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narcusprince

narcusprince

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As the "new" guy I got my first taste of sick patients. Here we go 92 y/o with hx of of with 2+ mitral regurgitation CAD s/p CABG 26 years ago, recent echo roughly 3 years ago showed depressed EF 40% PA systolic pressures 60mmhg, history of atrial fibrillation currently in NSR, currently with chronic dementia currently delirious secondary to pain, with hip dislocation which needs a revision.Vitals 120/60 hr 85 RR 20. Not oriented only moans in pain. Not cooperative.
 
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narcusprince said:
As the "new" guy I got my first taste of sick patients. Here we go 92 y/o with hx of of CAD s/p CABG 26 years ago, recent echo roughly 3 years ago showed depressed EF 40% PA systolic pressures 60mmhg, history of atrial fibrillation currently in NSR, currently with chronic dementia currently delirious secondary to pain, with hip dislocation which needs a revision.Vitals 120/60 hr 85 RR 20. Not oriented only moans in pain. Not cooperative.
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Revision, like she already had a hip done and this is the second go around? Or are they just jerking on the leg to put it back in place?
 
Lumbar and sacral plexus blocks, har har.

LMA after 20mg PPF. Minimal or no fentanyl. Be ready to intubate and go to ICU intubated.
 
narcusprince said:
As the "new" guy I got my first taste of sick patients. Here we go 92 y/o with hx of of CAD s/p CABG 26 years ago, recent echo roughly 3 years ago showed depressed EF 40% PA systolic pressures 60mmhg, history of atrial fibrillation currently in NSR, currently with chronic dementia currently delirious secondary to pain, with hip dislocation which needs a revision.Vitals 120/60 hr 85 RR 20. Not oriented only moans in pain. Not cooperative.
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Anesthetic Plan
Due to ms not a good candidate for neuroaxial unless more cooperative after a little versed/fentanyl which I highly doubt.

Pre-op:
Make sure her BB is on board for both post mi prevention and afib control. Assess previous coronary studies if on hand.
Lines: A-line. Extra Monitor: TEE if accessible. Assess RV fx/preload/EF/new RWA/Atrial appendage.

Induction:
Versed and Fentanyl titrate to BIS. Maybe a touch of propofol (20 mg). Airway looks good, roc. tube.

Maintenance:
Anesthesia: Low mac (0.3 to 0.5) titrated to bis, with narcotic for BP/HR spikes.
CAD/CHF: Insure HR 60-80s. Treat stimulation with narcotics/esmolol. Insure low normal preload to decrease wall stress while maintaining CO. NG on hand for HTN. HR control is very important seeing as high HR will diminish both LV and RV subendocardial perfusion for this pt.
A. Fib: R2 pads and connect to defibrillator to insure working. Bare minimum at least one in room. Esmolol on hand for rate control.
PHTN: Keep oxygenation high and avoid any desat on induction, minimize acidosis by staying ahead of Hbg/CO, avoid light anesthesia.

Emergence:
Slow, smooth extubation to avoid any rapid VS changes. Epidural placement would be nice for post op pain control if possible to sneak one in but most likely not due to positioning .Supplement with narcotics.


What is most worrisome: LV and/or RV failure.
LV: A. Fib that converts to RVR-> already no atrial kick with poor coronary circulation->Rapid decompensation,
RV: increase pulm HTN-> RV strain-> lose forward flow -> Rapid decompensation
 
narcusprince said:
They are going to attempt closed but surgeon thinks an acetabular revision so prepare for open revision.
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Didn't know it was closed. If closed would LMA and treat VS with IV cardiac drugs, little narcotics. If converts to open, would convert to my plan above.
 
RxBoy said:
Anesthetic Plan
Due to ms not a good candidate for neuroaxial unless more cooperative after a little versed/fentanyl which I highly doubt.

Pre-op:
Make sure her BB is on board for both post mi prevention and afib control. Assess previous coronary studies if on hand.
Lines: A-line. Extra Monitor: TEE if accessible. Assess RV fx/preload/EF/new RWA/Atrial appendage.

Induction:
Versed and Fentanyl titrate to BIS. Maybe a touch of propofol (20 mg). Airway looks good, roc. tube.

