Crappy sedation for cardioversion

[ProRealDoc]

[YOUTUBE]http://www.youtube.com/watch?v=2nsN0vdXZuY&NR=1&feature=fvwp[/YOUTUBE]

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[fascinoma]

When I do bedside procedures I usually let family stay, if they want. After this video, I think I may have to reconsider. That being said: "oh, god..." At least he got back in sinus.

 

[ProRealDoc]

When I do bedside procedures I usually let family stay, if they want. After this video, I think I may have to reconsider. That being said: "oh, god..." At least he got back in sinus.

Poor guy was feeling every shock.

 

[fascinoma]

Question: if he doesn't remember any of it, then is it a successful anesthetic?

 

[proman]

Two thoughts: you just need anxiolysis/amnesia for cardioversion, and what the hell's up with those hideous two-tone Two Face scrubs.

 

[ProRealDoc]

Question: if he doesn't remember any of it, then is it a successful anesthetic?

It depends how you define successful.

 

[ProRealDoc]

Two thoughts: you just need anxiolysis/amnesia for cardioversion, and what the hell's up with those hideous two-tone Two Face scrubs.

Agreed but having a pt complain after every shock even though he is amnestic, IMHO, makes you look like an amateur. I'd expect a bit more finesse from the anesthesia resident/attending.

 

[proman]

What would be your anesthetic plan for this patient:

Known difficult airway with impossible mask
ICD placed, time for it to be tested
Cardiomyopathy with EF of 10%
HIV on HAART
Morbid obesity

EP wants to test the ICD by inducing VF and terminating it with the ICD, twice.

 

[aredoubleyou]

Agreed but having a pt complain after every shock even though he is amnestic, IMHO, makes you look like an amateur. I'd expect a bit more finesse from the anesthesia resident/attending.

Two letters sum it up: VA

At least it looks like a va

 

[aredoubleyou]

What would be your anesthetic plan for this patient:

Known difficult airway with impossible mask
ICD placed, time for it to be tested
Cardiomyopathy with EF of 10%
HIV on HAART
Morbid obesity

EP wants to test the ICD by inducing VF and terminating it with the ICD, twice.

Hand the cardiologist a dosing chart for precedex or versed and leave the room. They dont need us.

Or better yet, suggest they hire an unsupervised crna, since it works so well for the gi guys.

Im not bitter...really

 

[Planktonmd]

What would be your anesthetic plan for this patient:

Known difficult airway with impossible mask
ICD placed, time for it to be tested
Cardiomyopathy with EF of 10%
HIV on HAART
Morbid obesity

EP wants to test the ICD by inducing VF and terminating it with the ICD, twice.

A line, awake FOB, ETT and GA.

 

[dA pilot]

This is what the patient said in the youtube comments "freddyp321 2 years ago didnt feel or remeber a thing. the last thing you will remember is feeling euphoric as they sedate you. it will make you real tired afterward though. dont sweat it."

 

[ProRealDoc]

What would be your anesthetic plan for this patient:

Known difficult airway with impossible mask
ICD placed, time for it to be tested
Cardiomyopathy with EF of 10%
HIV on HAART
Morbid obesity

EP wants to test the ICD by inducing VF and terminating it with the ICD, twice.

nasal cannula, versed, hit of brevital. Difficult airway equipment on standby. Done.

 

[sevoflurane]

Two thoughts: you just need anxiolysis/amnesia for cardioversion, and what the hell's up with those hideous two-tone Two Face scrubs.

Absolutely. I don't even mask my patients. Nasal canula + propofol. It is easier to make someone apnic than it is to make them amnestic. Why complicate things? Keep 'em breathing for crying out loud! Cardioversion is a 1 sec. procedure... maybe a little more if you are not succesful the first time.

 

[Planktonmd]

nasal cannula, versed, hit of brevital. Difficult airway equipment on standby. Done.

