Couple of consults I've had

[militarymd]

Case 1)

58 year old ASA 2 patient goes to the OR for a laparscopic colon resection for diverticular disease. Induction with propofol, rocuronium, and fentanyl. Case maintained with oxygen, sevoflurane, and fentanyl...duration around 4 hours.

At the end of the case, patient was extubated and taken to the PACU. Vital signs stable, and O2 sats 100% on face tent...although patient is not awake.

Anesthesia provider leaves the patient with the pacu staff in above condition. Gets called back 1 hour later because patient is STILL not awake, so she orders narcan to be administered....No effect...Anesthesia provider goes back to her cases....another hour passes...and patient is still not awake but vital signs shows high sympathetic state.....Anesthesia provider now orders a blood gas...which shows that the patient has severe respiratory acidosis but pO2 is 200 +....

Anesthesia provider now decides that she needs to order a head CT...this is when the pacu staff calls me to take a look.

I take one look and ask whether NMB reversal was given...answer was no, but patient had "adequate twitches and is OBVIOUSLY breathing fine with his sats at 100%"....She insists that a CT scan needs to be done to rule a perioperative stroke...explaining the hypertension.

I walked away and brought back 5 milligrams of neostigmine which I gave to the patient (with glyco) while this woman was babbly away about how I'm wasting my time....5 minutes later, the patient woke up.

Case 2)

82 year old ASA3 having a similar procedure for malignancy. At end of the case, the anesthesia provider was taking so LONG to wake the patient up and extubate that I was called into the OR to see what was going on. This anesthesia provider told me that she had reveresed the patient, but she just didn't seem to be breathing quite right and doesn't appear awake....even though they had everthing off for over 45 minutes.

I say to her...patient is still paralzyed...she is doubtful, but accepts my consult ...to restart anesthesia and put the patient on the vent in the pacu.

Patient "wakes up" 2 hours later in the pacu....



Summary:

no recall for either patients.
no permanent injury to either patients.

case 1 - anesthesia provider didn't reverse patient and didn't recognize signs of weakness.

case 2 - anesthesia provider DID reverse the patient, recognized weakness, but didn't what else to do.....I'm not sure why patient 2 was weak, but I surmised that she may have had something similar to eaton lambert because of her malignancy.


The anesthesia provider in case 1 was a Board Certified anesthesiologist who trained at a big name university that many here talk about...and who the surgeons think does a good job.


The anesthesia provider in case 2 was a newly graduated CRNA...who couldn't get a job at the other hospital because one of the anesthesiologists there thought she was incompetent.

Moral of this post??? I don't know...I just thought I would post it.

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[invitro]

So are you trying to say that BC anesthesiologists are unyielding and stupid? That CRNAs are not?

Everybody makes mistakes, and everybody can be stubborn sometimes. I guess the people who just realize their mistakes and learn from them are the ones who make out the best.

Given that I'm a CA-1 (who has made (and continues to make) mistakes) I think am qualified to say this.

 

[militarymd]

So are you trying to say that BC anesthesiologists are unyielding and stupid? That CRNAs are not?

Everybody makes mistakes, and everybody can be stubborn sometimes. I guess the people who just realize their mistakes and learn from them are the ones who make out the best.

Given that I'm a CA-1 (who has made (and continues to make) mistakes) I think am qualified to say this.

I just wanted to remind everyone of the above....especially seeing how we have all these threads about how CRNA's can't intubate....which I view as a monkey skill....meaning you can train a monkey to do it.


I figure I would show an example of how a BC anesthesiologist from a BIG name university that has posters here couldn't DIAGNOSE and TREAT something that a lowly CRNA DIAGNOSED.

 

[coprolalia]

1) Residual weakness may have played a role. The patient had inadequte spontaneous respirations, which despite being well-oxygenated under the face tent, probably led to hypercarbia that resulted in an additional narcosis. The hypercarbia may have been exacerbated by residual CO2 used in the belly during the laparscopic part of the procedure as it was resorbed. Also, pain and splinting respirations could've affected it too. Providing a little extra strength so she could take deeper breaths (and allowing her to blow-off some of that CO2) probably made the difference. Although, being weak after six hours of an intubating dose of rocuronium seems unusal.

