Case- Neuro Exam under anesthesia and other questions

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Katheudontas parateroumen

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Hello everyone, a few basic questions for you all about the utility of a neuro exam under anesthesia.

Pt- 40yM with NICM EF ~20%, hx of VT/VF events s/p AICD placement admitted for CHF exacerbation. Had a weight gain about 10kg over past week and observed decrease in UOP. He's getting a bumex drip seems while on the floor and seems to be responding well and getting tuned up for a AICD CRT upgrade during the admission. He was admitted about 4 days prior to my encounter.

As a resident, I cover the airways at night. I get called to this guy's room at 3AM for code blue. Nurse says she saw tele say VF/VT and she finds him unconscious lying on the floor. She does CPR for a couple minutes and gets pulses back. AICD apparently fired multiple times. I get to the room and pulm crit fellow is already there and RT is aggressively bagging due to reported agonal breathing but has pulse and good O2 sat. I'm busy trying to get my airway stuff ready, so to be honest, I don't remember what the rhythm was on the monitor but I believe it was reported NSR by the time I get there. A couple minutes while i'm there, the patient starts waking up screaming and moving everything. Pulm fellow still wants to intubate so I let him do it. He slugs him with like 30mg of etomidate and 50mg Roc and gets the tube in. Here, I am thinking my job is over and about to leave and I notice on monitor HR is in the 40s. I ask them to check a pulse. The Pulm fellow checks the patient's eyes and yells both eyes are fixed and dilated and has no occulocephalic reflex. Check pulse he's got nothing of course. ACLS again and get ROSC. They end up doing STAT Head CT and negative except for possible chronic lobe infarct, nothing acute. He's apparently following basic commands the next morning on chart check.

My question is I don't feel if I learned this completely, but how useful is a neuro exam under anesthesia? I believe that we lose ALL our brainstem reflexes in a sequential matter from medulla to pons under GA. Does etomidate or any of the other agents cause pupillary dilatation after induction? I know emergence causes pupilary changes during "stage 2". Also, what do you think about intubating a guy after he apparently wakes up from his VT? Also, what's the word on a case like this for targeted temperature management?

Thanks!
 
Katheudontas parateroumen said:
Hello everyone, a few basic questions for you all about the utility of a neuro exam under anesthesia.

Pt- 40yM with NICM EF ~20%, hx of VT/VF events s/p AICD placement admitted for CHF exacerbation. Had a weight gain about 10kg over past week and observed decrease in UOP. He's getting a bumex drip seems while on the floor and seems to be responding well and getting tuned up for a AICD CRT upgrade during the admission. He was admitted about 4 days prior to my encounter.

As a resident, I cover the airways at night. I get called to this guy's room at 3AM for code blue. Nurse says she saw tele say VF/VT and she finds him unconscious lying on the floor. She does CPR for a couple minutes and gets pulses back. AICD apparently fired multiple times. I get to the room and pulm crit fellow is already there and RT is aggressively bagging due to reported agonal breathing but has pulse and good O2 sat. I'm busy trying to get my airway stuff ready, so to be honest, I don't remember what the rhythm was on the monitor but I believe it was reported NSR by the time I get there. A couple minutes while i'm there, the patient starts waking up screaming and moving everything. Pulm fellow still wants to intubate so I let him do it. He slugs him with like 30mg of etomidate and 50mg Roc and gets the tube in. Here, I am thinking my job is over and about to leave and I notice on monitor HR is in the 40s. I ask them to check a pulse. The Pulm fellow checks the patient's eyes and yells both eyes are fixed and dilated and has no occulocephalic reflex. Check pulse he's got nothing of course. ACLS again and get ROSC. They end up doing STAT Head CT and negative except for possible chronic lobe infarct, nothing acute. He's apparently following basic commands the next morning on chart check.

My question is I don't feel if I learned this completely, but how useful is a neuro exam under anesthesia? I believe that we lose ALL our brainstem reflexes in a sequential matter from medulla to pons under GA. Does etomidate or any of the other agents cause pupillary dilatation after induction? I know emergence causes pupilary changes during "stage 2". Also, what do you think about intubating a guy after he apparently wakes up from his VT? Also, what's the word on a case like this for targeted temperature management?

Thanks!
Click to expand...
I'm sorry, KP, you seem to be a good person, but I wouldn't graduate you in a month, as a CA-3, if you were my resident. The lack of JUDGMENT in this post is CRIMINAL, from all parties involved.

(This seems to be par for the current generations of trainees. Their relatively frequent lack of medical knowledge and/or common sense should be scary and unacceptable beyond the first year.)

A few obvious questions:
1. WHY intubate a post-arrest patient who not only has regained consciousness, but is also doing the right things, i.e. screaming and moving everything?
2. WHY use 30 mg of etomidate on ANYBODY's intubation, not to mention on an EF<20% barely post-ROSC patient? And, most importantly:
3. WHY, as a graduating CA-3, stand there like a ***** and tolerate this to happen to a patient, without even trying to intervene, when YOU are the most expert person in inducing and intubating present? And, after it happened,
4. WHY not file some kind of patient safety report, or at least send an email to the PDs, and make sure that the "fellow" doesn't get to kill some patients as part of his/her "education"?
5. And WHY, for God's sake, WHY not ask some of these questions from that stupid fellow, at a time when it would have actually made a difference for the patient? (Especially since some of them have common sense answers.) When you let somebody do something stupid to a patient in your presence, without speaking up, you can be considered an accomplice, did you know that?

You becoming a critical care fellow in a month... scary.

And this is why residents/fellows should not be allowed to cover intubations/codes alone, just because the hospital wants to save a buck.

Congratulations to the patient for surviving an assassination attempt from the American medical system. Maybe, on Memorial Day, we should also remember the millions of patients who didn't.
 
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FFP said:
I'm sorry, KP, you seem to be a good person, but I wouldn't graduate you in a month, as a CA-3, if you were my resident. The lack of JUDGMENT in this post is CRIMINAL, from all parties involved.

(This seems to be par for the current generations of trainees. Their relatively frequent lack of medical knowledge and/or common sense should be scary and unacceptable.)

A few obvious questions:
1. WHY intubate a post-arrest patient who not only regained consciousness, but is also doing the right things, i.e. screaming and moving everything?
2. WHY use 30 mg of etomidate on ANYBODY's intubation, not to mention on a <EF 20% barely post-ROSC patient? And, most importantly:
3. WHY, as a graduating CA-3, stand there like a ***** and tolerate this to happen to a patient, without even trying to intervene, when YOU are the most expert person in inducing and intubating present? And, after it happened,
4. WHY not file some kind of patient safety report, or at least send an email to the PDs, and make sure that the "fellow" doesn't get to kill some patients as part of his/her "education"?
5. And WHY not ask some of these questions from that stupid fellow, at a time when it would have actually made a difference for the patient? (Especially since some of them have common sense answers.) When you let somebody do something stupid to a patient in your presence, without speaking up, you can be considered an accomplice, did you know that?

You becoming a critical care fellow in a month... scary.

And this is why residents/fellows should not be allowed to cover intubations/codes alone, just because the hospital wants to save a buck.

