Dallas Jury awards $21M for anoxic brain injury under anesthesia at BUMC

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I’ve talked to several immunologists about this and they were all unconvinced this is a clinically important effect.
And yet, epi is usually the only medication that fixes these people.

I too am unconvinced that those immunologists have clinically important effects.

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That's all well and good, but based on the plausible basophil/mast cell b2 mechanism, my personal anecdotes of nothing working but epi, and the fact that a randomized trial of epi vs. anything else in human anaphylaxis is never going to happen, I'm gonna continue with the standard of care.
It’s the standard of care because of the bronchodilatory effects, it’s potency, and the fact that it’s easy for untrained people to learn how to give it IM, not because of some in vitro study done in the 60s.

If you’re interested, a similar in vitro effect has been demonstrated with norepi. And actual studies done on dogs have failed to show any effect on the duration of anaphylaxis with epi.

Epi is the way. But we don’t need BS extrapolations from in vitro/non clinical studies as support for its use.
 
What about an anaphylactic reaction to Roc or ancef?

I had a case recently that sounds similar. Healthy woman in her 40s. First BP after easy intubation was normal. After ancef 50/30. The memory of a recent m&m in the back of my mind had me push solid doses of ephedrine and phenylephrine but immediately start mixing epi. A few 10 mcg epi boluses and a high phenylephrine infusion kept her MAP above 65 and the requirements came down as the case moved along. Slightly higher peak pressures but never difficult to ventilate. Went through the Stanford manual.

Wouldn’t surprise me if a similar scenario combined with some of the typical excuses (gotta position the patient and not hold up the surgeon, probably just the tucked arms or the surgeon on the cuff, he’s a healthy guy, yada yada yada) and hesitancy to jump to epi could have been the real story here. MAP of 40 and hitting that pressure=cerebral perfusion end of the curve is a place we don’t venture much. I don’t have any research on it, but I wouldn’t want my brain to rely on those kinds of pressures for more than a few minutes.

Side note: I really don’t like paper charts and bad EMR systems. Doesn’t make sense to me that there isn’t some financial penalty for HCAs offering up Meditech and acting like it isn’t an direct risk to patient care
I've had at least 2 admits to the ICU/hospital from anesthesia for 'anaphylaxis' on induction. Both times I have grabbed a tryptase under 2 hours from the event which has been completely normal. Please draw a tryptase asap before slapping an anaphylaxis label on someone!
 
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I've had at least 2 admits to the ICU/hospital from anesthesia for 'anaphylaxis' on induction. Both times I have grabbed a tryptase under 2 hours from the event which has been completely normal. Please draw a tryptase asap before slapping an anaphylaxis label on someone!
That doesn't mean anything. It's not a sensitive test, especially as time passes.

Please come to the OR, draw your own tryptase and put in the order in the EMR, next time we're busy treating a shock. :p
 
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I've had at least 2 admits to the ICU/hospital from anesthesia for 'anaphylaxis' on induction. Both times I have grabbed a tryptase under 2 hours from the event which has been completely normal. Please draw a tryptase asap before slapping an anaphylaxis label on someone!
I grabbed a tryptase. I’ll follow up on it but I am 0 for 4 on them so far. It was actually a huge pain getting the right tube brought to the OR. I left a pretty detailed note about what happened, so hopefully they’ll actually open the allergy tab on epic instead of just picking an inferior abx
 
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Please come to the OR, draw your own tryptase and put in the order in the EMR, next time we're busy treating a shock. :p
Why don't you just draw the blood in the PACU? I have done it a couple of times and it came back sky high.
 
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That doesn't mean anything. It's not a sensitive test, especially as time passes.

Please come to the OR, draw your own tryptase and put in the order in the EMR, next time we're busy treating a shock. :p
It is the gold standard of diagnosis and has important outpatient implications, far from meaningless I would think.

I work with a bunch of allergists-the specialty you send these people to uses this information to figure out how to proceed especially if it occured in the setting of getting 3+ drugs simultaneously. By the time I get alerted of these cases the useful window to draw this is either closed or closes while I am getting logistics figured out unless there is a pacu nurse who is particularly motivated. And sure you get a pass if you are still managing anaphylactic shock 2 hours in to the event but this is underutilized and useful information that isn't that big of an imposition for you guys to grab as part of caring for a patient.
 
It is the gold standard of diagnosis and has important outpatient implications, far from meaningless I would think.