2) Who knows what the hell happened. Eaton-Lambert or some other neuromuscular problem may have been at work there. Patient should probably be referred for further testing on an outpatient basis.

Just my $0.02.

-copro

 

[militarymd]

1) Residual weakness may have played a role. The patient had inadequte spontaneous respirations, which despite being well-oxygenated under the face tent, probably led to hypercarbia that resulted in an additional narcosis. Providing a little extra strength so she could take deeper breaths (and allowing her to blow-off some of that CO2) probably made the difference. Although, being weak after six hours of an intubating dose of rocuronium seems unusal.

2) Who knows what the hell happened. Eaton-Lambert or some other neuromuscular problem may have been at work there. Patient should probably be referred for further testing on an outpatient basis.

Just my $0.02.

-copro

Unpredictability of roc is well known.

 

[coprolalia]

Unpredictability of roc is well known.

Why is that? That's a serious question. I've heard that before, and I also have seen some people breathing 10 minutes after a monster dose, while others seem to be paralyzed for 50+ minutes with the same dose.

Is it a patient-variability thing? Is it a pharmacologic/manufacturing thing?

-copro

 

[militarymd]

Why is that? That's a serious question. I've heard that before, and I also have seen some people breathing 10 minutes after a monster dose, while others seem to be paralyzed for 50+ minutes with the same dose.

Is it a patient-variability thing? Is it a pharmacologic/manufacturing thing?

-copro

I don't know the answer....only that it is reported that you can have prolonged duration of action from even a single dose....

Well, at least I thought it was well known.

 

[urge]

Case number 1 is rather odd. A patient not being able to move a little bit even? With twitches? Easily reversed after such deep paralysis? And no recall? Very odd. In the abscence of any testing for twitches done before or after you gave the neostigmine I can only responsibly conclude that it was casuality more than causality. I work with a lot of new CRNAs and residents. I see weak pts almost everyday. My pts move a little bit if they have twitches and the gas has been off for a while.

 

[militarymd]

Case number 1 is rather odd. A patient not being able to move a little bit even? With twitches? Easily reversed after such deep paralysis? And no recall? Very odd. In the abscence of any testing for twitches done before or after you gave the neostigmine I can only responsibly conclude that it was casuality more than causality. I work with a lot of new CRNAs and residents. I see weak pts almost everyday. My pts move a little bit if they have twitches and the gas has been off for a while.

He was moving...floppy fish...and breathing with guppy breaths...and he had 1 twitch (I checked ...I just didn't post it)....before I gave the neosti

and you're missing the point of the post.

 

[2ndyear]

Mil, thanks for the great post. One of the best I've read in a while. I like case 1 because it brings up the issue of 'grounding' or 'anchoring'. When we get so hung up on one thing that we forget about the other causes of whatever symptom we're seeing. I'm sure anesthesia provider #1 is smart, clinically savvy, etc. But she became anchored on the must be the head tract. Done. I like provider #2's approach. As a new grad, even if she sucks, she seems like she knows when to call for help. Sucking and not knowing would be a bad combo.

 

[bullard]

I've been taught (as a CA1) that it's a patient variability thing, and thus I always reverse if I've given roc, no matter the dose, no matter how much time has elapsed since previous dose.

I don't understand why people are loathe to reverse neuromuscular blockade. Neostigmine causing PONV? Dexamethasone, ondansetron, scopolamine patch...they're cheap and they work.

I don't know the answer....only that it is reported that you can have prolonged duration of action from even a single dose....

Well, at least I thought it was well known.

 

[Planktonmd]

I think the moral should be:
People should stop using muscle relaxants when there is no indication and only to make a crappy anesthetic look good.

 

[TIVA]

Mil, thanks for the interesting cases ... nice diversion from studying for the orals.

Another take home point I've learned the hard way in the past: always give some antidote to your poisons. Even if you have full twitches, give some reversal agent. Because if the patient hypoventilates (which they did), they will become acidotic and recurarize their neuromuscular junctions. It has something to do with the Pka's of paralytics ... causing increase in free fraction ... blah, blah, blah.

