CA-1 Bad day today, a case to discuss

[bne_12mne]

I'm a 4th month CA1 at a major academic center on the east coast. Here's what happened today.

Case: 58 yo female ASA2 comes in for redo parathyroidectomy for primary Hyperpara. Induce GA, paralyze, intubate etc, no problems. Surgery resident starts draping, basically from stem to stern giving me no access to airway, head, face, forehead or anything, and with both arms tucked and also unaccessible. I anticipated the arms being tucked so placed my IV in the hand with armboard on wrist wrapped in kerlex and extension set to avoid difficulty there. Was not expecting to have zero access to airway and head (without undraping or contaminating field) and said as much to resident. He gave the "this is how we always do it," response with the typical amount of PGY5 attitude. I move on. Other thyroid surgeons in my institution leave at least some room for BIS, access to airway etc. Anyway, case continues with residents doing almost everything. I'm running Sevo at 1.3 MAC, 3mg of morphine on board. They start to close and draw another PTH level. I start my remi infusion at 0.1-0.12 and come down on the volatile to 0.6 or 0.7 MAC for a no buck, no cough wake up. VS are 90/60 (requiring slow neo gtt) and HR 59-60 and more or less stable this way for 20 min or so. As they are closing platysma, which is taking forever since it's junior residents, with no warning signs that I can see whatsoever, again there is no BIS, face, extremity, no change in PIPs, ETCO2, HR, nothing, the patient starts moving her right arm up towards her neck. Meanwhile the surgeons make noise, and the junior residents start talking to the patient. ""It's okay, we're almost done," that kind of thing. I'm standing right there, so I grab the propfol and give 50mg and run it in. I tell them, "she's not awake, she's just moving, hold down her arm". Anyway, they don't grab her arm in time and she manages to get her hand to her neck and brush the open wound. Apparently, they didn't actually secure her arms when they tucked them. They flip out, especially the PGY5 who is no longer scrubbed. Flip out and start cursing at me. Not in the direct cursing way, but sort of indirectly. I think if he made eye contact and cursed directly at me, I might have knocked his teeth out, I was so pissed. Anyway, as to what happened, I had no warning signs whatsoever. My guess is they pushed on the trachea a bit too hard and stimulated her as she was otherwise anesthetized appropriately. So we have to cleanse, redose Abx, and redrape. For the next 2 hours (since they had to go back in as the PTH turned out too high), I got all kinds of attitude. Finally after extubation (which went great) they are, in typical fashion, trying to pull the patient over to the stretcher while I'm still disconnecting everything and moving over the IV, O2 etc, I have to tell them to stop unless they want half the OR riding with them to the Pacu. That gets their eyes rolling. The body language is unbelievable, and unfortunately mostly unaddressable. I freaking hate that.

My lessons in hindsight: Keep 'em deep even if you need pressors when residents are operating (since they are not very deft), screw trying to have nice wake-ups, let them bitch about the cough and buck if it happens. Tell them to screw off when they try to drape the patient leaving you access to nothing. Finally, most surgeons think that the the on-off switch on the Datex is all we have to manipulate to give anesthesia. They have no clue.

What do you all think?

Benny

---

Members don't see this ad.

 

[2ndyear]

I know its hard, but don't get all stressed about one (minor) bad thing happening your CA1 year. They had to re-prep, things like this happen. I had a patient sit up and try to take out his LMA my CA1 year . Your wakeup plan seemed pretty good. Remi in that dose will keep most people down with a whif of Sevo. Most people...BIS won't help in all of these situations either. I've had it sit at a nice 40, then the patient wakes up and moves, about a minute later it will shoot up to 85. There is a pretty good lag there.

 

[gasnewby]

i'm not criticizing you- i'm junior too. these are my junior thoughts:

1. don't YOU tuck the arms? wasn't there a sled/sheet to restrain her? and i guess if you or your colleagues didn't tuck the arms, you should have

2. you should be able to control the draping from the head of the bed. ie, move the IV poles closer or change the angle. clamp the drapes up high on the pole. i don't understand how you had no access at all. it's your airway, dammit.