Congratulations to the patient for surviving an assassination attempt from the American medical system. Maybe, on Memorial Day, we should also remember the millions of patients who didn't.
Click to expand...
FFP I respect you very much so on this forum. I would have expected such a response from you and criticism. I understand where you are coming from. My role is to cover airways as needed. The pulm fellow was there first and wanted to run the show. At that point, I was not needed. i know that is probably the wrong mindset and something that I need to speak up on for patient safety sake. When the pulm fellow was already doing his thing, i was asked my presence was not needed anymore. So i am not the one in control of what the person is asking for pushing meds etc. I would never have done what he had done and I recognize that he is clearly less experienced than I am. Both with the decision to intubate and the induction and monitoring afterwards and even how the was the code was ran. To be honest, i debriefed this with my attending who was present after the fact and he asked me why I didn't intervene when I saw things weren't being done. Honestly, I felt like i was stepping on toes and didn't feel it my place. I felt it in my gut to say/do something but didn't. I was wrong. Interesting thing is the patient arrested again in the ICU shortly afterward and I was more vocal about helping the medicine team and pt's lucky to be alive. I guess this was more of a lesson on team interactions/dynamics.
 
Katheudontas parateroumen said:
Hello everyone, a few basic questions for you all about the utility of a neuro exam under anesthesia.

Pt- 40yM with NICM EF ~20%, hx of VT/VF events s/p AICD placement admitted for CHF exacerbation. Had a weight gain about 10kg over past week and observed decrease in UOP. He's getting a bumex drip seems while on the floor and seems to be responding well and getting tuned up for a AICD CRT upgrade during the admission. He was admitted about 4 days prior to my encounter.

As a resident, I cover the airways at night. I get called to this guy's room at 3AM for code blue. Nurse says she saw tele say VF/VT and she finds him unconscious lying on the floor. She does CPR for a couple minutes and gets pulses back. AICD apparently fired multiple times. I get to the room and pulm crit fellow is already there and RT is aggressively bagging due to reported agonal breathing but has pulse and good O2 sat. I'm busy trying to get my airway stuff ready, so to be honest, I don't remember what the rhythm was on the monitor but I believe it was reported NSR by the time I get there. A couple minutes while i'm there, the patient starts waking up screaming and moving everything. Pulm fellow still wants to intubate so I let him do it. He slugs him with like 30mg of etomidate and 50mg Roc and gets the tube in. Here, I am thinking my job is over and about to leave and I notice on monitor HR is in the 40s. I ask them to check a pulse. The Pulm fellow checks the patient's eyes and yells both eyes are fixed and dilated and has no occulocephalic reflex. Check pulse he's got nothing of course. ACLS again and get ROSC. They end up doing STAT Head CT and negative except for possible chronic lobe infarct, nothing acute. He's apparently following basic commands the next morning on chart check.

My question is I don't feel if I learned this completely, but how useful is a neuro exam under anesthesia? I believe that we lose ALL our brainstem reflexes in a sequential matter from medulla to pons under GA. Does etomidate or any of the other agents cause pupillary dilatation after induction? I know emergence causes pupilary changes during "stage 2". Also, what do you think about intubating a guy after he apparently wakes up from his VT? Also, what's the word on a case like this for targeted temperature management?

Thanks!
Click to expand...
Some people forget what it was like to be a resident. Short of putting the Pulm CCM fellow in a headlock, you can’t stop people above you in the medical hierarchy from doing dumb stuff.

A Neuro exam while paralyzed is essentially pupils. Intubating someone who is awake and stable-adjacent after this is probably not necessary (hopefully can get to an ICU for adult supervision to see if it keeps happening). TTM could go either way - if they do get long acting NMB you could reverse and hold sedation and see if they wake up and what their Neuro exam is.
 
Regardless of other details for this case, side note on dosing:
30mg of etomidate suggests someone was thinking 0.3mg/kg and the patient was likely around 100kg as most patients seem to be. Yet 50mg of roc was used. This is stupid.

I don’t know what it is about non-anesthesiologists choosing doses but they seem to think 1 vial has to be enough. Granted they aren’t the same level of aspiration risk as a small bowel obstruction but these patients are more likely than not true full stomachs.

It’s painfully obvious when i hand off a patient reversed with sugammadex to some ICU docs that a lot of them don’t even know what sugammadex is, so i have a hard time believing that a non-anesthesiologist using 50mg of roc has a clue what they’re actually doing. Sure It’s possible as an anesthesiologist who knows what they’re doing to safely induce a 100kg appropriately NPO gall bladder coming from home with 50mg of roc and intubate without ventilating. This is not the same as a coding presumed full stomach. If their k isn’t through the roof, feel free to just use succinylcholine instead of roc, at least you’ll know it’s circulated when they fasciculate. IDGAF about the risk of myalgias in a patient coding on the floor.

I have seen this way too many times on patients who weigh 300 lbs. It you don’t know how to dose, you shouldn’t be intubating.

Yes, it is possible to aspirate as soon as propofol hits the vein. Aside from the increased difficulty of obtaining a view before muscle relaxation reaches peak effect, I personally think the highest risk point of aspiration is trying to intubate before a belly is completely relaxed and in the case of an SBO stomach full of brown liquid, the abdomen tenses and that full stomach spews out the esophagus.
 
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I have seen this many times by non anesthesia people who have such insane dosing. But sadly it’s a department thing to allow EM, ICU, etc to have first dibs. Which also means we kind of zip up even if they want “80 of etomidate!”. It didn’t used to be that way. I assume it was for educational purposes things changed. Which FFP has said probably leads to a lot of morbidity for the sake of training. I posted this subconsciously I guess knowing all the things wrong with this scenario and that I didn’t step in when I should have. I need to learn.
 
There seems to have been confusion and acquiescence in roles during this episode. I went through the same thing many times during residency when you're called for an airway, but there is much more going on that you can give insight into, albeit prevent further harm. However this is difficult in a closed unit where there's someone else running the show and it's 3am.

Its surprising how few intubations some of the pulm fellows had where I trained. You probably should have taken control of the airway when the decision was made to intubate (being that you were in agreement). Sounds like this guys episode of VF must have been quickly converted from his AICD (secondary prevention ftw). I personally wouldn't have intubated this patient given the circumstances. If this patient was going to aspirate they would have already done so during the aggressive bagging episode.

In regards to your targeted temperature management question I don't think it would have a place here due to the fact the patient seemed to be responsive after ROSC, and then you put him into a medically-induced etomidate coma. Also, I've noticed cookie-cutter induction meds over the years by lots of non-anesthesia providers whether it be in the ED or in the ICU that never seem to change based on how sick the patient is. This is a pretty good example of that.

To my knowledge and a quick search there should still be pupillary reflexes (reduced) under GA, however not sure how long after he pushed the etomidate he checked the eyes. Patients should lose their corneal and oculocephalic reflex under induction of general anesthesia, the eyelash test everyone does is basically a poor mans test of this.

See this for a more baller in-depth explanation: A Neurologic Examination for Anesthesiologists | Anesthesiology | American Society of Anesthesiologists
 
Katheudontas parateroumen said:
Hello everyone, a few basic questions for you all about the utility of a neuro exam under anesthesia.

Pt- 40yM with NICM EF ~20%, hx of VT/VF events s/p AICD placement admitted for CHF exacerbation. Had a weight gain about 10kg over past week and observed decrease in UOP. He's getting a bumex drip seems while on the floor and seems to be responding well and getting tuned up for a AICD CRT upgrade during the admission. He was admitted about 4 days prior to my encounter.

