Chest Wall ridigity?

[nitecap]

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Had a talk today both on a forum and lecture. Just wanted to get a feel for how how many of you guys out there experience this(chestwall ridigity) and how often?

What was the common culprit? I see most of the literature on Fent but what about sufent ect?

I have seen the the literature about it being centrally mediated in caudate or raphe pontus nuclei not sure about the source of that one? Any one know the exact mech of action here?

How did you intervene? Relaxant, narcan, GABAminergic drugs? Defisiculate to prevent?

Any patterns as far as pt populations that this happened with more than one or the other?

How did you realize that this indeed was what it was and how long did it take you to realize and trouble shoot this?

Have a few recent discussions on this topic and wasnt that impressed with some of the literature that I looked thru, even with your main anesthesia text books. Just wanted to see what you peeps thought.

 

[militarymd]

there was data to suggest that it is not chest wall rigidity, but actually glottic closure.......although, I think that there is more than one cause of inability to ventilate after induction with narcotics.

 

[jetproppilot]

Had a talk today both on a forum and lecture. Just wanted to get a feel for how how many of you guys out there experience this(chestwall ridigity) and how often?

What was the common culprit? I see most of the literature on Fent but what about sufent ect?

I have seen the the literature about it being centrally mediated in caudate or raphe pontus nuclei not sure about the source of that one? Any one know the exact mech of action here?

How did you intervene? Relaxant, narcan, GABAminergic drugs? Defisiculate to prevent?

Any patterns as far as pt populations that this happened with more than one or the other?

How did you realize that this indeed was what it was and how long did it take you to realize and trouble shoot this?

Have a few recent discussions on this topic and wasnt that impressed with some of the literature that I looked thru, even with your main anesthesia text books. Just wanted to see what you peeps thought.

Very rare incidence...especially if you are a succinylcholine advocate.

As an aside, I loved N20-narcotic technique as a resident. For the big-back-cases, I'd have the patient wasted by the time we hit the OR on midazolam (usually about 5mg)...patient slurring, nystagmus...

monitors, pre02, push the other 5mg midazolam, follow it with 500ug sufentanil (about 7ug/kg for a regular size dude) and a stick of vec (10mg).

Eyes taped (before intubation folks-will save you alotta corneal abrasions from the syringe flapping off your ETT), intubate, PPP, Bare Hugger...

...70% N20, 30%O2, didnt even crack the vaporizer ( 😱 ), sufentanil infusion .2ug/kg/hr, additional midazolam 1mg every hour of surgery.

Nitrous/narcotic is a "light" technique, so ya gotta keep'em well paralyzed...one twitch-to-no-twitch for most of the surgery...

as it winds down 4-5 hours later, lighten up the paralysis to 1-2 twitches (i.e. reversible)

turn off the sufenta infusion at least 45 minutes before expected extubation...suction oropharynx while patient is still deep, remove esophageal temp probe, don't mess with oropharynx anymore after this...

surgeon asks for skin stapler....N2O off, crank the O2 to 10L, neostigmine 5mg/glycopyrrolate 1 mg, turn off the vent, APL counterclockwise...

if you've timed it right your bag will start to move.

With 3-4 skin staples left to go, tap patient-dude on the forehead.

His eyes will pop open.

"Open your mouth, dude."

Dude opens mouth.

Quick last-suction, balloon down, rip the tube out as the last skin staple goes in.

Curtains come down and your patient is extubated, supporting his own airway.

Great, great technique for academic medicine.

Problem in private practice is there isnt alotta five-plus hour back surgerys to eat up all the front-loaded sufenta.

 

[ThinkFast007]

Eyes taped (before intubation folks-will save you alotta corneal abrasions from the syringe flapping off your ETT), .....

WOW.

If i only learned one thing today. That's hot. no joke. mks sense, but never seen anyone do it that way! 👍

 

[jetproppilot]

Had a talk today both on a forum and lecture. Just wanted to get a feel for how how many of you guys out there experience this(chestwall ridigity) and how often?

What was the common culprit? I see most of the literature on Fent but what about sufent ect?

I have seen the the literature about it being centrally mediated in caudate or raphe pontus nuclei not sure about the source of that one? Any one know the exact mech of action here?

How did you intervene? Relaxant, narcan, GABAminergic drugs? Defisiculate to prevent?

Any patterns as far as pt populations that this happened with more than one or the other?

How did you realize that this indeed was what it was and how long did it take you to realize and trouble shoot this?

Have a few recent discussions on this topic and wasnt that impressed with some of the literature that I looked thru, even with your main anesthesia text books. Just wanted to see what you peeps thought.

More to your storyline though, Nite, before the tangential prone-extubation-story, I'm not sure of the mechanism. But I've seen it (anecdotally) much more with sufentanil than fentanyl.