I work with a bunch of allergists-the specialty you send these people to uses this information to figure out how to proceed especially if it occured in the setting of getting 3+ drugs simultaneously. By the time I get alerted of these cases the useful window to draw this is either closed or closes while I am getting logistics figured out unless there is a pacu nurse who is particularly motivated. And sure you get a pass if you are still managing anaphylactic shock 2 hours in to the event but this is underutilized and useful information that isn't that big of an imposition for you guys to grab as part of caring for a patient.
I was saying 2 things:
1. Just because the tryptase is normal it doesn't necessarily mean that the anesthesiologist misdiagnosed the clinical syndrome, or that the patient does not deserve an ICU/stepdown admission for observation.
2. Please don't blame anesthesiologists about not doing X or Y. They usually have fewer resources than we do in the ICU, and can be juggling multiple things at the same time. It can be harder than in the ICU.

They are also not necessarily experts in anaphylaxis (hopefully one doesn't see more than one every 10 years or so) or internal medicine, so they can miss the importance of drawing a tryptase ASAP, also because the circulator will whine about not having an order for the label etc.

The solution is to go to the OR, as soon as one hears about an ICU admission, have a dialogue with the anesthesiologist and ask for everything one needs while the patient is still in the OR. Yes, it can be unpleasant to don a bunny suit, but it's for the patient. Better communication leads to better outcomes.
 
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It’s the standard of care because of the bronchodilatory effects, it’s potency, and the fact that it’s easy for untrained people to learn how to give it IM, not because of some in vitro study done in the 60s.

If you’re interested, a similar in vitro effect has been demonstrated with norepi. And actual studies done on dogs have failed to show any effect on the duration of anaphylaxis with epi.

Epi is the way. But we don’t need BS extrapolations from in vitro/non clinical studies as support for its use.

Can you provide those sources?

Because literally every society guideline about the issue (in anaphylaxis or mast cell disorders) says part of the reason epi is indicated is because it inhibits further immune/vasoactive mediator release.
 
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Can you provide those sources?

Because literally every society guideline about the issue (in anaphylaxis or mast cell disorders) says part of the reason epi is indicated is because it inhibits further immune/vasoactive mediator release.
Sure.. this one for the norepi


And this summarizes the previous clinical/animal studies of epi in the introduction plus provides a new study. Note that in summary boluses of epi have short lived hemodynamic effects consistent with its plasma half life and not consistent with an effect on histamine release.


On a somewhat related note, there are scattered case reports of patients not responding to epi but responding to vasopressin or metaraminol (a norepi precursor). Also a different situation, but I have anecdotes of patients with persistent “anaphylactic shock” on epi infusions who get better once it’s changed for norepi.

I often find that clinical guideline makers don’t evaluate physiological/basic science evidence or make recommendations based on it very well. It makes sense tho- sticking to some commonly accepted but poorly supported claim is unlikely to get challenged- it’s why people still believe in contrast nephropathy and that the RV is preload dependent
 
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Sure.. this one for the norepi


And this summarizes the previous clinical/animal studies of epi in the introduction plus provides a new study. Note that in summary boluses of epi have short lived hemodynamic effects consistent with its plasma half life and not consistent with an effect on histamine release.


On a somewhat related note, there are scattered case reports of patients not responding to epi but responding to vasopressin or metaraminol (a norepi precursor). Also a different situation, but I have anecdotes of patients with persistent “anaphylactic shock” on epi infusions who get better once it’s changed for norepi.

Thanks for the links

- sticking to some commonly accepted but poorly supported claim is unlikely to get challenged- it’s why people still believe in contrast nephropathy and that the RV is preload dependent

I agree that people believe in those nonsense examples based on faulty old evidence or unsupported claims their mentor told them two decades ago, but, the evidence (or lack thereof) for epi's immunologic mechanism is nowhere near as well-studied as CIN or RV hemodynamics (mostpy because the studies are impossible from an ethical standpoint).

For instance

Screenshot_20221114_185841.jpg


Look at the first citation for the pulmcrit article on the myth of CIN. There is no analogous exhaustive, modern metanalysis showing lack of immunologic benefit with epi. And in modern cardiology teaching, it's well-understood that the RV is exquisitely sensitive to adverse volume or pressure conditions and will simply dilate with worsening TR and eventually fail if you jam preload to a geometry-distorting wits end. Like, that's literally a fact that been demonstrated by 3 different cardiac imaging modalities + invasive cath hemodynamics in every disease process which causes RV failure. I mean, you know this, but a rat peritoneum and dog study are nowhere close comparatively in regard to epi and anaphylaxis.
 