As a resident, I cover the airways at night. I get called to this guy's room at 3AM for code blue. Nurse says she saw tele say VF/VT and she finds him unconscious lying on the floor. She does CPR for a couple minutes and gets pulses back. AICD apparently fired multiple times. I get to the room and pulm crit fellow is already there and RT is aggressively bagging due to reported agonal breathing but has pulse and good O2 sat. I'm busy trying to get my airway stuff ready, so to be honest, I don't remember what the rhythm was on the monitor but I believe it was reported NSR by the time I get there. A couple minutes while i'm there, the patient starts waking up screaming and moving everything. Pulm fellow still wants to intubate so I let him do it. He slugs him with like 30mg of etomidate and 50mg Roc and gets the tube in. Here, I am thinking my job is over and about to leave and I notice on monitor HR is in the 40s. I ask them to check a pulse. The Pulm fellow checks the patient's eyes and yells both eyes are fixed and dilated and has no occulocephalic reflex. Check pulse he's got nothing of course. ACLS again and get ROSC. They end up doing STAT Head CT and negative except for possible chronic lobe infarct, nothing acute. He's apparently following basic commands the next morning on chart check.

My question is I don't feel if I learned this completely, but how useful is a neuro exam under anesthesia? I believe that we lose ALL our brainstem reflexes in a sequential matter from medulla to pons under GA. Does etomidate or any of the other agents cause pupillary dilatation after induction? I know emergence causes pupilary changes during "stage 2". Also, what do you think about intubating a guy after he apparently wakes up from his VT? Also, what's the word on a case like this for targeted temperature management?

Thanks!
Click to expand...
"Checking the eyes" and their reflexes never would have crossed my mind. Thats a bizarre and scarily bad thought from the fellow.

This case seems like its all cardiac related. The guy had an arrythmia and was transiently coding.

Why are we concerned about his brain? Based on the fellows observation of "dilated pupils"

He has lots of reasons to have dilated pupils. Just coded. Probably got epi/other drugs. Got heavy anesthesia induction. WHO CARES ABOUT THE EYES.

I would have let him try breathing on his own with a NRB and 100% fio2 before intubating once he awakened.
 
**** happens man, all you can do is learn from it.

Couple years back i had a neurosurg fellow wanted to admit a tbi to our icu 'for a few hours to palliate him'. Same story-ish to yours he did a neuro exam and found him brain dead, not triggering the vent etc. This was about 10 mins after the patient had been intubated with 100mg Roc...

so like lazarus we brought him back from the dead in about 5seconds with some bridion and off he went to the OR. He was never great after but better than dead

Stupid people are everywhere, i mean ffp is right here... But as you go along in work you have to decide if that stupid person is just going to putter around for a while and harm no-one or is he actually going to murder someone right now.

In this case, this stupid **** was about to murder someone. In those instances you need to find ways to distract them. Remember he is stupid so stupid people are easily distracted or turned around. You can say things like, oh - looks a difficult airway best get him to icu first with the glidescope etc then you can tube

Bla bla bla...
In general you need to praise stupid people, then you can win them over and change their minds... A fellow is obviously above you in the pecking order so this is hard but you can do it with distraction

ffp, you're great!
 
To be clear about this post, i wouldn’t have intubated this guy after him regaining consciousness. I would have definitely placed a non rebreather and watched him closely and see if he continues to become more lucid. At that point I would have transferred him to the CCU because he did have an arrhythmia arrest and cpr. This whole situation would have been avoidable possibly. I have been thinking more about that zentensivism stuff. I think a lot of people would have jumped the gun and thought code = tube. Another part of me was thinking that this is not going to be my patient, it was going to be the fellow’s team etc. it was some of that feeling that made me question if I should say anything. He made the decision to intubate and I didn’t feel like I had the right at the moment to say Hey No dude don’t. But I probably should have. I actually didn’t hear anyone say give 30 etomidate, I only read it afterward in the notes. By the time he decided to intubate and going down that road, he already said hey don’t need you here.

my thing about this post was that I outwardly heard the fellow say he was checking the eyes when I finally said you guys need to check this guys pulse. He’s Brady after your intubation. I wanted to say hey man you lose your reflexes when you induce anesthesia. But then I don’t remember if someone gets pupilary dilitation. I have read that article said above before. But it doesn’t mention light reflex on induction.
 
OK, so let me present the educational version of why I so vehemently disagreed, and also how one should approach this kind of situation.

The scenario is based on assumptions, so please correct me if I'm wrong, @Katheudontas parateroumen.

You walked in, they were doing CPR. While you were looking for your blade etc., they told you about the patient. Then, by the time you were just ready to intubate, they got ROSC, and the patient became alive. At this point the fellow announced that he still wants the patient to be intubated. And this is the moment to ask WHY? He gives you BS, maybe he even says that HE will intubate the patient, so it's not your worry. Still, this is the moment when you have to say out loudly, so that everybody can hear: "IN MY OPINION (AS THE AIRWAY EXPERT IN THIS ROOM) THIS PATIENT DOES NOT NEED TO BE INTUBATED." Then, if the ICU team still insists, you take your toys and walk out.

Now let's assume that you're still around, gathering your stuff, when you hear the fellow ask for "30 of etomidate". You would hear it, because they are generally too dumb to draw it up themselves, maybe even to push it. Again, in the loudest voice possible, you announce that it's an inappropriately high dose for a post-arrest patient who also has an EF of 20% on his best day. Again, they can do whatever they want; your role, as a consultant, is to CONSULT, not to police. Then, again, if you're not wanted, you leave the area.

What's the first thing you do next? You document the heck of what just happened, including the patient being intubated against your recommendations (and you explain them in your note), and the overdose of etomidate. Then, if the patient dies from their stupidity, nobody can blame you for saying nothing, like I did. Especially not in a court of law.

The one thing that you do NOT do, is stand around to "help" the ICU fellow. If he wants to intubate, especially inappropriately, he's on his own.

You are almost an attending, KP. Start behaving like one. Your role is of a consultant physician, not of a tech. You are NOT the airway monkey. They don't get to tell you who to intubate, or what to do. They can ask you to evaluate a patient for intubation, and you may do it or not. Never do anything inappropriate just because some other team wants you to. That is especially important for difficult airways. Remember: if they actually knew more than you, they wouldn't need YOU! So don't be afraid to politely put them into their place, regardless of their rank.

YOU are the airway expert, so YOU get to decide what to do about the airway. If they don't like it, they can do it themselves, but make it clear that you won't be a part of it. If they mess up and then call you to bail them out, document the heck out of it. "Called for failed intubation in the patient, after I recommended against and refused to do it myself. Patient blue, no detectable O2 sat etc." Do not cover for reckless physicians; don't pass judgment, but document all the facts. And don't hesitate to report an unsafe doctor, for a big deal like this one; you may save some lives.

That's also the reason I was so tough on you. If you didn't hate me, even for a moment, you will not remember this for long.

P.S. KP posted above while I wrote this, so some of my assumptions were wrong.
 
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Katheudontas parateroumen said:
I have seen this many times by non anesthesia people who have such insane dosing. But sadly it’s a department thing to allow EM, ICU, etc to have first dibs. Which also means we kind of zip up even if they want “80 of etomidate!”. It didn’t used to be that way. I assume it was for educational purposes things changed. Which FFP has said probably leads to a lot of morbidity for the sake of training. I posted this subconsciously I guess knowing all the things wrong with this scenario and that I didn’t step in when I should have. I need to learn.
Click to expand...
That is very unfortunate. If it's a difficult airway, they should NEVER be allowed first dibs. If it's an easy one, why the heck are you there? So that they can feel comfortable f-ing up the airway? Nope.

Where I trained, the ED used to pull the same crap. We occasionally indulged them, but, most of the time, we were like: "call us if you can't get it, bye". One never wants to be part of somebody else's **** up, not in this litigious country. If they insist on having first dibs, they should be on their own. Not fair for the patient, but your family comes first.