Wow!
So, let's say they zap him and the AICD fails, the guy is now in Vfib, what is the plan?
Is it possible you might wish you had a secure airway in that situation?
Why did you pick Methohexital?
Apnea with Methohexital is very unpredictable especially when combined with Midazolam or other drugs in a patient that obviously has sleep apnea.

 

[Jay K]

Two thoughts: you just need anxiolysis/amnesia for cardioversion

I agree - we do many cardioversions daily, and anxiolysis and amnesia are the goals in this anesthetic. To the lay-person, the video may have looked like an unsuccessful anesthetic. The patient's comments validating amnesia during the procedure likewise prove a "successful" anesthetic. The pain requirements are also minimal to none after a cardioversion, therefore pre-medication/induction with narcotics is likewise unnecessary and/or detrimental.

I don't even mask my patients. Nasal canula + propofol. It is easier to make someone apneic [sp] than it is to make them amnestic. Why complicate things? Keep 'em breathing for crying out loud! Cardioversion is a 1 sec. procedure... maybe a little more if you are not succesful the first time.

I agree. Dude busted out an ambu bag AND a face mask for O2 later - generated extra cost and created significant medical waste. An ambu bag? I'll give the resident the benefit of a doubt and blame it on his attending's instructions.

Furthermore we also provide anesthesia for ICD tests all the time after new implantation or generator change. They get the same anesthetic from us - a touch of propofol for amnesia. In fact they're usually quite sedated already on midazolam and fentanyl from the cath lab crew during implantation, so we don't give very much propofol.

 

[bigeyedfish]

LOL at the two tone scubs. WTF?

The guy at the head is making the mistake I see all the time. People, if you don't squeeze an ambu bag, nothing is coming out of the mask. Nothing.

 

[proman]

A line, awake FOB, ETT and GA.

Interesting. We did just the opposite. Benzodiazepines are contraindicated in patients on HAART due to CYP450 inhibition. We had a couple of prolonged respiratory depression events by benzos given by non-anesthesiologists. It's my institution's policy to not give midazolam in these patients. Anyone have the same guideline?

We gave remifentanil 1mcg/kg boluses with appropriate oxygenation. We picked remi because of the very rapid metabolism and the availability of a reversal agent. It worked well, the patient actually didn't remember anything.

 

[urge]

What would be your anesthetic plan for this patient:

Known difficult airway with impossible mask
ICD placed, time for it to be tested
Cardiomyopathy with EF of 10%
HIV on HAART
Morbid obesity

EP wants to test the ICD by inducing VF and terminating it with the ICD, twice.

Pent, sux, tube

 

[Licoricestick]

The guy at the head is making the mistake I see all the time. People, if you don't squeeze an ambu bag, nothing is coming out of the mask. Nothing.

Are you sure?

Try it sometime, use a self inflating bag with a reservoir bag. You will find that the patient is perfectly able to spont vent through a self inflating bag, and the reservoir bag will empty with inspiration.

Can also use one with a PEEP valve on it to provide CPAP for a SV patient needing transport. I've done that too.

However, you are correct that there is no FGF in the absence of either PPV or SV (with a good seal) by the patient. There does need to be a pressure gradient to cause the valve to open.

 

[bigeyedfish]

However, you are correct that there is no FGF in the absence of either PPV or SV (with a good seal) by the patient. There does need to be a pressure gradient to cause the valve to open.

this is what I'm talking about. Yea, it's true if you have a good seal a spontaneously breathing patient will open the valve, but rarely do I see a anything resembling a seal. usually I see the mask lightly resting against the pts face. I think people think they're giving blow by or something

 

[proman]

Pent, sux, tube

Fail.

 

[Planktonmd]

Interesting. We did just the opposite. Benzodiazepines are contraindicated in patients on HAART due to CYP450 inhibition. We had a couple of prolonged respiratory depression events by benzos given by non-anesthesiologists. It's my institution's policy to not give midazolam in these patients. Anyone have the same guideline?

We gave remifentanil 1mcg/kg boluses with appropriate oxygenation. We picked remi because of the very rapid metabolism and the availability of a reversal agent. It worked well, the patient actually didn't remember anything.