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Thanks for the links



I agree that people believe in those nonsense examples based on faulty old evidence or unsupported claims their mentor told them two decades ago, but, the evidence (or lack thereof) for epi's immunologic mechanism is nowhere near as well-studied as CIN or RV hemodynamics (mostpy because the studies are impossible from an ethical standpoint).

For instance

View attachment 362104

Look at the first citation for the pulmcrit article on the myth of CIN. There is no analogous exhaustive, modern metanalysis showing lack of immunologic benefit with epi. And in modern cardiology teaching, it's well-understood that the RV is exquisitely sensitive to adverse volume or pressure conditions and will simply dilate with worsening TR and eventually fail if you jam preload to a geometry-distorting wits end. Like, that's literally a fact that been demonstrated by 3 different cardiac imaging modalities + invasive cath hemodynamics in every disease process which causes RV failure. I mean, you know this, but a rat peritoneum and dog study are nowhere close comparatively in regard to epi and anaphylaxis.
True. You make a good point.

I guess it depends on what your threshold is for how much evidence is required to start vs stop believing something. By the same token I don’t think a few studies of adrenaline in a rat peritoneum (or equivalent) are sufficient reason to teach the adrenaline-mast cell hypothesis as fact. I might be wrong, but I look to the history of promising science in a Petri dish that never translated to anything clinical.
 
True. You make a good point.

I guess it depends on what your threshold is for how much evidence is required to start vs stop believing something. By the same token I don’t think a few studies of adrenaline in a rat peritoneum (or equivalent) are sufficient reason to teach the adrenaline-mast cell hypothesis as fact. I might be wrong, but I look to the history of promising science in a Petri dish that never translated to anything clinical.
Who cares? Epi is literally a human cheat code. Bronchospasm? Epi. Anaphylaxis? Epi. Shock? Epi. You literally can’t screw it up. Just give 10-20 mcg at a time….
 
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The solution is to go to the OR, as soon as one hears about an ICU admission, have a dialogue with the anesthesiologist and ask for everything one needs while the patient is still in the OR. Yes, it can be unpleasant to don a bunny suit, but it's for the patient. Better communication leads to better outcomes.
lol what? just draw the blood.
 
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True. You make a good point.

I guess it depends on what your threshold is for how much evidence is required to start vs stop believing something. By the same token I don’t think a few studies of adrenaline in a rat peritoneum (or equivalent) are sufficient reason to teach the adrenaline-mast cell hypothesis as fact. I might be wrong, but I look to the history of promising science in a Petri dish that never translated to anything clinical.

It's a fact that epinephrine reduces the release of biogenic amines and other inflammatory mediators in humans during an event. Zero question about that.

The only point of contention is how significant that reduction is in the overall treatment of anaphylaxis.
 
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The pt in that CFE case report had multiple punctate foci on MRI. The pt in OP had global anoxic injury…which is not consistent with emboli
I am out of country and slow internet so please forgive me. Do we know for a fact how the report was actually read. From what I remember earlier in the Pages and it’s been a few weeks it was all narratives and second hand reports of the actual results. This is exactly what I was actually thinking the report would say with fat emboli because they shower everywhere.
 
I've worked with one shoulder guy who wanted TIVA for all of his cases (his brother is ortho spine), but some crna at some point told his TIVA is the best anesthetic. So what everyone did is hang something (eg Mag) and tell him that was the anesthesia. Then PACU thought they all got TIVA because he requested it. It was absurd.
This just seems like asking for trouble. In case something now happens everyone is lying or being lied to. And they will get deposed. This is just stupid.
 
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I am out of country and slow internet so please forgive me. Do we know for a fact how the report was actually read. From what I remember earlier in the Pages and it’s been a few weeks it was all narratives and second hand reports of the actual results. This is exactly what I was actually thinking the report would say with fat emboli because they shower everywhere.

One of the legal documents filed talked about the subsequent neurology consult and CT scan results but that link from earlier in the thread isn't working now .
 
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I believe this petition request for disclosure is essential reading for every anesthesiologist. It clearly reveals how everything you document, do, and say, "can and will be used against you."

The foundation upon which the plaintiff is maligning Cline's note really rests up on the claim that she was never in the room, so much so that they repeat that claim a couple times in the document.

I don't know if it's a medical direction or supervision practice but it seems rather unlikely she was *never* in the room, not even once. And if she was monitoring the case at regular intervals (including popping in the room occasionally), then that 'CYA' note stating the pt was fine from a cardiopulmonary standpoint the whole time seems rather helpful.
 