3. when the pt is moving, it's not really possible for the surgeons to grab the arm- obviously they will contaminate themselves. which may have been preferable to contaminating the wound, but...don't forget they probably have a sharp (needle/needle driver) in their hands, it's best that they don't start waving that around and sticking themselves or others.

4. gotta be firm- the pt doesn't get moved until the head of the bed (ie, YOU) says so...you control the airway, they can all go piss off

5. if she was anesthetized appropriately, i'm going to argue that surgeons pushing on the trachea shouldn't wake the pt up.

6. what did they end up doing, reprepping and draping?

7. in my limited experience, i don't think surgeons really care about an easy vs bucking wakeup. do what you need to do.

sorry you had a bad day though, that sucks...i'll drink a beer for you tonight

 

[bne_12mne]

Just to address a few of the points raised, in no particular order:

1) Positioning: No, in my experience, the anesthesia resident (me) does not routinely, personally, tuck the arms. I'm usually helping position the head, bed, and addressing peri-induction issues, putting on bear hugger (not in this case), or whatever. the surgeons usually do the tucking, and rather quickly after induction, when there is a lot for me to be busy with. So this was not somthing I was personally involved with. So I can't really say how secure they were to begin with.

2) Re depth of anesthesia: You are probably right, clearly they weren't deep enough, but I had very little indication of that. And yes pressure on the trachea wouldn't be expected to cause that dramatic of an effect. So I learned one there.

3) Size of problem: It's started sinking in over the course of the day, how it really is a SMALL problem overall. I think it was blown up in my mind because of how big a deal the surgeons were making it with their comments and non-verbal communication skills.

4) Access to airway: The surgical field towels were placed as far north as teh forehead and then half sheets placed over and "kelly'd" down. As I looked under there, to peel up the drapes on teh patients head would have created a sizeable gap that would have communicated with the surgical field. There was no fold placed in the drape to seal off the face. I hope that makes sense. The location of poles, height of sheet, were immaterial issues considering how she was prepped. Yes I found it annoying, commented on it at the beginning of the case, as airway issues are what kill thyroid patients, and obviously was not forceful enough in what I wanted. I figured I'd cope....

5) Grabbing the arm: All I was expecting them to do was to push down on the field where her arm was encroaching, and if need be, grab her arm/wrist or whatever presenting part was migrating under the drapes toward the exposed field. They did not do this... Only one of them had the needle driver (the one on the opposite side of the movement. The other had the sucker and was basically watching. In the end, one of the surgeons contaminated their hand anyway, and yes they sort of redraped part of the field and threw some more half-sheets down after reprepping a bit.

6) Surgeons caring about wake-ups: I find this to be rather variable. I find that some surgeons do care enough to make it a point to ask for a no-buck wake up at the beginning (if possible). These residents did not ask for this, in fact they were sufficiently overwhelmed for some reason at the start of the case, that the PGY5 had forgotten to put on his loops, and had the circulator do it for him while sterile, and I drew the pre-op PTH level for them on one of the feet right after induction, because I felt like being a nice guy aand felt like I could do that and handle all the peri-induction stuff like minor hypotension (which we did have) by myself. The staff was out of the room. Also, from what I can tell it is relatively standard practice among my colleagues to attempt a narcotic wake up for neck cases given that several of the surgeons ask for this anyway. The length of wake-up is obviously style points, and a turnover issue, one that in this case I prioritized too much. But knowing I was using sevo at 1.3 MAC with no nitrous for 3 hours, I knew it would take a little while for it to come off unless I made a head start.

 

[swpm]

Heh. I read the thread title and was expecting to read about an intraoperative death. If this is the worst thing that happens to you, you'll have a good year. Surgeons are often jerks. They are that way because they're bitter about having chosen the wrong specialty.