As a resident, I have witnessed my attendings refuse even ICU attendings when they wanted to intubate under our "supervision", to maintain their skills. Do not play with sick patients, and don't allow others to. We always told them: if you want to maintain your skills, come to the OR and we'll let you intubate stable elective cases.
 
FFP is correct on all points. It’s a good experience to learn from. Anyone who covered airways without faculty in residency has been in that same position. Most of us have a story that’s nearly identical.

If you’re graduating in a month, I won’t excuse the questions at the bottom of your post.

For residents out there- no need to make the situation confrontational if the fellow disagrees in this scenario. Suggesting transporting the patient to the icu first might be enough to snap the tunnel vision.
 
My CA-3 story: 40 y/o M breathing like 3-4 times/min in the MICU, on face mask. They wanted to intubate, to protect his airway. I asked for Narcan, because of the respiratory rate. After I titrated in about a vial, the patient woke up, told us that he had bitten and sucked on his fentanyl patch. Then, of course, fell back asleep. They still wanted to intubate, for when the Narcan wore off. I said No, make a Narcan drip with about 10 vials in a liter of crystalloid and drip it in. They asked how fast, how long? I said only as fast as it's needed to keep him awake, for as long as it's needed, bye.

They basically wanted me to intubate the patient because they knew how to manage that, but they had no idea how manage a narcotic overdose. So they just wanted the patient intubated until the fentanyl wore off. I had to keep saying No.

As I walked out, I noticed their attending at the end of the hallway. Walked up to him, told him what happened and the plan. He agreed 100% and thanked me. Never heard about that patient again.

There are a number of anesthesiologists who behave like airway or line or epidural monkeys, because they don't want to "make waves". They just do what they are told. IMO, that's absolutely the wrong thing to do. Be polite, be nice, but be thorough and always do the right thing for the patient.

New attendings, remember: you are CONSULTING PHYSICIANS, not techs, not nurses, not trained monkeys, and definitely not other services' b*tches. If somebody punishes you for having done the right thing, the damage to your career (and psyche) will be much smaller than for having done the wrong thing, not to "make waves", and having gotten a bad outcome.
 
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FFP said:
My CA-3 story: 40 y/o M breathing like 3-4 times/min in the MICU, on face mask. They wanted to intubate, to protect his airway. I asked for Narcan, because of the respiratory rate. After I titrated in about a vial, the patient woke up, told us that he had bitten and sucked on his fentanyl patch. Then, of course, fell back asleep. They still wanted to intubate, for when the Narcan wore off. I said No, make a Narcan drip with about 10 vials in a liter of crystalloid and drip it in. They asked how fast, how long? I said only as fast as it's needed to keep him awake, for as long as it's needed, bye.

They basically wanted me to intubate the patient because they knew how to manage that, but they had no idea how manage a narcotic overdose. So they just wanted the patient intubated until the fentanyl wore off. I had to keep saying No.

As I walked out, I noticed their attending at the end of the hallway. Walked up to him, told him what happened and the plan. He agreed 100% and thanked me. Never heard about that patient again.

There are a number of anesthesiologists who behave like airway or line or epidural monkeys, because they don't want to "make waves". IMO, that's absolutely the wrong thing to do. Be polite, be nice, but be thorough and always do the right thing. Trainees, remember: you are CONSULTING PHYSICIANS, not techs, not nurses, not trained monkeys.
Click to expand...

Responded to a code like this once in residency. My attending slipped in an oral airway out of his pocket. Patient started breathing, woke up. My attending barely even said anything to the rest of the people who had responded, just kind of smirked and walked away. It was epic.
 
I have skimmed this thread up until this point, but in response to the question about Neuro exam under anesthesia... This (below) is a teaching thing that I put together for the residents a while back. I gave them a piece of paper in the OR that just had the questions- this is the “answer key”. Enjoy...



More than you ever wanted to know about the eye:

→ Lash reflex: what is a proxy for?
Basically an approximation of the corneal reflex… But, “lash reflex” has limitations when compared to corneal reflex. Non-standardized stimulus, both in method of application and in intensity of stimulus… However, easier to perform than a corneal reflex, and tends to dissapear/reappear at approximately the same depth of anesthesia

→ If you wanted to properly test a corneal reflex, how should you do it?
To test the corneal reflex, use a wisp of cotton or a drop of sterile water to touch the cornea. Intact reflex = eyes blink consensually. Impaired reflex = just one eye blinks. Absent reflex = no blinking.

→ What neurologic pathways are we testing?
Corneal reflex (and by proxy lash reflex): Afferent limb is ophthalmic branch of CN V (V1) → synapses in nucleus of CN V in the pons → efferent limb of reflex is CN VII (facial nerve), also originating from it’s nucleus in the pons → CN VII synapses on orbicularis oculi, causing constriction and eyelid closure

→ What information does it give us?
Assuming no muscle relaxation on board, loss of corneal (and by proxy, maybe also the lash reflex) tells us that our anesthetic agents have caused dysfunction of the motor and sensory nuclei of the eyes and the face. These nuclei, in the pons, are adjacent to the arousal centers in the midbrain/pons/hypothalamus, and so we infer that there is also likely anesthetic effect on those arousal centers

→ What is the oculocephalic reflex?
Eyes turn opposite way that head is turned (aka doll’s eyes). Horizontal motion of head activates vestibular system → afferent limb is CN VIII → synapses on it’s nucleus in the pons → sends projections to nuclei of CN III (oculomotor), IV (trochlear), and VI (abducens) → Synapses back on extrinsic eye musculature

→ Does an awake patient have an an oculocephalic reflex?
No- can be voluntarily suppressed in an awake state.

→ Why shouldn’t we see it in patients under anesthesia?
Disappearance of oculocephalic reflex under anesthesia reflects anesthetic-induced dysfunction of brainstem. Similarly to corneal reflex, the nuclei for CN III, IV, and VI live near arousal centers in pons and medulla.

→ What muscle dilates the pupil? How is it innervated, and what neurotransmitter mediates it’s contraction?
Radial muscle of the iris. Innervated by sympathetic nervous system (specifically fibers originating from superior cervical sympathetic ganglion, which travel with carotid artery to enter the skull base, and then join the long ciliary nerve). Neuromuscular transmission is mediated by alpha -1 receptors; topical phenylephrine drops will dilate the eye, for example

→ What muscle constricts the pupil? How is it innervated, and what neurotransmitter mediates it’s contraction?
Sphincter muscle of the iris. Innervated by the parasympathetic nervous system (specifically fibers originating in the Edinger-Westphal nucleus, which travel with the oculomotor nerve before synapsing in the ciliary ganglion and then continuing in the short ciliary nerve). Neuromuscular transmission is mediated by muscarinic (M3) receptors; anti-muscarinic agents like atropine, for example, will block these receptors and cause flaccid paralysis of the sphincter muscle of the iris (leaving the radial muscles unnoposed, causing mydriasis)

→ Do circulating catecholamines and vasopressors with alpha-1 agonist activity cause mydriasis? Why or why not?
No. Normal circulating level of catecholamines (including usual dosing of vasopressors) will not reach high enough levels to activate radial muscle of iris. Extreme catecholamine excess, like with pheochromocytoma, can cause mydriasis.