Maintenance:
Anesthesia: Low mac (0.3 to 0.5) titrated to bis, with narcotic for BP/HR spikes.
CAD/CHF: Insure HR 60-80s. Treat stimulation with narcotics/esmolol. Insure low normal preload to decrease wall stress while maintaining CO. NG on hand for HTN. HR control is very important seeing as high HR will diminish both LV and RV subendocardial perfusion for this pt.
A. Fib: R2 pads and connect to defibrillator to insure working. Bare minimum at least one in room. Esmolol on hand for rate control.
PHTN: Keep oxygenation high and avoid any desat on induction, minimize acidosis by staying ahead of Hbg/CO, avoid light anesthesia.

Emergence:
Slow, smooth extubation to avoid any rapid VS changes. Epidural placement would be nice for post op pain control if possible to sneak one in but most likely not due to positioning .Supplement with narcotics.


What is most worrisome: LV and/or RV failure.
LV: A. Fib that converts to RVR-> already no atrial kick with poor coronary circulation->Rapid decompensation,
RV: increase pulm HTN-> RV strain-> lose forward flow -> Rapid decompensation
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Great Answer.
 
So the big boys do not answer.
Here was my plan.
Preop
All the labs I needed were the CBC+ BMP and echo results and type and screen. I had a long talk with the family explaining that it is very likely that patient X will not make it through the procedure. Given pt X high risk factors IE pulmonary htn, MR, old CAD w/o a stress test. Also to complicate matters they were DNR/DNI out of the operating room. The patient was not aware of their surroundings the only thing I knew for sure was that hip was hurting. I placed a pre-induction arterial line. Used a gileho continous cardiac output monitor for Cardiac Index monitoring. Also, I placed Zahl pad on the patient so that if any malignant arrythmias occur we can shock it also had the defibrillator in the room( I did not want anyone scrambeling around trying to find it). Also pt was NPO for 12 hours( realizing demented head full stomach)
Induction
I came to a few conclusions no Midazolam and no Propofol. I gave 250 mcgs of Fentanyl in divided doses. Had IV scopalamine in the room if I needed to turn off agent. Had an experianced set of hands in the room. IV fentanyl, a little inhalational agent 2.5% Sevo APL set at 20(for bagging). Defasiculating dose of roc Succ tube. Pt had a little jaw rigidity(MH lights went off in back of head). Tupe slid in like butter. Got another 14 IV. Hemodynamics STABLE throghout induction. I prefer tubes in pulmonary hypertensives because one I think hypoxia, hypercarbia, acidosis can be better controlled with an ET tube than a LMA plus demented head demented stomach. I placed the patient on pressure control ventilation to limit the intrathoracic pressure component contributing to the pulmonary hypertension. So tubes in pt is stable. Sevo at about 1.5% surgeons try closed reduction which was does not work. Now we proceed to open reduction. Surgeons make incision pt hemodynamics rock stable HR starts creeping up into the 90-100's I give 50mcgs of fentanyl HR creeps down. HR starts creeping up 100's and irregular looks like Afib start hitting him with Esmolol 30-40 mgs gets the rate down into the 70's. Have to play this cat and mouse game throughout case. ABG sent throughout case was fine Hgb 10/30 no acidosis present. They start closing the hip pt starts breathing spontaneously give a touch of reversal agent pt taking in tidal volumes of 600-700cc with a rate of 8. Case goes well with occasional pressers tried to avoid Neo but had to use it I move the patient off the OR bed into the transport bed. While their is still some agent on board and extubate on the mobile bed. Pt does fine. Goes to PACU has some ST depressions in PACU. I stated that what can we do if patient does have an interoperative or postop MI nothing other than standard 100% O2 beta blockade, Morphine cannot transfuse secondary to the DNR order. Saw the patient 1 day postop looked like a completely different person actively moving does not remember a thing about the case. I will never forget his smile with the new hip in place. Tough case!
 