 

[johankriek]

my advice.. Dont worry about a perfect timing wake up.. really it doesnt amount to a hill of beans.. especially at an academic center where there is zero efficiency at all. keep them deep until they are done.. really done. you can lighten up a little but not too much.. the issue with face procedures and the like is the patient needs to be deep or awake there is no in between. In between will get you in trouble like what you had.So it will take you longer to wake the patient up.. so what.. it takes them hours to drape patients at academic centers. anyway.. good case.. excellent learning point. now you know.. keep them deep. in those kind of cases.. lighten up when the drapes are off or when the last stitch is in. The attitude that the surgical staff demonstrated will not last 2 days in any private environment.

 

[Fastrach]

Just to address a few of the points raised, in no particular order:

But knowing I was using sevo at 1.3 MAC with no nitrous for 3 hours, I knew it would take a little while for it to come off unless I made a head start.

Umm.... 3 HOURS for a parathyroidectomy?!?!? Wow... what a bunch of hacks. We knock these out routinely in less than an hour, 1.5 hrs if they have to dig a little further.

Sounds like your slightly light anesthesia is the least of their problems, so I wouldn't sweat it too much. But that tracheal stimulation on these cases is classic for catching people off guard. I'd recommend 0.5mg/kg lidocaine IV just around the time when that's a possibility.

Also, has anyone else used these ETT's with NIM monitors built into the cuff for these cases? We've started using them so we can tell if any nerves get bagged, seem to work pretty well so far.

 

[bne_12mne]

...based on the thread title. I don't think I would ever post in detail on the internet about an intraop death. Too much potential medicolegal baggage.

And yes, I'm realizing this is a small deal. But I was still pretty pissed and embarrassed at the time...

 

[bne_12mne]

Yeah, today was conference day, so the surgical start was 10:15am and this even occurred at 12:45pm, and they were at least 15-20 min still to go at the rate they were working. After it was all said and done because of the high PTH, and them going back in, it was like a 5 hour case. They rechecked the original post-resection lab, and we sat there and waited, then we waited for them to make the decision to go back in, then the same thing all over again (though fortunately a little quicker this time). Again this was a redo, so there was some scarring on the right side which made the 2 1/2-ectomy they were doing take a bit longer than normal. But yes, still too slow... Although in general, I have no problem waiting for junior residents, because I too am a junior residents and don't like to be rushed through my learning opportunities...

 

[lvspro]

Hi
I've had a cuppla "moving towards noxious stimuli" events. All happened when trying to get the timing perfect along with a smooth wake-up. It happens, and I'm sure the surgeons made a few boo-boos during residency too. Either way, I've learned exactly what you said... keep 'em deep until you see the last 2-3 stitch mark being reached. If they're breathing spontaneously, then they seem to wake up faster despite being at a full MAC, or even 1.2 MAC (needed that for an OH abuser yesterday).
For smoother wakeups, I've started titrating in morphine mid-case, and for shorter cases fentanyl seems to work. I know, resp depression blah blah blah, but if you titrate them in while watching resp rate then you should be fine. Toradol works wonders here too. I wish we had remi (and precedex) but being careful with morph/fent is working fine for me.
About the surgeons moving your pt thing... unacceptable. They are not to touch YOUR Pt until you have them disconnected, and you give the signal. If they have a problem with that, call your attending and explain to him how the surgeons have decided that moving a fully wired pt without control of the head/neck was an appropriate move. He'll have a field day with their a$$es.
I've had a couple of complex cases, and having a fully draped head shouldn't be much of a problem as long as you have easy access, meaning you should be able to pop your head under the drape, to the airway.
Finally, pts don't remember b/c they're in stage 2, or maybe even 3, so the event is not remembered. Even so, it sucks for us when it happens b/c you feel kinda foolish, but don't sweat it and learn from it.

About the bis monitor, I use that thing to see how deep my pt gets during induction, and keeping them above 45, then it's pretty much useless after that. Like the other poster mentioned, it has a serious lag. it goes from 45-96 about 40-70 seconds after the pt moves, but by then it's a little late.