Remifentanyl in a patient with a known history of difficult intubation and "impossible" mask ventilation as you stated requires big cojones, obviously you guys have some of those.
The short half life of Remifentanil is not a guarantee that your patient will start breathing when you want him to, and that's precisely why I stopped using Remi for "awake" FOB intubation.

 

[Licoricestick]

this is what I'm talking about. Yea, it's true if you have a good seal a spontaneously breathing patient will open the valve, but rarely do I see a anything resembling a seal. usually I see the mask lightly resting against the pts face. I think people think they're giving blow by or something

I quite agree with that, and agree that the guy in the video above is probably breathing RA around the mask.

 

[ProRealDoc]

Wow!
So, let's say they zap him and the AICD fails, the guy is now in Vfib, what is the plan?
Is it possible you might wish you had a secure airway in that situation?
Why did you pick Methohexital?
Apnea with Methohexital is very unpredictable especially when combined with Midazolam or other drugs in a patient that obviously has sleep apnea.

I like brevital because is ultra-short acting and has minimal pain on injection, substantial lipid solubility aiding in quick redistribution. (actually helpful in this obese pt).

If the pt goes into vfib while testing the AICD, then he gets another zap by EPS. Hell, they induce vfib to test the device anyways. We always have a difficult airway cart in the EPS labs area and LMAs/glidescope are readily available.

I believe you can use anything you like as long as you have a way to bail yourself out of trouble in a safe manner. So the threat of apnea, although important is not an absolute contraindication to the use of a medication. At least in my book.

 

[Planktonmd]

I like brevital because is ultra-short acting and has minimal pain on injection, substantial lipid solubility aiding in quick redistribution. (actually helpful in this obese pt).

If the pt goes into vfib while testing the AICD, then he gets another zap by EPS. Hell, they induce vfib to test the device anyways. We always have a difficult airway cart in the EPS labs area and LMAs/glidescope are readily available.

I believe you can use anything you like as long as you have a way to bail yourself out of trouble in a safe manner. So the threat of apnea, although important is not an absolute contraindication to the use of a medication. At least in my book.

Methohexital is not a bad induction agent but the margin between sedation and apnea is very unpredictable.
In the business of anesthesia we usually try to not rely on other people's actions so saying if he goes into vfib you will wait for them to fix it is a little weak IMHO.
I am also not sure that having the difficult airway cart in the EPS lab is a good enough plan of action in a patient who was a known difficult intubation and "impossible" mask ventilation as proman stated.
This all remains my personal opinion and ultimately there are multiple ways to skin a cat.

 

[proman]

Remifentanyl in a patient with a known history of difficult intubation and "impossible" mask ventilation as you stated requires big cojones, obviously you guys have some of those.
The short half life of Remifentanil is not a guarantee that your patient will start breathing when you want him to, and that's precisely why I stopped using Remi for "awake" FOB intubation.

It's possible to keep someone spontaneously breathing even with remi. 1mcg/kg (without any other med) hasn't caused apnea in the few times I've done it. I don't like using remi infusions (or opioid) for awake FOB for the reason you stated.

Methohexital is not a bad induction agent but the margin between sedation and apnea is very unpredictable.
In the business of anesthesia we usually try to not rely on other people's actions so saying if he goes into vfib you will wait for them to fix it is a little weak IMHO.

Just curious how many of these you do? The EP guys here usually test the ICDs on their own, obviously exercised good judgement involving us on this case. The point of testing the ICD is to determine the minimum energy requirement needed to terminate VF (along with impedence etc). At some point the VF won't be terminated (but they have the console that adjusts the ICD, as well as the external defib). Our EPs know what they're doing; I don't think trying to take over would work very well.

 

[ProRealDoc]

It's possible to keep someone spontaneously breathing even with remi. 1mcg/kg (without any other med) hasn't caused apnea in the few times I've done it. I don't like using remi infusions (or opioid) for awake FOB for the reason you stated.