Also, I'm surprised you didn't re-intubation case 1 in order to fix the CO2. Because even if you give reversal, you still have a PCO2 of 200 which is acting as an anesthetic unto itself and will keep the patient asleep and hypoventilating (thus no surprises that the patient has no recall). I would've re-intubated the patient in order to control their ventilation and bring their CO2 down in order to waken them (in addition to giving reversal). Besides, I'm sure a PCO2 of 200 must be equivalent to an arterial pH of less than 6.1.

Anyways, back to the books ...

 

[Coastie]

I just wanted to remind everyone of the above....especially seeing how we have all these threads about how CRNA's can't intubate....which I view as a monkey skill....meaning you can train a monkey to do it.


I figure I would show an example of how a BC anesthesiologist from a BIG name university that has posters here couldn't DIAGNOSE and TREAT something that a lowly CRNA DIAGNOSED.

Mil, my post wasn't about CRNA's being "unable to intubate", although, as we saw, the attending did it in 3 seconds flat, that wasn't the point of the post.

 

[militarymd]

Mil, thanks for the interesting cases ... nice diversion from studying for the orals.

Another take home point I've learned the hard way in the past: always give some antidote to your poisons. Even if you have full twitches, give some reversal agent. Because if the patient hypoventilates (which they did), they will become acidotic and recurarize their neuromuscular junctions. It has something to do with the Pka's of paralytics ... causing increase in free fraction ... blah, blah, blah.

Also, I'm surprised you didn't re-intubation case 1 in order to fix the CO2. Because even if you give reversal, you still have a PCO2 of 200 which is acting as an anesthetic unto itself and will keep the patient asleep and hypoventilating (thus no surprises that the patient has no recall). I would've re-intubated the patient in order to control their ventilation and bring their CO2 down in order to waken them (in addition to giving reversal). Besides, I'm sure a PCO2 of 200 must be equivalent to an arterial pH of less than 6.1.

Anyways, back to the books ...

re-intubation would have been the next thing, but the patient responded very quickly to reversal.

 

[militarymd]

Mil, my post wasn't about CRNA's being "unable to intubate", although, as we saw, the attending did it in 3 seconds flat, that wasn't the point of the post.

I just don't think we should throw stones.....we all live in glass houses....MD's and nurses both do a lot of the same things....

I felt that stones were being cast at the nurses' houses.......why? I don't know.

 

[joshmir]

i second, one of the best i've seen in a while

please keep stories, insights like those coming. we learn a great deal form them

 

[InGasWeTrust]

As already mentioned perhaps a neuromuscular junction disease. One that crosses my mind is post polio syndrome. This situation could manifest in a patient with post polio syndrome.

Thanks for sharing Mil.

 

[SleepIsGood]

......something that a lowly CRNA DIAGNOSED.

Physicians diagnose..nurses do not.

This is another area where nurses want to say they can do the same. If anesthesiologists let them start misrepresenting themselves like this, good luck to your own job and the job of thousands of future anesthesiology grads.

Moral of the story that I've always been a proponent of is: Reverse everyone who you gave a mx relaxant to. I think someone quoted Dr. Miller as saying he would testify against anyone that didnt give reversal to someone who had NMB given.

 

[militarymd]

Physicians diagnose..nurses do not.

This is another area where nurses want to say they can do the same. If anesthesiologists let them start misrepresenting themselves like this, good luck to your own job and the job of thousands of future anesthesiology grads.

Moral of the story that I've always been a proponent of is: Reverse everyone who you gave a mx relaxant to. I think someone quoted Dr. Miller as saying he would testify against anyone that didnt give reversal to someone who had NMB given.

then what did this particular CRNA do? Correctly I might add....that a Board Certified Anesthesiologist from a big name program did incorrectly.

 

[VentdependenT]

then what did this particular CRNA do? Correctly I might add....that a Board Certified Anesthesiologist from a big name program did incorrectly.

I know!

He/She got a CRNA degree instead of spending all the additional time and considerable resources of becoming a board certified anesthesiologist.

 

[militarymd]

I know!

He/She got a CRNA degree instead of spending all the additional time and considerable resources of becoming a board certified anesthesiologist.