 

[gasnewby]

[/b]

Umm.... 3 HOURS for a parathyroidectomy?!?!? Wow... what a bunch of hacks. We knock these out routinely in less than an hour, 1.5 hrs if they have to dig a little further.

your guys remove 4-5 parathyroid glands in under an hour? i doubt it. an adenoma perhaps, if you have preop localization and don't have to dig around.

 

[IceDoc]

What do you all think?

I think if that's the worst that happens to you in 3 years, then more power to ya.
As far as I can tell, you have a bruised ego and the patient has a very slightly increased risk of wound infection (rare in face/neck).
As a pointer, you may think a patient is deep, and then that tube gets moved a little and the coughing starts.

 

[bne_12mne]

that's hopefully the end of the story.

I've definitely experienced the phenomenon of slight movement of the tube starting the cough. typically happens when they are finishing up head/neck cases, and brush the drapes across the tube, knock into it, or whatever when you are emerging. but there was no cough, breath, nothing of the sort in this case. just arm movement. the pips, etco2 waveform were unchanged. that's part of what caught me off guard.

 

[toughlife]

Two days ago I had two thyroids and two parathyroids in 8 hours. All pts were above 65 y/o. I keep it simple and run them all on sevo, no nitrous, no narcotics except on induction and just a touch of propofol at the end when I am going light on the agent and extubate deep to avoid bucking or coughing. Nothing else and it works great. I get the impression you may have been keeping the pt too light. Like someone above said, they take their time draping and closing so you can also take your time waking up so run the pt deeper to avoid trouble, if needed be.

Crap happens and you just got to roll with the punches. Don't take any **** from surgery residents.

 

[VentdependenT]

You did everything fine. Remember that if you don't get into it with surgeons once in a while then its just not fun. Pt woke up fine so screw em.

You grabbed the propofol which is exactly what I would have done. SUX does the trick too.

THose guys should have tucked the arms better. We don't tuck the arms but we check the pressure points.

 

[Jeff05]

definitely a disheartening experience.

howerver, you must remember that you are the consultant. you are there to optimize operating conditions for the surgeon and keep the patient safe.

imagine the surgeons starting to do the foley and moving the patient while you're trying to intubate...you can appreciate their reaction when a patient start touching the surgical site when they're trying to close.

their response was unprofessional and not constructive. it happens.

as far as the actual case:

your remi infusion may not have hit a therapeutic level - you just started it at the end of the case. 3 mg of morphine is a very small dose. so, basically, all you had on board is 0.6 mac of gas during a stimulating wound closure
(50% of patients move during incision with 1 mac...)

also, i'm not clear why you were running a "slow neo gtt?"

 

[bullard]

A few random thoughts from another CA1:

1) Remi is cool for these kinds of cases, but unnecessary.

2) Add some nitrous, especially when you're working with residents. Increases your MAC and allows you to ditch that neo gtt. Use a bunch of antiemetics to compensate if you want.

3) Some of my attendings swear by using the LTA for these cases, especially when working with residents jerking around the trachea.

4) We use those special NIM ETTs sometimes. They are really big and probably don't work.

5) Who gives a sh i t if the patient bucks? When did these guys become neurosurgeons?

 

[Tenesma]

dude

this happens and is part of the learning experience - it will make you tougher

i think as a rule of thumb you should always check ALL pressure points - as you are just as liable for any nerve damage that may occure from positioning - that usually a good time to also make sure the patient is snug without too much pressure

for the most part there is not a lot of pain with these types of procedures - and remi (if your institution can afford it) is quite the nice luxury...

however, as a rule of thumb when it is the attending and/or senior/fellow closing then you can go for the quick impressive wake-ups because their speed is very predictable - if anybody is closing then do a sluggish anesthesia and slow wake-up.... if they give you any lip tell them that if they have the right to close at a snail's pace then you are going to wake the patient up at a snail's pace...

also when people are itching to move a patient and you aren't ready - then you tell them to STOP - that you are not assisting with any move until you are completely ready - being rushed really increases the risk of tearing out an IV or yanking on something you don't expect...

i would also talk to the patient to check for intra-operative awareness and if she has any questions then I would answer with honesty (but check with your attending first about how to address that)..

