case advice

[KungPOWChicken]

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So I had this I+D for a breast abscess that was scheduled as a mac. Patient was sedated had some fentanyl on board, breathing about 12 wasn't responding to voice, and was obstrucing a bit. Anyway, the surgeon start with some local which was fine but as soon as she made the incision the patient starting going ape ****, pulling at the drapes. I tried to calm her down which I couldn't so I turned off the propofol infusion and let her wake up a bit so she would listen. That didn't happen so I decided to stick in an LMA. Anyway, would you have done anything differently. I'm thinking I should have just deepened her with some blasts of propofol but I thought that might make the situation worse. She wouldn't even let me put a mask over her face before induction.

 

[drccw]

Was the abscess secondary to IVDU? I have a rule... no MAC for drug users. I go the LMA route....

 

[seinfeld]

likely inadequate local by surgeon or the tissue is too acidic for the local to work effectively. Most surgeons where i work want general when they book MAC, thinking they help the patient by not having an airway device, just turns into general with Oral Airway or LMA. I am doing less and less MAC unless i know the surgeon is able to tolerate a talking patient.

 

[urge]

I would have deepened. If breathing became an issue, lma would follow.

 

[Tenesma]

i would have given 100-150mg of propofol then +/- LMA vs holder her jaw for a bit...

for drug users the rule of thumb is an ETT in my book - you can't trust them or their NPO status...

 

[Gaseous Clay]

I am curious as to what number you were running the propoful infusion. I definitlely do not enjoy "MAC" cases. The only times patients have gone wild on me are during C/S's. In those cases, some versed and ketamine with possibly some fentanyl do quite well.

 

[ucsfgaspain]

This is of course a gross generalization but I think it has more truth than untruth:
Surgeon's impression/ expectation of MAC = General anesthestic without a secure airway

But somehow since there is no tube in...it is deemed safer.

Of course this couldn't be any farther from the truth.

That's why I hate MAC's.

Agreed about IVDA's or opioid tolerant patients. Usually if I must do them as a MAC I try to hit other receptors besides the opioid ones. So I've found that if you hit the other receptors i.e. NMDA, histamine, apha 2: ketamine,benadryl, actually haven't tried precedex you seem to do all right.

 

[KungPOWChicken]

thanks for your replies. I was running her at 140 initially and had titrated it down to 100 just before the local cause she was obstructing. a bit. The sats went down to mid 80's briefly. I've added versed in other cases with good success but only when patients squirm a bit or wake up a bit. this chick went crazy. Ketamine is a good option to. How much would you give. 20mg???

 

[drccw]

Propofol of 140 mcg/kg/min?

That's not a MAC dose. Nor is 100 mcg/kg/min. That's a GAWAC aka General Anesthesia without Airway Control... Make life easier. Just make it a GA. LMA, OET, whatever it takes....

If I run Propofol for a MAC, ie eyeball or fistula placement I bolus 30-50 mg then run it at 30-40 mcg/kg/min....

I am a big fan of the other receptor idea: I really like the NMDA receptor in the IVDU or opiod tolerant. 0.5 mg/kg after induction and before incision tends to help sort things out better for post-op

 

[huktonfonix]

I usually titrate in the ketamine 10mg at a time or for select cases mix it in with the propofol at 2 mg/cc.

 

[cubs3canes]

MIdazolam only MACs. A little Fentanyl maybe. I leave the propofol in the syringe in case I need to go LMA.

I have been known to make sure with the surgeon that it is okay if the patient talks a little.

Cubs

 

[Gaseous Clay]

thanks for your replies. I was running her at 140 initially and had titrated it down to 100 just before the local cause she was obstructing. a bit. The sats went down to mid 80's briefly. I've added versed in other cases with good success but only when patients squirm a bit or wake up a bit. this chick went crazy. Ketamine is a good option to. How much would you give. 20mg???

That is the reason I hate MAC is that it is very tricky, at least to me, to titrate propofol where the patient is asleep, doesn't move, and has adequate spontaneous respirations. In fact, I am doing some AV fistulas tomorrow and I basically want to tell the attending that I want to do LMA for all of them.

Ketamine 20 mg is a reasonable first dose. Off the top of my head, I want to say the dose is 0.25 mg/kg. For the OBers (crazy sections), I usually start with versed 2-4 then ketamine 20 mg and add 10 mg until they calm down.

 

[seinfeld]

sounds like this MAC = General thing is more common than i thought, I thought it was just what the surgeons where i worked wanted. I feel that surgeons define GA as something that involves an advanced airway device. Perhaps the newer surgeons dont know that you can use a mask and call it a GA.

 

[Laurel123]

The surgeons will never learn. Actually I'm sitting here today doing a MAC for a foot when the surgeon says 'I think the patients moving.... yeah, the patient is moving!!' I just looked at him. After a wierd pause it dawns on him, and reaches for a little more local.

Also, the other night I was working with an ortho doing an abdominal wound superficial closure (why the hell is an ortho doing that, dont ask) The patient had an LMA in and obviously breathing spontaeously. When he cuts he exclaims 'patient is awake!' I assure him patient is asleep because otherwise she would pull out the LMA and ask him to stop cutting her. Then he complains that the patient is feeling pain because she is moving. And it took five minutes of explanation including a demonstration by having him put his hand on his belly, to she show him that the patient was breathing and patients always breathe during surgery, they just dont usually notice it since they are working on the extremities.