narcusprince said:
So the big boys do not answer.
Here was my plan.
Preop
All the labs I needed were the CBC+ BMP and echo results and type and screen. I had a long talk with the family explaining that it is very likely that patient X will not make it through the procedure. Given pt X high risk factors IE pulmonary htn, MR, old CAD w/o a stress test. Also to complicate matters they were DNR/DNI out of the operating room. The patient was not aware of their surroundings the only thing I knew for sure was that hip was hurting. I placed a pre-induction arterial line. Used a gileho continous cardiac output monitor for Cardiac Index monitoring. Also, I placed Zahl pad on the patient so that if any malignant arrythmias occur we can shock it also had the defibrillator in the room( I did not want anyone scrambeling around trying to find it). Also pt was NPO for 12 hours( realizing demented head full stomach)
Induction
I came to a few conclusions no Midazolam and no Propofol. I gave 250 mcgs of Fentanyl in divided doses. Had IV scopalamine in the room if I needed to turn off agent. Had an experianced set of hands in the room. IV fentanyl, a little inhalational agent 2.5% Sevo APL set at 20(for bagging). Defasiculating dose of roc Succ tube. Pt had a little jaw rigidity(MH lights went off in back of head). Tupe slid in like butter. Got another 14 IV. Hemodynamics STABLE throghout induction. I prefer tubes in pulmonary hypertensives because one I think hypoxia, hypercarbia, acidosis can be better controlled with an ET tube than a LMA plus demented head demented stomach. I placed the patient on pressure control ventilation to limit the intrathoracic pressure component contributing to the pulmonary hypertension. So tubes in pt is stable. Sevo at about 1.5% surgeons try closed reduction which was does not work. Now we proceed to open reduction. Surgeons make incision pt hemodynamics rock stable HR starts creeping up into the 90-100's I give 50mcgs of fentanyl HR creeps down. HR starts creeping up 100's and irregular looks like Afib start hitting him with Esmolol 30-40 mgs gets the rate down into the 70's. Have to play this cat and mouse game throughout case. ABG sent throughout case was fine Hgb 10/30 no acidosis present. They start closing the hip pt starts breathing spontaneously give a touch of reversal agent pt taking in tidal volumes of 600-700cc with a rate of 8. Case goes well with occasional pressers tried to avoid Neo but had to use it I move the patient off the OR bed into the transport bed. While their is still some agent on board and extubate on the mobile bed. Pt does fine. Goes to PACU has some ST depressions in PACU. I stated that what can we do if patient does have an interoperative or postop MI nothing other than standard 100% O2 beta blockade, Morphine cannot transfuse secondary to the DNR order. Saw the patient 1 day postop looked like a completely different person actively moving does not remember a thing about the case. I will never forget his smile with the new hip in place. Tough case!
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Well done sir. To RxBoy, great answer as well.
 
narcusprince said:
cannot transfuse secondary to the DNR order.
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What does a DNR order have to do with transfusion, especially in light of everything else you have done?
 
I would not transfuse. First the pt h/h was 10/30. Blood loss during the case was minimal. Second the DNR I discussed with family stated no blood transfusiions outside of the OR. Could I have transfused in the OR yes. Another pearl if you have a patient whom presents to the OR with a Dnr in place it must be suspended for surgery.
 
narcusprince said:
I would not transfuse. First the pt h/h was 10/30. Blood loss during the case was minimal. Second the DNR I discussed with family stated no blood transfusiions outside of the OR. Could I have transfused in the OR yes. Another pearl if you have a patient whom presents to the OR with a Dnr in place it must be suspended for surgery.
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I still don't really get the relationship between transfusion and DNR?

I do not agree that a DNR "must" be suspended.
 
RxBoy said:
Anesthetic PlanPre-op:
Make sure her BB is on board for both post mi prevention and afib control. Assess previous coronary studies if on hand.
Lines: A-line. Extra Monitor: TEE if accessible. Assess RV fx/preload/EF/new RWA/Atrial appendage.

Induction:
Versed and Fentanyl titrate to BIS. Maybe a touch of propofol (20 mg). Airway looks good, roc. tube.
Click to expand...

I would not put a BIS on a demented 92 year old for all the tea in China😀.

Are you really going to put a TEE probe in this lady or just have it available if needed?
 
narcusprince said:
Another pearl if you have a patient whom presents to the OR with a Dnr in place it must be suspended for surgery.
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I don't think that is true. If you don't want to get chest compressions, it doesn't matter where you are when that happens, you shouldn't get compressions. Same with defib.