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If there was an electronic anesthesia record, there wouldn’t even be a question about the vitals. A large part of the case seems to rely on whether the recorded vitals were real or fictitious. The plaintiffs argument is that the BP/vitals written on the anesthesia record were made up and the patient’s injury was due to untreated or undertreated hypotension.
Agree anytime u give even ephedrine/neo and especially vasopressin/epi in paper chart. I make sure to document a lower bp. Than have the bp go up.

Did a case yesterday and as soon as the tourniquet as released. The frail Asa 4 84 year old lady bp obviously dropped (a line in already) . And she has hypotensive for at least 15 minutes.

U gotta show some type of bp drop if u are giving that.

But it’s a gray area here. Undocumented hypotension could have occurred. But a preponderance of the evidence is highly unlikely

I suspect the verdict will be overturn.

Frankly. I prefer 5 panel judges for cases (not jury and not one judge panel). If 4 out of the 5 think the evidence is strong. Then I’d live with that.

I don’t trust juries. Most of them are dumb as nails. I don’t trust one panel judge either.
 
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The foundation upon which the plaintiff is maligning Cline's note really rests up on the claim that she was never in the room, so much so that they repeat that claim a couple times in the document.

I don't know if it's a medical direction or supervision practice but it seems rather unlikely she was *never* in the room, not even once. And if she was monitoring the case at regular intervals (including popping in the room occasionally), then that 'CYA' note stating the pt was fine from a cardiopulmonary standpoint the whole time seems rather helpful.
It's a classic "if you don't document it, you didn't do it". Our Cerner EMR notes have the requisite notes for presence of the anesthesiologist at various times of the procedure. It requires an e-sig each time they're there.
 
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It's a classic "if you don't document it, you didn't do it". Our Cerner EMR notes have the requisite notes for presence of the anesthesiologist at various times of the procedure. It requires an e-sig each time they're there.
Same with EPIC, which is a PITA that is often omitted. Also supervise four rooms. I make point of checking king the intraop record multiple times throughout the case. Especially for sicker patients, bigger procedures or CRNAs that I have low confidence in. For a twenty something healthy person having a two hour peripheral procedure, I can see someone not walking into the OR or even looking at the EMR if they were supervising four rooms. Right or wrong, that is the way it is.
 
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Same with EPIC, which is a PITA that is often omitted. Also supervise four rooms. I make point of checking king the intraop record multiple times throughout the case. Especially for sicker patients, bigger procedures or CRNAs that I have low confidence in. For a twenty something healthy person having a two hour peripheral procedure, I can see someone not walking into the OR or even looking at the EMR if they were supervising four rooms. Right or wrong, that is the way it is.
Agree with everything you've said.
 
We bill as qz at our practice. If usap
It's a classic "if you don't document it, you didn't do it". Our Cerner EMR notes have the requisite notes for presence of the anesthesiologist at various times of the procedure. It requires an e-sig each time they're there.
u guys are clueless computer charting can also hurt u

They forced this good CRNA to resign in the south cause they thought she edited the chart too much for a case gone bad. All she did was edit the timing to make sure the drugs given match the acute decompensation times. Because when **** is hitting the room. U don’t have them to document immediately because well…u are taking care of the patient.

It’s all a blame game

We had another bad case 3 years ago. Icu tried to blame anesthesia by micro analyzing the chart why vasopressors weren’t given immediately when it was charted 10 min later on the computer records.

Everyone is trying to blame everyone
 
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For a twenty something healthy person having a two hour peripheral procedure, I can see someone not walking into the OR or even looking at the EMR if they were supervising four rooms. Right or wrong, that is the way it is.
Not an anesthesiologist so genuinely asking, would you still consider a scenario like this supervising four rooms?

It sounds a lot like supervising three rooms to me.
 
Not an anesthesiologist so genuinely asking, would you still consider a scenario like this supervising four rooms?

It sounds a lot like supervising three rooms to me.
It's considered 'medical supervision' from a billing standpoint. You pre-op the patient and formulate the plan that you communicate to the crna. Crna then performs the anesthetic calling you for anything they need help with. You are not actually required to be a part of the anesthetic.

Not many groups do this because it's not exactly the safest practice. No studies to back it up other than common sense.
 
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Agree anytime u give even ephedrine/neo and especially vasopressin/epi in paper chart. I make sure to document a lower bp. Than have the bp go up.
Jesus christ man you're telling us you practice anesthesia the way you do your taxes? Just make **** up so the paperwork passes a cursory review?