 

[toughlife]

dude

this happens and is part of the learning experience - it will make you tougher

i think as a rule of thumb you should always check ALL pressure points - as you are just as liable for any nerve damage that may occure from positioning - that usually a good time to also make sure the patient is snug without too much pressure

for the most part there is not a lot of pain with these types of procedures - and remi (if your institution can afford it) is quite the nice luxury...

however, as a rule of thumb when it is the attending and/or senior/fellow closing then you can go for the quick impressive wake-ups because their speed is very predictable - if anybody is closing then do a sluggish anesthesia and slow wake-up.... if they give you any lip tell them that if they have the right to close at a snail's pace then you are going to wake the patient up at a snail's pace...

also when people are itching to move a patient and you aren't ready - then you tell them to STOP - that you are not assisting with any move until you are completely ready - being rushed really increases the risk of tearing out an IV or yanking on something you don't expect...

i would also talk to the patient to check for intra-operative awareness and if she has any questions then I would answer with honesty (but check with your attending first about how to address that)..

Agree and I often see the surgeons do local infiltrations with marcaine at wound site. This decreases your post op pain significantly as expected.

 

[Fah-Q]

A few random thoughts from another CA1:

5) Who gives a sh i t if the patient bucks? When did these guys become neurosurgeons?

In response to bucking during neck cases. Yes, surgeons do care, especially if no drain is left in the neck (often the case in parathyroids). If you let them buck and/or become hypertensive during wake-up they will bleed into the wound. During thyroid/parathyroid surgery the central neck compartment is being dissected and it doesn't take much blood there to cause airway compression. Ever re-intubated an emergent takeback for neck hematoma? Not so fun.

Sorry to the OP for such a poor experience. **** happens and everybody in the room learned something that day.

 

[VentdependenT]

In response to bucking during neck cases. Yes, surgeons do care, especially if no drain is left in the neck (often the case in parathyroids). If you let them buck and/or become hypertensive during wake-up they will bleed into the wound. During thyroid/parathyroid surgery the central neck compartment is being dissected and it doesn't take much blood there to cause airway compression. Ever re-intubated an emergent takeback for neck hematoma? Not so fun.

Sorry to the OP for such a poor experience. **** happens and everybody in the room learned something that day.

It is impossible to guarantee that the patient will not "buck" during extubation or emergence (in which case it would be a cough). How is that different from the scenerio you mention other than its happening at the the end of the case.

 

[bne_12mne]

Thanks for all the comments. I didn't expect this thread to get so much attention, but it's great. Really I just wanted to vent.

Today, the day after went well thankfully to all those concerned...

As for some of the recent comments.

1) How long the remi had been on: It should have been quite therapeutic as it had been running 20+minutes at 0.1mcg/kg/min, so that's >3 half-lives to reach near steady state. The neo was required to maintain a pressure of 90/60 once the remi took effect. Do others find it necessary to run occasionally run neo when they are adding remi to their anesthetic? Part of my narcotic dosing, morphine 3mg/remi at 0.1mcg/kg/min with residual 0.7 MAC of volatile was based on the assumption that the surgey was not that painful and should have been adequately covered. So in my view, the neo was only required because the remi was working, if that makes sense. There was no foley, and she was a small woman, so the 1.5L of fluid I gave through the case seemed more than enough. I didn't want to push the volume issue much more.

2) Surgeons caring about neck cases and coughing: In my limited experience, they care as Fah-Q has pointed out, hence my anesthetic plan. Obviously there are no guarantees, but I thought it worth an attempt. And by the way, it worked great in the very end. No cough.

3) Awareness: Checked today after my cases, she had none. She was very grateful for the anesthetic she received. I did not suspect she'd have awareness however.

4) Jeff05: Your counterpoint about not wanting them placing the Foley while I'm intubated is well taken and appreciated, however I think it is a bit of a different animal. It's not like I was intentionally moving the patient's head or the drapes. But I do understand the surgeons consternation.