It's a conversation you need to have with the patient or family, of course, but I don't think you can state, across the board, that DNR orders must be suspended for all patients in the OR.
 
My rational is that if a patient comes to my or. I would want ful reign to rescucitate them as I see fit. Where does rescucitation start ACLS bolus pressors blood. Too murky a situation for the family to understand. So I make it simple for the family I will rescucitate them while they are in the OR once out and out of Pacu place the dnr/dni order back on.
 
narcusprince said:
My rational is that if a patient comes to my or. I would want ful reign to rescucitate them as I see fit. Where does rescucitation start ACLS bolus pressors blood. Too murky a situation for the family to understand. So I make it simple for the family I will rescucitate them while they are in the OR once out and out of Pacu place the dnr/dni order back on.
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Sounds like you are making this more about you. There are some patients that, under no circumstances, want a metallic robot thumping on their chest. I don't find it hard to explain this to people.
 
Arch Guillotti said:
I would not put a BIS on a demented 92 year old for all the tea in China😀.

Are you really going to put a TEE probe in this lady or just have it available if needed?
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I would have a TEE around and if numbers weren't looking good, def wouldn't hesitate to take a look. The fact that she hasn't had a echo in 3 years is worrisome. A lot can happen to a 90 something sick pt in 3 years.


Interesting regarding BIS and dementia. Did a quick literature search, looks like they do have a lower baseline BIS, but not by much. I would have baseline awake values before induction. So I think it still has utility.

http://www.ncbi.nlm.nih.gov/pubmed/12707138
 
Nice case, solid management. That DNR intraop thing is always a tricky situation to me. When you're watching a pt going down the tubes its very hard to not do anything when you know that if you stablize them now they might recover post op. I don't think there's any good answer to the DNR thing for any case because you're going to start by intubating him so that's already violated so now we say no more stuff? How bout pressors? Neo ok but epi a no? These are tough ethical questions that can get you into a very grey area.

Re Bis - I wouldn't use it in this case because it doesn't add anything to my anesthetic plan and just makes things more confusing. You've got a 90 y/o demented pt w/a bad heart, their pressure is gonna drop like a stone so I'm going to run him very light. Will I do anything different if the bis reads 60 or 20? Not really, I'm just trying to get through this case w/out running a code. I'm not going to load this guy up w/drugs so my bis number looks better so how is it goin to change anything? I'd just skip it
 
I think the BIS has some utility in these cases. We did a demented 96 yo for a femur fx, on 0.4 et sevo her BIS was 35. It's not gonna help you stop the pt from coding, but it gives you an idea of just how sensitive these super old people are to our drugs/gases.
 
narcusprince said:
My rational is that if a patient comes to my or. I would want ful reign to rescucitate them as I see fit. Where does rescucitation start ACLS bolus pressors blood. Too murky a situation for the family to understand. So I make it simple for the family I will rescucitate them while they are in the OR once out and out of Pacu place the dnr/dni order back on.
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always a tough situation, many hospitals have a policy on this. i used to demand that DNR be suspended for the OR, but now I realize that doesnt have to be the way. is blood transfusion specifically mentioned in the DNR? i dont think it is in ours, I would have no problem transfusing someone who is DNR if they needed it, in fact if they are symptomatic and will improve with blood then its perfectly reasonable.
 
I chose no BIS because it was not going to really tell me anything. The guy was demented and delirious and if I had to run him light(agent off) I had IV scop(which could make his emergence more difficult). Balance risk of recall vs risk myocardial suppression.
 