→ Do neuromuscular blocking agents affect pupil size? Why or why not?
No. Neuromuscular blockers do not cross the intact blood/brain barrier. Also, sphincter and radial muscles of the iris are smooth muscle (not dependent on nicotinic neuromuscular transmission); recall that sphincter muscle contraction is mediated by muscarinic receptors, and radial muscle contraction is mediated by alpha-1 receptors

→ What happens to baseline pupillary size upon induction of general anesthesia? Why?
Under anesthesia, sympathetic input to the radial muscle of the iris is lost (sympathetic activity continues in other areas of the autonomic nervous system- for example, cardiovascular reflexes remain intact. The reason for this selective ablation of sympathetic input to the eye isn’t totally understood; one theory is that the sympathetic pathways which mediate pupillary dilation are located in the upper mesencephalon, which may be more sensitive to anesthetic-induced suppression than the lower brainstem areas where other sympathetic reflexes are mediated). Because sympathetic tone to the radial muscles of the iris are lost, and because circulating catecholamines don’t reach high enough levels to cause radial muscle contraction, the sphincter muscle of the iris is now relatively unopposed. Therefore, the pupils will tend to become smaller (on average 1-3mm) after induction of anesthesia. In general any changes in pupillary size under anesthesia are due to changes in parasympathetically mediated sphincter muscle tone

→ You are providing anesthesia for a radical neck dissection, and the surgeon is concerned that they may have damaged the cervical sympathetic chain. They ask you to check for Horner’s syndrome. What do you tell them?
Because the sympathetic innervation to the eye is suppressed under anesthesia, the anisocoria with ipsilateral miosis that is typical of Horner’s syndrome will not be able to be detected while under anesthesia

→ You examine the pupils of a patient who is under anesthesia, being maintained on 0.8 MAC of isoflurane. Do you expect the pupils to constrict in response to light?
Yes. Volatile anesthetics and propofol both depress the magnitude of the pupillary light reflex, but values > 1 MAC are required to see any significant change. At values of 1 MAC or less, the pupillary light reflex should remain unchanged (other than starting from a slightly smaller pupil size)

→ What will happen to the pupillary size of a patient under anesthesia who receives a strong painful stimulus? What is the term for this, and how does it happen?
Pupillary Reflex Dilation (PRD) refers to dilation of the pupils in response to a painful stimulus. PRD is actually amplified about 3-fold in patients under general anesthesia. How does this happen given that the sympathetic input to the eye is suppressed? As it turns out, even though general anesthesia suppresses direct sympathetic input to the eye, it will actually enhance the activity of sympathetic inhibitory interneurons which synapse onto the Edinger-Westphal nucleus (recall that this is the origin of the parasympathetic innervation to the eye). Activation of nociceptors → Increased firing of inhibitory interneurons onto Edinger-Westphal nucleus → decreased parasympathetic outflow to the eye → sphincter muscle relaxation → pupillary dilation

→ What is the effect of opioids on pupillary size in anesthetized patients? What is the mechanism?
1) As with awake patients, opioids will cause a decrease in the baseline pupillary size of an anesthetized patient. 2) Opioids may depress the pupillary light reflex. 3) Most interestingly, opioids will also blunt PRD in response to a painful stimulus in a dose-dependent manner. There are 2 proposed sites of action, both of which inhibit the PRD reflex arc: firstly, opioids will diminish the intensity of ascending pain signals via their action in the spinal cord; secondly, opioids directly inhibit the firing of the sympathetic inhibitory interneurons that suppress parasympathetic outflow from the EW nucleus (they directly inhibit the inhibitor of parasympathetic tone). It is possible to suppress PRD entirely

→ At the conclusion of a case, before turning off your anesthetic, you examine the patient’s eyes and note that the pupils appear pinpoint. Does this reassure you that you have given enough opioid to ensure analgesia? Why or why not?
No. Baseline miosis may be from opioid effect, or simply from GABA-ergic sedative hypnotic agents (propofol, volatile agent)

→ You have placed a thoracic epidural for an exploratory laparotomy, and you want to know if you have dosed it adequately before you wake your patient up. How can you use pupillary size to evaluate the adequacy of anti-nociception in an anesthetized patient?
Assuming that you have not given an excessive amount of opioid, you can monitor for the presence and amplitude of PRD in response to a painful stimulus over the dermatomes which you are seeking to anesthetize. For example, you could place electrodes on the skin and use the TOF monitor to deliver a strong tetanic stimulus while monitoring the pupils. Lack of PRD may suggest adequate antinociception over the dermatome(s) being stimulated. One could also use this same approach to assess the adequacy of analgesia using opioids prior to awakening a patient.

→ This all sounds great. Can I go ahead and get started using changes in pupillary size to assess analgesia?
Probably shouldn’t (or at the very least, proceed with caution). Changes in pupillary size may be small and hard to quantify accurately without specialized equipment. Handheld infrared pupillometers are available for this purpose; however, we do not currently have them available at XXX hospital. Furthermore, once PRD in response to a painful stimulus is elicited, it can take several minutes for the pupillary size to return to baseline (even though the painful stimulus is removed). For this reason, it is recommended to assess PRD no more frequently than every 5 minutes. And of course, there is always the risk of corneal abrasion during pupillary examination… If your patient wakes up with an adequate degree of surgical analgesia but a painful eye, they will not be happy with you


  1. A Neurologic Examination for Anesthesiologists | Anesthesiology | American Society of Anesthesiologists
  2. Portable Infrared Pupillometry: A Review : Anesthesia & Analgesia
  3. https:// deleted to avoid doxxing myself : )
 
FFP said:
I'm sorry, KP, you seem to be a good person, but I wouldn't graduate you in a month, as a CA-3, if you were my resident. The lack of JUDGMENT in this post is CRIMINAL, from all parties involved.

(This seems to be par for the current generations of trainees. Their relatively frequent lack of medical knowledge and/or common sense should be scary and unacceptable beyond the first year.)

A few obvious questions:
1. WHY intubate a post-arrest patient who not only has regained consciousness, but is also doing the right things, i.e. screaming and moving everything?
2. WHY use 30 mg of etomidate on ANYBODY's intubation, not to mention on an EF<20% barely post-ROSC patient? And, most importantly:
3. WHY, as a graduating CA-3, stand there like a ***** and tolerate this to happen to a patient, without even trying to intervene, when YOU are the most expert person in inducing and intubating present? And, after it happened,
4. WHY not file some kind of patient safety report, or at least send an email to the PDs, and make sure that the "fellow" doesn't get to kill some patients as part of his/her "education"?
5. And WHY, for God's sake, WHY not ask some of these questions from that stupid fellow, at a time when it would have actually made a difference for the patient? (Especially since some of them have common sense answers.) When you let somebody do something stupid to a patient in your presence, without speaking up, you can be considered an accomplice, did you know that?

You becoming a critical care fellow in a month... scary.

And this is why residents/fellows should not be allowed to cover intubations/codes alone, just because the hospital wants to save a buck.

Congratulations to the patient for surviving an assassination attempt from the American medical system. Maybe, on Memorial Day, we should also remember the millions of patients who didn't.
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Just curious. Would you have wrote a similar post of criticism...say the pt didn’t get an airway and ended up aspirating due to AMS post rosc or what if a staff physician made this decision?

Not an aneshesiologist so I don’t know how much of a mess up this is but I think residents should be given slack and not be accused of assassination when mid levels are out there really killing pts.

EDIt: after reading some more this seems like a pretty big fowl up but I still think it’s not super fair to blame residents when there’s a fellow in the room wanting to run code. The automatic “blame trainee” culture is a lot of the reason why trainees now are weak. Patient doesnt allow residents to work on them. Suddenly junior staff are getting their initial experience in some situations.
 
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IRattending2021 said:
Just curious. Would you have wrote a similar post of criticism...say the pt didn’t get an airway and ended up aspirating due to AMS post rosc or what if a staff physician made this decision?

