the dysphoria that was associated with Droperidol, it was thought this would lessen the abuse potential and thus help sales of the drug.
 
FYI, Anesthesiologists would sometimes give 10-20 mg I.V. Droperidol for cases. CAn you imagine getting 20 mg of Droperidol? Anyway, low dose has a new meaning in 2012 compared to 1994 when this study was published:

http://www.anesthesia-analgesia.org/content/79/5/983.short

Prolongation of the QTc interval is a predictable and dose-dependent side effect after injection of high-dose DRO.
 
The average prolongation was not different compared with patients who received placebo, although a patient receiving 0.625 mg had a maximum QT prolongation of 120 ms, and a patient receiving 1.25 mg had a maximum QT prolongation of 133 ms. By 2 h after arrival in the postanesthesia care unit, the QTc was almost back to baseline.


http://www.anesthesia-analgesia.org/content/106/5/1414.full
 
Multifidus said:
I have ready access to droperidol and have used it a few times in small doses for patients at high risk for PONV. Do you all ever give Zofran in addition, or does the risk of QT prolongation make the concurrent use of both drugs prohibitive?
Click to expand...

I usually give dexamethasone to flush the propofol in. If I'm using droperidol, it follows a few minutes later (my rationale being that I get the entire case of ECG monitoring + PACU monitoring, which approaches the black box recs). If there's no QT prolongation during the case, and the patient is high risk for PONV, sometimes I'll give Zofran before wakeup.

More often, I "save" the Zofran for the PACU nurses.

I think the black box recommendations are a bunch of crap:

Perform baseline 12 lead ECG prior to initiation of therapy
Do not administer if QTc > 440 msec in males or 450 msec in females.
Baseline ECG monitoring and continued for 2-3 hrs post completion of therapy
Risk factors for QT prolonged syndrome: CHF, bradycardia, diuretic use, cardiac hypertrophy, hypokalemia, hypomagnesemia, drugs which prolong QT interval, >65 yrs, alcohol abuse, benzodiazepines, volatile anesthestics, IV opiates.
Initiate at low dose and titrate slowly
Black Box Warning revised/added December 2001
Click to expand...

As I mentioned earlier, my favorite patient population is the 20-something, catecholamine charged males that look like they're at risk for waking up angry. I do not get 12 lead ECGs on them preop; that's ******ed. I look at their ECG in the OR and if the QT looks longish, I don't use it.

Risk factors: volatile anesthetics, IV opiates ... 🙄

I use 0.625 mg. I do not redose it.
 
narcusprince said:
Educate me what is a psychosis inducing dose and please include resources. All of the research I have done regarding steroid induced psychosis is long term use of steroids not just one dose. And she was not screened as high risk. 26 year old female for endoscopic sinus surgery otherwise healthy. Now she definitely his in the high risk category given her emergence delirium.
Click to expand...

Did you not see the 😀 at the end of my post? Get off my balls, son.

So fair enough, I'll take you at your word that you searched and established that a one-time of a corticosteroid cannot cause psychosis. Fantastic. At the same time, I'm clearly not the only one who heard the story and thought 10mg of dexamethasone and a crazy patient could have some relationship. I'm willing to be that prior to this happening to you, YOU thought the same thing too.

Re: screening. You say "she was not screened as high risk," and yet your reason for posting here is to ask what other clinicians do to screen patients at risk of emergence delirium. I would suggest that you indeed HAD screened this patient, because according to your own description the patient was young and had a history of "psycho trauma" and this maybe pinged your radar for someone who's at risk for a crazy wakeup.
 
dr doze said:
Yeah, drope and dope. 1 ml had 50 mcg of fentanyl and 2.5mg of of droperidol. Would use it for sedation for awake fiberoptic intubations. Sometimes worked beautifully. Sometimes made you hate the drug.
Click to expand...

As one of my grayhair attendings pointed out, the combination of a 3-hr-acting antipsychotic with a 1-hr-acting opioid is a little dodgy.
 
jwk said:
The appropriately named Antilirium (physostigmine) also works wonders.
Click to expand...

Missed this my first time through. Can you elaborate? It sounds like you're saying it's generally useful for postop delirium.

As a treatment for central anticholinergic syndrome, physostigmine makes sense. Only -stigmine that crosses the BBB, treats the crazy if it's caused by BBB-crossing anticholinergics like scopalamine or atropine. Classic board question but I've never seen it used in real life.
 
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