narcusprince said:
I came to a few conclusions no Midazolam and no Propofol. I gave 250 mcgs of Fentanyl in divided doses. Had IV scopalamine in the room if I needed to turn off agent. Had an experianced set of hands in the room. IV fentanyl, a little inhalational agent 2.5% Sevo APL set at 20(for bagging). Defasiculating dose of roc Succ tube. Pt had a little jaw rigidity(MH lights went off in back of head). Tupe slid in like butter. Got another 14 IV. Hemodynamics STABLE throghout induction. I prefer tubes in pulmonary hypertensives because one I think hypoxia, hypercarbia, acidosis can be better controlled with an ET tube than a LMA plus demented head demented stomach. I placed the patient on pressure control ventilation to limit the intrathoracic pressure component contributing to the pulmonary hypertension. So tubes in pt is stable. Sevo at about 1.5% surgeons try closed reduction which was does not work. Now we proceed to open reduction. Surgeons make incision pt hemodynamics rock stable HR starts creeping up into the 90-100's I give 50mcgs of fentanyl HR creeps down. HR starts creeping up 100's and irregular looks like Afib start hitting him with Esmolol 30-40 mgs gets the rate down into the 70's. Have to play this cat and mouse game throughout case. ABG sent throughout case was fine Hgb 10/30 no acidosis present. They start closing the hip pt starts breathing spontaneously give a touch of reversal agent pt taking in tidal volumes of 600-700cc with a rate of 8. Case goes well with occasional pressers tried to avoid Neo but had to use it I move the patient off the OR bed into the transport bed. While their is still some agent on board and extubate on the mobile bed. Pt does fine. Goes to PACU has some ST depressions in PACU. I stated that what can we do if patient does have an interoperative or postop MI nothing other than standard 100% O2 beta blockade, Morphine cannot transfuse secondary to the DNR order. Saw the patient 1 day postop looked like a completely different person actively moving does not remember a thing about the case. I will never forget his smile with the new hip in place. Tough case!
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Nice job, sounds like a satisfying case.

Is that a typo on the sevo?

Agree with you on favoring intubation over LMAs in these patients. I've really come to like fascia iliaca blocks in old people going to the OR for open hip cases. With them I find I can usually get away with about 3% des, less than 100 mcg fentanyl, and esmolol & phenylephrine/vasopressin to keep their hemodynamics where I want them. Sometimes a little ketamine. Most of the time they're awake at their baseline mental status & pain free in the PACU. Old people never remember anything.
 
pgg said:
Nice job, sounds like a satisfying case.

Is that a typo on the sevo?

Agree with you on favoring intubation over LMAs in these patients. I've really come to like fascia iliaca blocks in old people going to the OR for open hip cases. With them I find I can usually get away with about 3% des, less than 100 mcg fentanyl, and esmolol & phenylephrine/vasopressin to keep their hemodynamics where I want them. Sometimes a little ketamine. Most of the time they're awake at their baseline mental status & pain free in the PACU. Old people never remember anything.
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Pgg not a typo 2.5% to start during the bag mask portion o2 flow at maximum. Then titrated down to half that once the tube was in. I wanted gradual titration of agent. Realizing that the FA/FI equalization was going to take awhile.
 
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narcusprince said:
Pgg not a typo 2.5% to start during the bag mask portion o2 flow at maximum. Then titrated down to half that once the tube was in. I wanted gradual titration of agent. Realizing that the FA/FI was going to take awhile.
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explain to me why you think it would take longer in this patient
 
Idiopathic said:
explain to me why you think it would take longer in this patient
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On the iphone here. So the FA/FI so a few factors that would slow it is the b/g solubility of the agent the concentration of agent used and alveolar ventilation also the patient has a depressed CO which would increase the equalization of the Fa/fi ratio( less volatile washed away). I wanted slow gradual titration. The narcotic and the patients baseline dementia/delerium provided the amnesia. I know the inhalational agent during this time provided minimal anesthesia but I wanted it on.
 
okay, i feel like relative to other patients, the equalization of Fa/Fi would be quicker in this patient (quicker induction with volatile), suggesting that a high inspired concentration up front would actually get you anesthetized quicker (maybe the opposite of what you were trying to do?) obviously you did an excellent job, just fun to debate the science.
 
btbam said:
I think the BIS has some utility in these cases. We did a demented 96 yo for a femur fx, on 0.4 et sevo her BIS was 35. It's not gonna help you stop the pt from coding, but it gives you an idea of just how sensitive these super old people are to our drugs/gases.
Click to expand...