Greatest case of chest wall rigidity ever involved a mutual friend/colleague of Noyac and I (J.P., Noy).

J.P. had the pt on the OR table, buzzed on midaz (during our residency) and decided to find out what a cuppla hundred mikes of sufentanil would do. So he pushed it. Patient-dude got more rigid than Peter North during a screen-shoot.

No big deal, though. Just paralyze 'em and ventilate away.

 

[Noyac]

More to your storyline though, Nite, before the tangential prone-extubation-story, I'm not sure of the mechanism. But I've seen it (anecdotally) much more with sufentanil than fentanyl.

Greatest case of chest wall rigidity ever involved a mutual friend/colleague of Noyac and I (J.P., Noy).

J.P. had the pt on the OR table, buzzed on midaz (during our residency) and decided to find out what a cuppla hundred mikes of sufentanil would do. So he pushed it. Patient-dude got more rigid than Peter North during a screen-shoot.

No big deal, though. Just paralyze 'em and ventilate away.

I think I know of that case cause a partner of J.P.'s and I did a cysto. He went to the OR pharmacy and asked for 2mg midaz and 100mcg fent. went back to the cysto and pushed these two for some MAC sedation. Pt became apneic immediately and then partner-dude couldn't mask this healthy 25 yo male. He pushed sux and intubated without any problem and pt was easy to ventilate. He came back to the front area where J.P. and I were shootin the **** and said "Man I had the weirdest thing just happen". He told us the story and I said immediatel, " Pharmacy dude gave you sufents instead of fent." He walked back and checked the vail and BINGO. J.P. then told me his story.

 

[nitecap]

Appreciate it. Thanks for the humor in the case you proposed. The buzzing on midaz had me laughing. Guess I rarely think about it as administering a buzz. That may make me a Studented Register Buzz Administrator (SRBA).

 

[VentdependenT]

Thanks for the case breakdown Jet. I'll tuck that bit o info into the back of my mind till neuro in CA-2 year.

 

[adleyinga]

Have a few recent discussions on this topic and wasnt that impressed with some of the literature that I looked thru, even with your main anesthesia text books. Just wanted to see what you peeps thought.[/QUOTE]

WE use to see rigidity when we induced with 50 cc of sufentanil for cardiac cases. Followed imm. with Paccuronium so avoid bradycardia.

Then again these pts were not extubated that day.

 

[jetproppilot]

Have a few recent discussions on this topic and wasnt that impressed with some of the literature that I looked thru, even with your main anesthesia text books. Just wanted to see what you peeps thought.

WE use to see rigidity when we induced with 50 cc of sufentanil for cardiac cases. Followed imm. with Paccuronium so avoid bradycardia.

Then again these pts were not extubated that day.[/QUOTE]

FIFTY CCs OF SUFENTANIL????? 😱

uhhhh....thats more s hit than John Travolta could handle on Pulp Fiction.

JOHN TRAVOLTA: "HEY WOLF! Gotta problem. Just gave this chick two-and-a-half milligrams of sufentanil."

WOLF: Uhhh, sorry, dude. I fix problems. But that old-style cardiac induction stuff, well, even THE WOLF is speechless. Can't fix it."

 

[Noyac]

WE use to see rigidity when we induced with 50 cc of sufentanil for cardiac cases. Followed imm. with Paccuronium so avoid bradycardia.

Then again these pts were not extubated that day.

FIFTY CCs OF SUFENTANIL????? 😱

uhhhh....thats more s hit than John Travolta could handle on Pulp Fiction.

JOHN TRAVOLTA: "HEY WOLF! Gotta problem. Just gave this chick two-and-a-half milligrams of sufentanil."

WOLF: Uhhh, sorry, dude. I fix problems. But that old-style cardiac induction stuff, well, even THE WOLF is speechless. Can't fix it."

[/QUOTE]

Red Headed Dude: "Uh don't be bringing that bitch to my house"

 

[bullard]

Lance: I ain't givin her the shot! Next time, when I bring an ODin' b itch to your house, I'll give her the shot. Give her the shot!

 

[jetproppilot]

FIFTY CCs OF SUFENTANIL????? 😱

uhhhh....thats more s hit than John Travolta could handle on Pulp Fiction.

JOHN TRAVOLTA: "HEY WOLF! Gotta problem. Just gave this chick two-and-a-half milligrams of sufentanil."

WOLF: Uhhh, sorry, dude. I fix problems. But that old-style cardiac induction stuff, well, even THE WOLF is speechless. Can't fix it."

Red Headed Dude: "Uh don't be bringing that bitch to my house"[/QUOTE]

HAHAHAHHAHAHHAHAHHAHAHHAHAHAHAHAHAHAHAHAHHAHAHA

 

[imnodr]

red headed dude: "if you're ok........say something"

od'n bitch, with needle still in chest: "something"