That's why we have different jobs,opportunities, responsibilities and different pay, but do many of the same things...including diagnosing things.

Don't put them down....and they won't put you down.

As for the politics ....leave it outside of the OR...and with the members of our societies who have political tendencies.

 

[Noyac]

Everybody can have an off day. But this is the basics. I'm not surprised by the crna and I'll bet the crna learned something from this (meant to be a compliment towards the crna) . I wonder if the MD learned anything? I wonder if the MD can learn anything or if her education (in general) is getting in the way?

Remember, it's called the practice of medicine. Don't be too confident.

 

[Noyac]

then what did this particular CRNA do? Correctly I might add....that a Board Certified Anesthesiologist from a big name program did incorrectly.

Some may say she reversed the pt.

I disagree, I don't think everyone needs to be reversed. I don't treat every pt in a cookbook format. I make medical decisions. And this is what the crna did correctly. She noticed something was wrong. And did what she was trained to do. It doesn't sound like she was willing to extubate the pt in this state and accepted help.

The BC MD didn't notice anything wrong in a reasonable amount of time and didn't ask for help.

 

[urge]

I hate to be the one asking this, but I'm marveled that nobody has brought this issue. It crossed my mind the first time I read the post but I was waiting for someone else to point it out. Since no one has done it, I guess I will. Where was the attending for scenario 2? 45 min seems like a long time for a wake up with no supervision.

 

[Planktonmd]

I hate to be the one asking this, but I'm marveled that nobody has brought this issue. It crossed my mind the first time I read the post but I was waiting for someone else to point it out. Since no one has done it, I guess I will. Where was the attending for scenario 2? 45 min seems like a long time for a wake up with no supervision.

The way it works usually:
If we don't get a call from the OR we assume that everything is running smoothly and don't necessarily show up for extubation unless we think there is a reason to expect problems.
In private practice usually you are doing more than just supervising 3-4 OR's, you could be doing procedures in holding, seeing consults, doing pre-ops, doing labor epidurals......

 

[coprolalia]

The way it works usually:
If we don't get a call from the OR we assume that everything is running smoothly and don't necessarily show up for extubation unless we think there is a reason to expect problems.
In private practice usually you are doing more than just supervising 3-4 OR's, you could be doing procedures in holding, seeing consults, doing pre-ops, doing labor epidurals......

Are you present during intubation? Who pushes the drugs? Who puts in central lines, if the case requires one? What if you are titrating multiple pressors in someone who's labile and/or going into dysrhythmias? How often do you "check-in" on your room? Do the CRNAs have the understanding (or policy) that they should always call you if there is a potential for a problem or something during the case significantly changes? If so, what do you do if find out later that they didn't?

Serious questions. I might find myself in your position not too long from now. And, judging by the wide variance in practice abilities I've seen amongst our own CRNAs, I can't be sure that I would feel comfortable not being there during the critical portions of the case.

-copro

 

[urge]

The way it works usually:
If we don't get a call from the OR we assume that everything is running smoothly and don't necessarily show up for extubation unless we think there is a reason to expect problems.
In private practice usually you are doing more than just supervising 3-4 OR's, you could be doing procedures in holding, seeing consults, doing pre-ops, doing labor epidurals......

I understand your point. But, 45 minutes!! That's a LONG time in the OR. Even 5 min is a long time when you are looking at each others faces. OR time is calculated on average at $20/min based on salaries of staff. That little stunt cost $900. Shouldn't the attending be called earlier to avoid this? Are mid levels getting more freedom than they can handle? PP is all about efficiency. This wasn't efficient at all. And, I'm sure the surgeon was pissed too.

 

[Planktonmd]

Are you present during intubation? Who pushes the drugs? Who puts in central lines, if the case requires one? What if you are titrating multiple pressors in someone who's labile and/or going into dysrhythmias? How often do you "check-in" on your room? Do the CRNAs have the understanding (or policy) that they should always call you if there is a potential for a problem or something during the case significantly changes? If so, what do you do if find out later that they didn't?

Serious questions. I might find myself in your position not too long from now. And, judging by the wide variance in practice abilities I've seen amongst our own CRNAs, I can't be sure that I would feel comfortable not being there during the critical portions of the case.