Maybe you could just, I dunno, document what actually happened and what you actually did?
 
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Not an anesthesiologist so genuinely asking, would you still consider a scenario like this supervising four rooms?

It sounds a lot like supervising three rooms to me.

I’m not sure I understand your question. Are you asking if it’s okay to essentially ignore 1 of the 4 rooms that an anesthesiologist is medically directing (I assume medical direction is the model USAP is/was using)? Could you explain what you’re asking a little further because I’d like to respond?
 
It's considered 'medical supervision' from a billing standpoint. You pre-op the patient and formulate the plan that you communicate to the crna. Crna then performs the anesthetic calling you for anything they need help with. You are not actually required to be a part of the anesthetic.

Not many groups do this because it's not exactly the safest practice. No studies to back it up other than common sense.

Well the study about outcomes comparing ACT 1:2 vs 1:3 vs 1:4 ratios show significant differences in patient morbidity and mortality. This would be an obvious extension of this. I do medical "direction" and would never agree to medically "supervise" a term i consider a huge misnomer
 
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The foundation upon which the plaintiff is maligning Cline's note really rests up on the claim that she was never in the room, so much so that they repeat that claim a couple times in the document.

I don't know if it's a medical direction or supervision practice but it seems rather unlikely she was *never* in the room, not even once. And if she was monitoring the case at regular intervals (including popping in the room occasionally), then that 'CYA' note stating the pt was fine from a cardiopulmonary standpoint the whole time seems rather helpful.
Healthy 27 year old with anoxic injury. Someone is getting paid. I don’t know what happened, though I suspect something more than simple hypotension. No amount of charting will save you. Yes, the ACT model is very hard to explain and defend to a jury and the plaintiffs attorney will certainly seize upon that. It is what it is. If a solo MD did this case and had the same outcome there would be a similar payout.
 
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It's considered 'medical supervision' from a billing standpoint. You pre-op the patient and formulate the plan that you communicate to the crna. Crna then performs the anesthetic calling you for anything they need help with. You are not actually required to be a part of the anesthetic.

Not many groups do this because it's not exactly the safest practice. No studies to back it up other than common sense.
It’s not dependent on the “group”. You and I both know that there is a wide variety of “direction/supervision” styles. Let’s just say that some docs consider being somewhere in the building as “medical direction”. Others take their job seriously and are involved. This case was a healthy 27 year old undergoing a routine procedure with an experienced CRNA (CRNA graduated in 2007, case happened in 2017). I suspect that the plaintiffs attorney was not lying about the minimal/no involvement of the MD. Most groups bill medical direction if 1:4 or less and supervision if more. Yes, TEFRA rules are violated routinely. It’s all good until $hit hits the fan…
 
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It’s not dependent on the “group”. You and I both know that there is a wide variety of “direction/supervision” styles. Let’s just say that some docs consider being somewhere in the building as “medical direction”. Others take their job seriously and are involved. This case was a healthy 27 year old undergoing a routine procedure with an experienced CRNA (CRNA graduated in 2007, case happened in 2017). I suspect that the plaintiffs attorney was not lying about the minimal/no involvement of the MD. Most groups bill medical direction if 1:4 or less and supervision if more. Yes, TEFRA rules are violated routinely. It’s all good until $hit hits the fan…
All I'm saying is that, yes, you can be 'supervising' and never once step in the OR.
 
Posted earlier in this thread.

Interesting things in the filing:

1. They claim the anesthesiologist was never in the operating room during this procedure.

2. They allude to the relationship between ETCO2 and CBF.

3. They use the term “CYA note”.

The attorneys are pretty sophisticated or had good experts to review the case.



It's terrifying to think a jury rewarded damages with such little evidence.

I agree that it raises suspicion for not all vitals being recorded, but if those were actually the true vitals what would anybody here have done differently?

They suspiciously say "ETCO2 <30". That could just as easily be 28-29 or as low as 5.
 
It's terrifying to think a jury rewarded damages with such little evidence.

I agree that it raises suspicion for not all vitals being recorded, but if those were actually the true vitals what would anybody here have done differently?

They suspiciously say "ETCO2 <30". That could just as easily be 28-29 or as low as 5.
Bad outcomes will get paid. Surprising that USAP opted to take this to court.
 