Just curious how many of these you do? The EP guys here usually test the ICDs on their own, obviously exercised good judgement involving us on this case. The point of testing the ICD is to determine the minimum energy requirement needed to terminate VF (along with impedence etc). At some point the VF won't be terminated (but they have the console that adjusts the ICD, as well as the external defib). Our EPs know what they're doing; I don't think trying to take over would work very well.

We are involved in the majority of cases where AICD testing takes place. It's usually an attending/CRNA/resident team that's assigned to the EPS lab everyday.

 

[Planktonmd]

It's possible to keep someone spontaneously breathing even with remi. 1mcg/kg (without any other med) hasn't caused apnea in the few times I've done it.

Eventually it will.

Just curious how many of these you do? The EP guys here usually test the ICDs on their own

When you are not there they can do what ever they want, if they called you to help them then this means they don't want to do things on their own and they are requesting a consultant (you) to take care of the patient, so you take care of the patient the way an anesthesiologist does.

The point of testing the ICD is to determine the minimum energy requirement needed to terminate VF (along with impedence etc). At some point the VF won't be terminated (but they have the console that adjusts the ICD, as well as the external defib). Our EPs know what they're doing; I don't think trying to take over would work very well.

The point of testing the AICD is to know if it will be able to terminate an arrhythmia so this is a question that can have one of 2 answers:
1- The AICD works: everyone is happy
2- The AICD does not work: You are left with a morbidly obese patient, with known difficult airway that you can not ventilate who is now in full cardiac arrest.

 

[ProRealDoc]

Eventually it will.




When you are not there they can do what ever they want, if they called you to help them then this means they don't want to do things on their own and they are requesting a consultant (you) to take care of the patient, so you take care of the patient the way an anesthesiologist does.


The point of testing the AICD is to know if it will be able to terminate an arrhythmia so this is a question that can have one of 2 answers:
1- The AICD works: everyone is happy
2- The AICD does not work: You are left with a morbidly obese patient, with known difficult airway that you can not ventilate who is now in full cardiac arrest.

LMA, swivel adapter, attach circuit, have nurse bag with 100% O2, fireup bronchoscope with aintree catheter loaded, pass aintree, slide tube in, done!

next case.


http://www.bellmedical.com/Products/Connectors-Adapters/Swivel-Adapters/B060300.html
http://www.bellmedical.com/Connectors-Adapters/Swivel-Adapters/Images/Products/Large/B060302_1.jpg


http://www.bellmedical.com/Products/Connectors-Adapters/Swivel-Adapters/B060302.html

 

[Planktonmd]

LMA, swivel adapter, attach circuit, have nurse bag with 100% O2, fireup bronchoscope with aintree catheter loaded, pass aintree, slide tube in, done!

next case.


http://www.bellmedical.com/Products/Connectors-Adapters/Swivel-Adapters/B060300.html
http://www.bellmedical.com/Connectors-Adapters/Swivel-Adapters/Images/Products/Large/B060302_1.jpg


http://www.bellmedical.com/Products/Connectors-Adapters/Swivel-Adapters/B060302.html

You can do that but I prefer not to deal with a difficult airway while the patient in cardiac arrest and getting CPR, Just too much drama for my taste.

 

[Frank Rizzo]

NC O2, small amount of propofol titrated slowly, shock. Next patient.

 

[ProRealDoc]

You can do that but I prefer not to deal with a difficult airway while the patient in cardiac arrest and getting CPR, Just too much drama for my taste.

I was just messing around. I do like how you push us to think of alternatives because that's what the oral boards test. The approach I present now is based on the tools and support I had in residency. Once I finish training and join the real world, I'd likely be more conservative.

 

[SleepIsGood]

I was just messing around. I do like how you push us to think of alternatives because that's what the oral boards test. The approach I present now is based on the tools and support I had in residency. Once I finish training and join the real world, I'd likely be more conservative.

LOL...man tell me about it.