Not an aneshesiologist so I don’t know how much of a mess up this is but I think residents should be given slack and not be accused of assassination when mid levels are out there really killing pts.

EDIt: after reading some more this seems like a pretty big fowl up but I still think it’s not super fair to blame residents when there’s a fellow in the room wanting to run code. The automatic “blame trainee” culture is a lot of the reason why trainees now are weak. Patient doesnt allow residents to work on them. Suddenly junior staff are getting their initial experience in some situations.
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If the patient is screaming, I am pretty sure his airway is protected and he doesn't need intubation. 😉

That's actually the most reassuring thing after a code (or general anesthesia, or any coma), that the patient starts wrestling you purposefully and wants to get free, especially if he also shouts at you. No vegetable will do that. The right solution is not to knock out the patient, but to reassure and reorient them, repeatedly.

KP is not just any trainee. He's an anesthesiology attending minus 1 month of training. Different standards. He's also one month from a fellowship where, when things go south, everybody will be looking at him. He needs to learn to lead.

Do you know the best recipe for getting midlevels? You hire resident physicians and you keep telling them how marvelous they are. The reason current trainees are weak is that everybody is afraid to criticize or fire them, because they are experts at playing victim and making scandal. Oh no, can't say anything, because they will write a bad review about you, and then the program will penalize you, the attending. But please keep wondering why the midlevels don't feel inferior to our recent graduates (maybe because they aren't).

I keep asking my residents and fellows to think about what makes them much more valuable than a midlevel, besides the unique ability of being the fall guy in a lawsuit. Because that's exactly what their future employer will wonder about.
 
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FFP said:
.

If the patient is screaming, I am pretty sure his airway is protected and he doesn't need intubation. 😉

That's actually the most reassuring thing after a code (or general anesthesia, or any coma), that the patient starts wrestling you purposefully and wants to get free. No vegetable will do that. The right solution is not to knock out the patient, but to reassure and reorient them, repeatedly.

KP is not just any trainee. He's an anesthesiology attending minus 1 month of training. Different standards. He's also one month from a fellowship where, when things go south, everybody will be looking at him. He needs to learn to lead.

Do you know the best recipe for getting midlevels? You hire resident physicians and you keep telling them how marvelous they are. The reason current trainees are weak is that everybody is afraid to criticize or fire them, because they are experts at playing victim and making scandal. Oh no, can't say anything, because they will write a bad review about you, and then the program will penalize you, the attending. But please keep wondering why the midlevels don't feel inferior to our recent graduates (maybe because they aren't).
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I feel you. I heard about staff physicians actually getting cancelled by residents and guess what, I got a family to feed in my dream job. When my residents **** up I usually just quietly mop up because most of the time they learn. Some don’t.

I had tough love in my training. My favorite kind of tough love is when staff **** on me in my face and then turn around and tell others we are the best because we are, after all that tough love.
 
Just...all around terrible decision-making on the part of the fellow. Amongst many other questions, why is the code leader intubating the patient when a more qualified individual is right there?

Agree with all of the above. They called you to secure the airway. If they don't want/need you to secure the airway, just leave. It's not your job to "stand-by" while someone FUBARs the situation, plus your presence informally validates their decision-making unless you're vocal in your protestations.

The only time I will "help out" with an airway or procedure if it's someone in the PICU/PCICU I have a good relationship with, and even still, that has it's limits. If you woke me up at 3AM, 100% I'm putting the f*ing tube in.
 
IRattending2021 said:
I feel you. I heard about staff physicians actually getting cancelled by residents and guess what, I got a family to feed in my dream job. When my residents **** up I usually just quietly mop up because most of the time they learn. Some don’t.

I had tough love in my training. My favorite kind of tough love is when staff **** on me in my face and then turn around and tell others we are the best because we are, after all that tough love.
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In real life, I tend to mop up, too. I am counter-incentivized against producing quality graduates, or even giving honest feedback.

I actually prefer working solo, so they are doing me a favor on the days they don't give me residents. Depending on the resident, I can teach for hours, or I can just walk away and mind my other room. Trainees have to understand that it's actually harder to supervise than to do the work solo.

But I do know, from my own residency, that tough love is necessary for quality durable training, at least for the important stuff. Early and frequent feedback is part of good training, especially for beginners. Like a ballet instructor correcting every single move. That's the kind of tough love I mean.
 
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FFP said:
OK, so let me present the educational version of why I so vehemently disagreed, and also how one should approach this kind of situation.

The scenario is based on assumptions, so please correct me if I'm wrong, @Katheudontas parateroumen.

You walked in, they were doing CPR. While you were looking for your blade etc., they told you about the patient. Then, by the time you were just ready to intubate, they got ROSC, and the patient became alive. At this point the fellow announced that he still wants the patient to be intubated. And this is the moment to ask WHY? He gives you BS, maybe he even says that HE will intubate the patient, so it's not your worry. Still, this is the moment when you have to say out loudly, so that everybody can hear: "IN MY OPINION, AS THE AIRWAY EXPERT IN THIS ROOM, THIS PATIENT DOES NOT NEED TO BE INTUBATED." Then, if the ICU team still insists, you take your toys and walk out.

Now let's assume that you're still around, gathering your stuff, when you hear the fellow ask for "30 of etomidate". You would hear it, because they are generally too dumb to draw it up themselves, maybe even to push it. Again, in the loudest voice possible, you announce that it's an inappropriately high dose for a post-arrest patient who also has an EF of 20% on his best day. Again, they can do whatever they want; your role, as a consultant, is to CONSULT, not to police. Then, again, if you're not wanted, you leave the area.

What's the first thing you do next? You document the heck of what just happened, including the patient being intubated against your recommendations (and you explain them in your note), and the overdose of etomidate. Then, if the patient dies from their stupidity, nobody can blame you for saying nothing, like I did. Especially not in a court of law.

The one thing that you do NOT do, is stand around to "help" the ICU fellow. If he wants to intubate, especially inappropriately, he's on his own.

You are almost an attending, KP. Start behaving like one. Your role is of a consultant physician, not of a tech. You are NOT the airway monkey. They don't get to tell you who to intubate, or what to do. They can ask you to evaluate a patient for intubation, and you may do it or not. Never do anything inappropriate just because some other team wants you to. That is especially important for difficult airways. Remember: if they actually knew more than you, they wouldn't need YOU! So don't be afraid to politely put them into their place, regardless of their rank.

YOU are the airway expert, so YOU get to decide what to do about the airway. If they don't like it, they can do it themselves, but make it clear that you won't be a part of it. If they mess up and then call you to bail them out, document the heck out of it. "Called for failed intubation in the patient, after I recommended against and refused to do it myself. Patient blue, no detectable O2 sat etc." Do not cover for reckless physicians; don't pass judgment, but document all the facts. And don't hesitate to report an unsafe doctor, for a big deal like this one; you may save some lives.

That's also the reason I was so tough on you. If you didn't hate me, even for a moment, you will not remember this for long.

P.S. KP posted above while I wrote this, so some of my assumptions were wrong.
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FFP said:
OK, so let me present the educational version of why I so vehemently disagreed, and also how one should approach this kind of situation.

The scenario is based on assumptions, so please correct me if I'm wrong, @Katheudontas parateroumen.

You walked in, they were doing CPR. While you were looking for your blade etc., they told you about the patient. Then, by the time you were just ready to intubate, they got ROSC, and the patient became alive. At this point the fellow announced that he still wants the patient to be intubated. And this is the moment to ask WHY? He gives you BS, maybe he even says that HE will intubate the patient, so it's not your worry. Still, this is the moment when you have to say out loudly, so that everybody can hear: "IN MY OPINION, AS THE AIRWAY EXPERT IN THIS ROOM, THIS PATIENT DOES NOT NEED TO BE INTUBATED." Then, if the ICU team still insists, you take your toys and walk out.