5) Use of nitrous: I had been using it almost routinely for my first several months. But as we all know, nitrous has it's downsides too (different topic). So I was avoiding it in this case, and was using remi basically like I would have used nitrous.

6) Remi as a luxury: Hadn't thought much about it. Guess I'll be more choiceful from now on. Just trying to learn a few different techniques. Where I'm training, if you don't push for things to learn, they won't spoon feed you (meaning the attendings). Sound familiar?

BNE

 

[Voodoo]

After reading the story, all I can say is:

Congratulations! Good job on the case and for not falling asleep during that case. Things happen and patients buck. It comes on unexpectedly sometimes to EVERYONE. It won't be the first or last time for you.

The thing you can take home from this is not about anesthetic technique - it's about relationships. Understand that sometimes confrontations will happen, and don't be scared to stand up for what you believe is right.

LTA may not help in this case because it's 3 hours long. Unless you spray marcaine with epi on the cords and maybe add some clonidine and fairy dust

And realistically, if a bucking patient concerns the surgeon after their thyroid surgery, maybe you should refer them back to a pig's foot and suggest they learn how to sew. I'm not saying you should TRY and make the patient buck, but people with large tubes in their larynx OCCASSIONALLY buck - it's a scientific fact just like that blondes have more fun.

Good job, keep up the diligent work, and don't let snippy residents ruin your day. They're just pissed off because they see how good you have it.

 

[nimbus]

In response to bucking during neck cases. Yes, surgeons do care, especially if no drain is left in the neck (often the case in parathyroids). If you let them buck and/or become hypertensive during wake-up they will bleed into the wound. During thyroid/parathyroid surgery the central neck compartment is being dissected and it doesn't take much blood there to cause airway compression. Ever re-intubated an emergent takeback for neck hematoma? Not so fun.

Sorry to the OP for such a poor experience. **** happens and everybody in the room learned something that day.

I believe this is a fallacy. In practice for 14 years. Despite my best efforts, had many patients buck/cough/retch in OR or Pacu. No neck hematomas as a result. Neck hematomas are caused by inadequate surgical hemostasis. When can these folks start coughing like the rest of us?

 

[Fah-Q]

I believe this is a fallacy. In practice for 14 years. Despite my best efforts, had many patients buck/cough/retch in OR or Pacu. No neck hematomas as a result. Neck hematomas are caused by inadequate surgical hemostasis. When can these folks start coughing like the rest of us?

Never seen a hematoma? You better knock on wood. How many of your neck cases get drains? How big? What style?

I definitely agree that most hematomas are the surgeons fault, but I've seen a handful that were clearly the result of a rough wake-up. A smooth wake-up is more than just style points in a neck case in my opinion.

I'm not sure anyone has good data on the coughing question but we always tell them 24 hours. Again, no real science behind that but it seems the thrombi should be well organized by then.

Ever wondered why we ask for a Valsalva before closing the neck?

 

[huktonfonix]

The valsalva is great for checking venous bleeders which may be at risk with the coughing, bucking etc.... The arterial bleeders may also be at risk with increases in BP but those usually should be ok if adequate hemostasis is achieved. I'll try to wake em up as smooth as possible but its all about risk vs benefit. If the pt. was a ridiculous airway then they get the fully awake extubation and hopefully the narcotics/lidocaine will keep them from bucking.

 

[Tenesma]

surgical sites bleed ... nature of the beast... not to mention that when somebody bucks against the tube it is not comparable to coughing without the tube....

so if somebody coughs in the PACU who is the surgeon going to blame poor hemostasis on??? gimme a break

sure hematomas occur - not all of them cause airway problems - and quite a few hematomas actually occur a day or so later - and who is the surgeon going to blame for that?

 

[bullard]

During my month of ENT anesthesia, I took care of thyroids, parathyroids, radical neck dissections, etc. Was not asked for a Valsalva at any point. Not once.