Thats exactly my point about why it's unecessary. As a learning tool for residents to understand the concepts, sure have at it, but for a seasoned attending it tells you exactly what you already know and just wastes $$. Demented old people don't need much anesthetic at all so you can go real low and just titrate to bp.
 
ssmallz said:
Thats exactly my point about why it's unecessary. As a learning tool for residents to understand the concepts, sure have at it, but for a seasoned attending it tells you exactly what you already know and just wastes $$. Demented old people don't need much anesthetic at all so you can go real low and just titrate to bp.
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Disagree. For younger people, yes I'll use it for recall.

For older people I use it to see just how little anesthesia I can get away with. I don't titrate up.. I titrate down. It amazing how often we overdose our anesthetics.

I've done inductions with 40 mg of propofol dropping them from bis of 90 to 30s. It lets me run my mac gases really low (mac 0.3) if I have narc on board. I agree its not always needed, but in this case I think it would be helpful.

Its especially helpful in a combined epidural/general case.
 
Without BIS, the alternative is to run as much mac as the vital signs tolerate albeit for this patient it will probably be low. What I am saying is even that amount is probably still overdosing.
 
its unnecessary, meaning you dont need it. certainly you can use it, but to extrapolate that you are otherwise overdosing patients may not be accurate.

the alternative is to run an acceptable anesthetic with age-related decreases in MAC and the combined effects of volatile anesthetic and opioids both understood and factored in.
 
RxBoy said:
For older people I use it to see just how little anesthesia I can get away with. I don't titrate up.. I titrate down. It amazing how often we overdose our anesthetics.

I've done inductions with 40 mg of propofol dropping them from bis of 90 to 30s. It lets me run my mac gases really low (mac 0.3) if I have narc on board. I agree its not always needed, but in this case I think it would be helpful.

Its especially helpful in a combined epidural/general case.
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These old, frail, +/- demented people never remember anything. I routinely induce them with 3-4 cc of propofol, 50 fentanyl, a little relaxant. Maybe 3% desflurane via ETT and an asleep FI block, done. I run them light, they wake up quick, it's a satisfying anesthetic.

Even if they did have recall, which they don't ... it's not that big a deal. A 30 yo having recall during an elective cholecystectomy is a problem. An old trainwreck who has some recall but survives a procedure with a 1-year mortality approaching 20-30% is not something I'm worried about.

I'm not arguing that there's anything wrong with using the bis. It appears you're using it in order to reassure yourself that a minimal induction and light anesthetic is OK. I think that's OK all the time in these patients.


narcusprince said:
Pgg not a typo 2.5% to start during the bag mask portion o2 flow at maximum.
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Gotcha, I was thinking/misreading that to be was your steady-state/maintenance gas level during the case ... my mistake. 🙂
 
pgg said:
i routinely induce them with 3-4 cc of propofol, 50 fentanyl, a little relaxant. Maybe 3% desflurane via ett and an asleep fi block, done. I run them light, they wake up quick, it's a satisfying anesthetic.
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+1
 
pgg said:
These old, frail, +/- demented people never remember anything. I routinely induce them with 3-4 cc of propofol, 50 fentanyl, a little relaxant. Maybe 3% desflurane via ETT and an asleep FI block, done. I run them light, they wake up quick, it's a satisfying anesthetic.
Click to expand...

What I am saying is that your 3% des is probably overdosing. You could probably get away with 2.5% or 2% but you wouldn't know without bis. To each his own though. The recall isn't even a factor why I place it for older, sicker population. I just want to avoid overdosing.
 
narcusprince said:
My rational is that if a patient comes to my or. I would want ful reign to rescucitate them as I see fit. Where does rescucitation start ACLS bolus pressors blood. Too murky a situation for the family to understand. So I make it simple for the family I will rescucitate them while they are in the OR once out and out of Pacu place the dnr/dni order back on.
Click to expand...

Sometimes it is easier to just suspend the DNR, especially when the family may have trouble understanding exactly what happens in the OR. I don't think we should make a blanket policy for all comers though.
 
Idiopathic said:
its unnecessary, meaning you dont need it. certainly you can use it, but to extrapolate that you are otherwise overdosing patients may not be accurate.

the alternative is to run an acceptable anesthetic with age-related decreases in MAC and the combined effects of volatile anesthetic and opioids both understood and factored in.
Click to expand...