-copro

Exactly.
Not all CRNA's are the same and you trust each one of them to a certain degree depending on your knowledge of their ability.
My presence in the room depends on multiple factors including:
Case complexity, CRNA ability, surgeon's ability....
We can watch all the rooms monitors from our office monitor.
We are present at induction for any case with issues, for all the thoracic and major vascular cases.
We place the Central lines, some of our CRNA's do place spinals and lumbar epidurals, we place all the thoracic epidurals and all the nerve blocks.
Our CRNA's place A lines....
It's not a perfect system but it works.

 

[toughlife]

then what did this particular CRNA do? Correctly I might add....that a Board Certified Anesthesiologist from a big name program did incorrectly.

OK, explain to me how you arrived at the notion that the old lady was still paralyzed after she had been given reversal.

If it took her a couple of hours to wake up once she was left on the vent, did you check how much narcotic she was given? was she given midazolam? Did she receive narcan?

Did the lady have four twitches and did you give any additional doses of reversal?

Somehow your idea that the patient was still paralyzed and took her two hours to "wake up" does not make sense.

 

[militarymd]

I understand your point. But, 45 minutes!! That's a LONG time in the OR. Even 5 min is a long time when you are looking at each others faces. OR time is calculated on average at $20/min based on salaries of staff. That little stunt cost $900. Shouldn't the attending be called earlier to avoid this? Are mid levels getting more freedom than they can handle? PP is all about efficiency. This wasn't efficient at all. And, I'm sure the surgeon was pissed too.

I was the attending...and I didn't type out the ENTIRE story...from last stitch to out of room ..45 minutes...

There was probably 10 minutes of clean up/dressing before the patient could even be moved...I was present for that....saw the reversal given....saw that vitals were good....

went on to attend other inductions/business...returned at around the 30 minute mark....patient left room at the 45 minute mark after ventilator, etc, arranged and plann discussed with surgeon.

 

[militarymd]

OK, explain to me how you arrived at the notion that the old lady was still paralyzed after she had been given reversal.

If it took her a couple of hours to wake up once she was left on the vent, did you check how much narcotic she was given? was she given midazolam? Did she receive narcan?

Did the lady have four twitches and did you give any additional doses of reversal?

Somehow your idea that the patient was still paralyzed and took her two hours to "wake up" does not make sense.

Nope..

I don't check any of that....I don't care how much narcotics , fluids, blood, nmb...any of that...

I just look at the patient and say that they are paralyzed....don't check anything....and tell the surgeon that....and just keep the patient on the ventilator for 2 hours because I want to......then extubate.

Yep, I'm a rookie,...I didn't know you have to do any of that when you evaluate a patient.

 

[toughlife]

Nope..

I don't check any of that....I don't care how much narcotics , fluids, blood, nmb...any of that...

I just look at the patient and say that they are paralyzed....don't check anything....and tell the surgeon that....and just keep the patient on the ventilator for 2 hours because I want to......then extubate.

Yep, I'm a rookie,...I didn't know you have to do any of that when you evaluate a patient.

well, nothing from your post said you did. More details would be good if you expect people to comment on the case.

 

[VentdependenT]

What MMD came from experience. That stuff takes time.

Imagine in your training, how easy it is to get lead down a path just because someone brought it up. You fixate. You forget options. Thats human.

 

[pd4emergence]

Good take home points from these cases.

Case 1: MD got stuck on one diagnosis and did not entertain other possibilities. She ruled out NMB's as the cause and did not reevaluate the situation. Most common cause of post op altered mental status is residual anesthetic drugs. Get an ABG. Also, if what you are doing is not working do something else.

Case 2: Everyone will see this scenario. You will be tempted to rush extubating the patient for the sake of time. I think if the patient looks weak to you take your time and make sure that they meet strict extubation criteria. Otherwise you will spend more time and expose the patient to more risk with their reintubation.

Both of these scenarios were on my orals. It comes up just about ever year. My patient like case one did have a stroke but if I would have went straight to CT and not ruled out the common/easy things I would have failed. Thanks for the post Mil.