Now let's assume that you're still around, gathering your stuff, when you hear the fellow ask for "30 of etomidate". You would hear it, because they are generally too dumb to draw it up themselves, maybe even to push it. Again, in the loudest voice possible, you announce that it's an inappropriately high dose for a post-arrest patient who also has an EF of 20% on his best day. Again, they can do whatever they want; your role, as a consultant, is to CONSULT, not to police. Then, again, if you're not wanted, you leave the area.

What's the first thing you do next? You document the heck of what just happened, including the patient being intubated against your recommendations (and you explain them in your note), and the overdose of etomidate. Then, if the patient dies from their stupidity, nobody can blame you for saying nothing, like I did. Especially not in a court of law.

The one thing that you do NOT do, is stand around to "help" the ICU fellow. If he wants to intubate, especially inappropriately, he's on his own.

You are almost an attending, KP. Start behaving like one. Your role is of a consultant physician, not of a tech. You are NOT the airway monkey. They don't get to tell you who to intubate, or what to do. They can ask you to evaluate a patient for intubation, and you may do it or not. Never do anything inappropriate just because some other team wants you to. That is especially important for difficult airways. Remember: if they actually knew more than you, they wouldn't need YOU! So don't be afraid to politely put them into their place, regardless of their rank.

YOU are the airway expert, so YOU get to decide what to do about the airway. If they don't like it, they can do it themselves, but make it clear that you won't be a part of it. If they mess up and then call you to bail them out, document the heck out of it. "Called for failed intubation in the patient, after I recommended against and refused to do it myself. Patient blue, no detectable O2 sat etc." Do not cover for reckless physicians; don't pass judgment, but document all the facts. And don't hesitate to report an unsafe doctor, for a big deal like this one; you may save some lives.

That's also the reason I was so tough on you. If you didn't hate me, even for a moment, you will not remember this for long.

P.S. KP posted above while I wrote this, so some of my assumptions were wrong.
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I don't hate you. but what you said lit a fire under my butt. I definitely am mad at myself and I have been thinking about this all day. I respect your criticism. It was warranted and I appreciate your feedback. And all the others
 
It doesn’t matter who the person is, it could be the chief of the service or head of surgery, etc, if you believe they are about to make a significant medical mistake you need to speak up. It can be nonconfrontational, a “clarifying question” for example, or a bit more boldly depending on the situation. You owe it to the patients to ask if they’re sure that’s what they want to do, maybe adding why you think it’s not the best idea, and if it’s your patient, you need to tread very carefully to protect yourself. If it’s not your patient, you tried to help them to recognize their possible error, and that’s all you can do. But do make sure to GTFO so you’re not dragged back in. In a couple weeks you will need to be protecting yourself because the helpful CNA who’s charting the code put your name on the record when you walked into the room. All those names will appear again in the lawsuit.
As noted above, if I’m there it’s my airway. If they don’t need me, it’s their airway and I’m long gone. The answer to “Do you want to stick around in case we have a problem?” Is “NO. But I’ll do the intubation if you think it will be difficult.” Then when it predictably goes to #*%¥ your note will indicate you offered to intubate, were dismissed, and then called back 10 minutes later when they lost the airway and the patient arrested.
Fortunately I don’t work at a place like that. But it was one of the reasons I didn’t moonlight at the local so called hospitals when I was in the .mil in a rural area.
If you really believe someone is practicing in a manner that’s grossly negligent that’s a whole different problem and as a trainee, outside of some really extreme circumstances, that’s above your pay grade.

tldr- See something? Say something.
 
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SnapperRocks said:
Regardless of other details for this case, side note on dosing:
30mg of etomidate suggests someone was thinking 0.3mg/kg and the patient was likely around 100kg as most patients seem to be. Yet 50mg of roc was used. This is stupid.

I don’t know what it is about non-anesthesiologists choosing doses but they seem to think 1 vial has to be enough. Granted they aren’t the same level of aspiration risk as a small bowel obstruction but these patients are more likely than not true full stomachs.

It’s painfully obvious when i hand off a patient reversed with sugammadex to some ICU docs that a lot of them don’t even know what sugammadex is, so i have a hard time believing that a non-anesthesiologist using 50mg of roc has a clue what they’re actually doing. Sure It’s possible as an anesthesiologist who knows what they’re doing to safely induce a 100kg appropriately NPO gall bladder coming from home with 50mg of roc and intubate without ventilating. This is not the same as a coding presumed full stomach. If their k isn’t through the roof, feel free to just use succinylcholine instead of roc, at least you’ll know it’s circulated when they fasciculate. IDGAF about the risk of myalgias in a patient coding on the floor.

I have seen this way too many times on patients who weigh 300 lbs. It you don’t know how to dose, you shouldn’t be intubating.

Yes, it is possible to aspirate as soon as propofol hits the vein. Aside from the increased difficulty of obtaining a view before muscle relaxation reaches peak effect, I personally think the highest risk point of aspiration is trying to intubate before a belly is completely relaxed and in the case of an SBO stomach full of brown liquid, the abdomen tenses and that full stomach spews out the esophagus.
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Keep in mind that you do not know the history of the patient or the shenanigans that took place before a patient on the floor codes. We have all witnessed serious lapses in care (IE intern year, patient presenting to ED with chest pain while on treadmill admitted to OBS without ECG because he was 40 and fit, apparently had a dissection and coded). We have all seen CXRs claim evidence of aspiration in their differential despite no issues with intubation. Don’t make yourself a target with textbook bonehead dosing. I am not just advocating defensive medicine for the sake of it, I genuinely think under-dosing roc on a coding patient is stupid.

There’s a new article in this months anesthesiology reviewing closed claims specifically on aspiration of gastric contents but unfortunately, I guess i let my membership lapse while studying for boards and am being punished with having to go on a wild goose chase tracking down old transcripts to rejoin.




Aspiration of Gastric Contents
We recently reviewed claims for aspiration of gastric contents from 1990 and later.6 Patients in aspiration claims were older, sicker, and more often had abdominal and emergency procedures than patients in other claims in the database, not surprising given the risk factors for aspiration of gastric contents. Although most cases of aspiration occurred during general anesthesia, 12 percent of cases occurred during regional anesthesia or monitored anesthesia care.
Aspiration occurred during induction in 60 percent of claims, with the remainder occurring most commonly intraoperatively or post-procedure [Figure 2]. Cases with intraoperative aspiration were performed during general anesthesia with a mask or laryngeal mask airway, during regional anesthesia or during MAC. Examples include a patient with an incarcerated hernia and vomiting, with repair occurring under subarachnoid block with sedation progressing to mask general anesthesia, and a patient for a Port-a-Cath placement during general anesthesia with a laryngeal mask airway, despite vomiting in the preoperative holding area. In some claims, aspiration occurred on induction despite what appeared to be an appropriate rapid sequence induction with cricoid pressure.

However, in many claims, the rapid sequence induction was either not performed in the presence of significant risk factors for aspiration or was performed unconventionally, such as with low doses of slow-onset muscle relaxants or after significant sedation. These types of cases suggest the need for heightened awareness of risk factors for aspiration of gastric contents and more cautious anesthesia choice and airway control during general anesthesia.
 
Katheudontas parateroumen said:
Hello everyone, a few basic questions for you all about the utility of a neuro exam under anesthesia.