Exactly. People did these cases on low MAC long before BIS came around.
 
narcusprince said:
I chose no BIS because it was not going to really tell me anything. The guy was demented and delirious and if I had to run him light(agent off) I had IV scop(which could make his emergence more difficult). Balance risk of recall vs risk myocardial suppression.
Click to expand...

You said his mental status was improved POD#1. Why? Was he a little gorked from narcs before you saw him pre-op?
 
Arch Guillotti said:
I think this is nuts.

I don't think any of us should need a little box that spits out a number to prevent recall.
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thats right, especially when its been proven not to do that.

the ways to prevent recall are: fill your vaporizer and make sure its on, label and administer your induction drugs appropriately, dont do trauma/cardiac/stat cesarean sections.
 
Idiopathic said:
thats right, especially when its been proven not to do that.

the ways to prevent recall are: fill your vaporizer and make sure its on, label and administer your induction drugs appropriately, dont do trauma/cardiac/stat cesarean sections.
Click to expand...

yeah the rest is gravy😀
 
Arch Guillotti said:
I think this is nuts.

I don't think any of us should need a little box that spits out a number to prevent recall.
Click to expand...

This is another argument in itself and not pertinent in this case.

But I mentioned 3 separate times why I use in older/sicker populations so I guess I'll have to mention it a 4th time seeing as I keep getting the same comments about "recall".

I use it to avoid overdosing the patient on gas. If I can run 0.3 mac, I'll run 0.3 mac.
 
RxBoy said:
I use it to avoid overdosing the patient on gas. If I can run 0.3 mac, I'll run 0.3 mac.
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That involves a great deal of trust in the BIS.

Not for me.
 
Back to the DNR status. We have a separate form that must be filled out and discussed with DNR patients and it offer them a couple of choices. I always take the time to explain things in very easy to understand terms. My conversation usually goes something like this:

I need to get some clarification on your wishes for your (your loved one's) care during the time they are in the operating room and the recovery room area. As I understand it, you wish not to be resuscitated if your heart stops beating or to have chest compressions or a breathing tube to assist you with your breathing if you are unable. The operating room is a little different environment and many of the drugs we give and situations that we will encounter will require some amount of resuscitation, even in young, healthy patients. These situations are usually brief and easily treated. I would like to have your permission to perform our standard resuscitation measures. Very rarely, an event will occur that is very life threatening and would require chest compressions or electricity to shock your heart back into a normal rhythm. These situations would not be considered routine. At this point, I just need to know what you would like for me to do in that situation. One option is to treat the issue if we think it is due to something easily reversible that you could recover from in a meaningful way (such as a CO2 embolus). That could mean some strong heart medicines to try and correct things or a couple of minutes of chest compressions. If it is your wish, we would not do any heroic measures if it appeared that the situation is not easily reversible.
At this point, most patients and families will understand this and re-emphasize that they have a strong desire not to be kept alive and on life support if they have no chance of recovery. I express understanding and promise to them that I will do routine resuscitation and possibly brief chest compressions if it is deemed appropriate and consistent with their wishes, but that heroic measures will not be taken if the situation does not appear to be hopeful.
Most patients and families are agreeable to that and are able to understand it in those terms.
A few families will want the DNR orders completely rescinded during the periop period. A handful of patients and families will say "absolutely not" to any kinds of strong resuscitation options such as Epi/Defib/Chest compressions. I usually try to mark down what the family and patient will and will not accept. For example, "Patient will accept chest compressions but no shocks." Some families will be that specific.
I like to use the phrase "heroic measures" since I feel that it lets the family know that I will make good faith efforts (which might include strong medicines or even brief CPR) to bring them back in situations I believe to be reversible but that I will also respect the patient/family's wishes to not let them suffer needlessly by ending up in the ICU intubated on a large number of drips with little chance for a meaningful recovery.

Blood transfusions are a separate issue and are usually not a part of the DNR discussion per se. Those consents are usually done by the surgeon. I usually try to touch on the issue with all patients if I think it is likely that I will need to transfuse (low starting Hgb or expected large EBL).
 
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