Pt- 40yM with NICM EF ~20%, hx of VT/VF events s/p AICD placement admitted for CHF exacerbation. Had a weight gain about 10kg over past week and observed decrease in UOP. He's getting a bumex drip seems while on the floor and seems to be responding well and getting tuned up for a AICD CRT upgrade during the admission. He was admitted about 4 days prior to my encounter.

As a resident, I cover the airways at night. I get called to this guy's room at 3AM for code blue. Nurse says she saw tele say VF/VT and she finds him unconscious lying on the floor. She does CPR for a couple minutes and gets pulses back. AICD apparently fired multiple times. I get to the room and pulm crit fellow is already there and RT is aggressively bagging due to reported agonal breathing but has pulse and good O2 sat. I'm busy trying to get my airway stuff ready, so to be honest, I don't remember what the rhythm was on the monitor but I believe it was reported NSR by the time I get there. A couple minutes while i'm there, the patient starts waking up screaming and moving everything. Pulm fellow still wants to intubate so I let him do it. He slugs him with like 30mg of etomidate and 50mg Roc and gets the tube in. Here, I am thinking my job is over and about to leave and I notice on monitor HR is in the 40s. I ask them to check a pulse. The Pulm fellow checks the patient's eyes and yells both eyes are fixed and dilated and has no occulocephalic reflex. Check pulse he's got nothing of course. ACLS again and get ROSC. They end up doing STAT Head CT and negative except for possible chronic lobe infarct, nothing acute. He's apparently following basic commands the next morning on chart check.

My question is I don't feel if I learned this completely, but how useful is a neuro exam under anesthesia? I believe that we lose ALL our brainstem reflexes in a sequential matter from medulla to pons under GA. Does etomidate or any of the other agents cause pupillary dilatation after induction? I know emergence causes pupilary changes during "stage 2". Also, what do you think about intubating a guy after he apparently wakes up from his VT? Also, what's the word on a case like this for targeted temperature management?

Thanks!
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You've already been scolded enough, but I really just have to reiterate that even if you didn't want to directly prevent the fellow from intubating, you needed to at least strongly have tried to punt it til later.

You do this by pointing out to the fellow that the pt may need to be be intubated, but let's at least slap on a NRB and get him to the ICU so he's actually positioned on a bed, has monitors on, and we're not just surrounded by 7 floor nurses who spend most of their day dispensing pills and doing vital checks.
 
I don’t think that you necessarily need to think about that stuff deeply on a daily basis... But at some point while you’re in training, you should. If residents want to be more than glorified CRNAs, they need to take subjects to depth and become experts in the pathophysiology of anesthesia, like a real doctor. Otherwise it’s just “monkey see, monkey do”. I put the above learning sheet together because I was sick of seeing residents check a lash reflex before giving paralytic, and when I asked them why they were doing it, not one could give me an answer other than “to make sure they’re asleep”.
 
Im wondering where are you all (above attendings) hiding ?!? I wish I had such tactful determined attendings during my residency...I got in trouble multiple times for expressing my opposite opinion to something disastrous being done. Most of the time I was ignored and bypassed; other times I was reported for being a rebel, and some other times I had no stamina to do anything because I knew the outcome. Some attendings would obey to totally irrational decisions just to not harm they precious image and only a few of them would truly speak up.
regardless I have appreciated the process, because I learnt how to get what I want without at least being reported lol
 
Lidolover said:
Im wondering where are you all (above attendings) hiding ?!? I wish I had such tactful determined attendings during my residency...I got in trouble multiple times for expressing my opposite opinion to something disastrous being done. Most of the time I was ignored and bypassed; other times I was reported for being a rebel, and some other times I had no stamina to do anything because I knew the outcome. Some attendings would obey to totally irrational decisions just to not harm they precious image and only a few of them would truly speak up.
regardless I have appreciated the process, because I learnt how to get what I want without at least being reported lol
Click to expand...

pp
 
Well now i can talk crap about FFP now that he's gone! too bad he can't defend himself. :poke:

First, the most educational portion of this thread is provided by @Hork Bajir . Thank you for that refresher. Just to verify, the lash reflex is a sound quick and dirty way to check whether or not the anesthetic depth has been reached. Correct?

Second, @Katheudontas parateroumen . We, including the man himself, all agree that @FFP was unnecessarily rough on you. But i'm happy you took the constructive part of this thread and made yourself better. That's the correct path to take.

Stepping back to look at the bigger picture, the decision to intubate isnt' egregious. We as the backup do not know the whole picture as well as the primary team, presumably. May be we missed something that pushes the decision towards intubation.

The execution of the intubation left something to be desired. Unless you know the Pulm Crit fellow is a joker, what you did wasn't exactly out of line. I would have encouraged a "time out" process to clarify what drugs to give so you can "guide" the fellow non-confrontationally about what drugs to give, as well as what is the backup plan if the intubation wasn't successful so everyone in the room is on the same page. The situation has gone from emergent to not emergent, no reason to not do the procedure as controlled as possible. That's an advanced move I learned from my upper level in residency, tact and skill can be very synergistic. 😉 You don't have to make the fellow feel like ****, a la @FFP 's method, to take care of the patient. Those aren't mutually exclusive processes.

The pupils were dilated because of PRD and epi. The doll reflex was absent because of the roc and etomidate. thanks again for @Hork Bajir 's refresher. It'll be god-level of awareness if you included that in your time out before intubation. But we are only human. Next time the adrenaline is running high, remember to try to make a friend in the process of saving a patient!
 
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Sadly we live in some dystopian future where singularity of thought is achieved through force- any non conformity is punished by “being reported”, often by your closest neighbour. At the same time, simulation training has encouraged this stupid idea that whenever something bad happens it’s always the system at fault rather than individuals. I sit through simulation debriefs where there is just a straight up refusal to talk about anything done by the individual, even when obviously m-o-r-o-nic- instead it is always brought back to the “team dynamic” somehow, or to communication. The importance of knowledge to medical care is completely swept under the rug. This leads to the inane situations being described in this thread, where people are confident in their lack of knowledge, and sensible objection is “reported”. If we train to ignore the importance of knowledge, then how will anyone ever believe they are making the wrong decision?

We are left in the state where we have to make a trade off- providing the best medical care vs protecting ourselves and our professional reputations. Advocating for the patient means sticking your neck out. It’s a sad state of affairs.
 
economycian said:
Sadly we live in some dystopian future where singularity of thought is achieved through force- any non conformity is punished by “being reported”, often by your closest neighbour. At the same time, simulation training has encouraged this stupid idea that whenever something bad happens it’s always the system at fault rather than individuals. I sit through simulation debriefs where there is just a straight up refusal to talk about anything done by the individual, even when obviously m-o-r-o-nic- instead it is always brought back to the “team dynamic” somehow, or to communication. The importance of knowledge to medical care is completely swept under the rug. This leads to the inane situations being described in this thread, where people are confident in their lack of knowledge, and sensible objection is “reported”. If we train to ignore the importance of knowledge, then how will anyone ever believe they are making the wrong decision?

We are left in the state where we have to make a trade off- providing the best medical care vs protecting ourselves and our professional reputations. Advocating for the patient means sticking your neck out. It’s a sad state of affairs.
Click to expand...
100%
 
SnapperRocks said:
30mg of etomidate suggests someone was thinking 0.3mg/kg and the patient was likely around 100kg as most patients seem to be.
Click to expand...
I’m pretty sure the manufacturer recommendations state that initial dose not exceed 20mg. And the guy is post-arrest and has a terrible heart. You could induce him 3-4times over with 30mg.
 
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