Healthy 27 year old with anoxic injury. Someone is getting paid. I don’t know what happened, though I suspect something more than simple hypotension. No amount of charting will save you. Yes, the ACT model is very hard to explain and defend to a jury and the plaintiffs attorney will certainly seize upon that. It is what it is. If a solo MD did this case and had the same outcome there would be a similar payout.

Yeah I'm not talking only specifically about this case. They're totally f'ed here.
 
Jesus christ man you're telling us you practice anesthesia the way you do your taxes? Just make **** up so the paperwork passes a cursory review?

Maybe you could just, I dunno, document what actually happened and what you actually did?
If u are giving meds that increase bp. There better be a reason.

Again we don’t know the specifics of the
Jesus christ man you're telling us you practice anesthesia the way you do your taxes? Just make **** up so the paperwork passes a cursory review?

Maybe you could just, I dunno, document what actually happened and what you actually did?
huh. If bp is low. I document it. I don’t understand ur point.
 
If u are giving meds that increase bp. There better be a reason.


Especially with Epic, I frequently start vasopressor infusions or bolus pressors to prevent hypotension, not just to treat it. Yes it’s CYA medicine but I try my best to keep the numbers looking good on the chart.
 
Especially with Epic, I frequently start vasopressor infusions or bolus pressors to prevent hypotension, not just to treat it. Yes it’s CYA medicine but I try my best to keep the numbers looking good on the chart maintain homeostasis
Fixed it for ya. ;)
 
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This may or may not be from a real patient and may or may not be from a former classmate of mine who may or may not have been supervising a person who may or may not have been a crna. Whatcha think? All's well that ends well right?
20221118_212447.jpg
 
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My previous post begs the question: if one is supervising and such a scenario arises, what does one do? No pressors were given, crna just chilling and states "ah he's young, he can handle it." Do you rip them a new one in the middle of the case? Do you excuse them and report for malpractice? Document furiously in the intraop record that said crna deviated from previously discussed plan and the anesthetic is completely unacceptable? Refuse to sign the chart acknowledging you were supervising?
How many of you work in a place that you could report this to your higher up in the anes department and expect to see corrective action taken?
 
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This may or may not be from a real patient and may or may not be from a former classmate of mine who may or may not have been supervising a person who may or may not have been a crna. Whatcha think? All's well that ends well right?
View attachment 362259


Yeah no big deal. Just a heart working twice as hard to receive half its normal perfusion. What rhythm was that? Usually that kind of pulse ox trace is atrial (or sometimes ventricular) bigeminy.


In these kind of situations if a CRNA is being malignant about it, I just let them stand there like a doofus and I start taking care of the patient, turning the gas down, pulling and giving whatever drugs are needed, and (if things are not shaping up) I start telling the surgeon what's happening and asking whether anything can be expedited. But usually I'll get the patient sorted out and by that point CRNAs not actually going to do anything to make the pt worse.
 
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My previous post begs the question: if one is supervising and such a scenario arises, what does one do? No pressors were given, crna just chilling and states "ah he's young, he can handle it." Do you rip them a new one in the middle of the case? Do you excuse them and report for malpractice? Document furiously in the intraop record that said crna deviated from previously discussed plan and the anesthetic is completely unacceptable? Refuse to sign the chart acknowledging you were supervising?
How many of you work in a place that you could report this to your higher up in the anes department and expect to see corrective action taken?

I encounter this not uncommonly when I am supervising. I have a good working relationship with the CRNAs here and am usually able to navigate this issue by inception.

“Hey, how’s it going? Everything good? … How are the MAPs?”

This usually sparks the conversation and introduces the idea that maybe something needs to be fixed. Then we discuss ways to improve the hemodynamics in a seemingly non-patronizing, non-judgmental way. They are free to disagree but haven’t had that happen often at all.

I have found that this works better than the “MAPs too low, fix it now” approach.

Just make sure you time the music to the kick.


Yeah no big deal. Just a heart working twice as hard to receive half its normal perfusion. What rhythm was that? Usually that kind of pulse ox trace is atrial (or sometimes ventricular) bigeminy.


In these kind of situations if a CRNA is being malignant about it, I just let them stand there like a doofus and I start taking care of the patient, turning the gas down, pulling and giving whatever drugs are needed, and (if things are not shaping up) I start telling the surgeon what's happening and asking whether anything can be expedited. But usually I'll get the patient sorted out and by that point CRNAs not actually going to do anything to make the pt worse.

I’ve had a colleague do this before, and it was not well-received (not that any of us really care). Some CRNAs are pretty clueless, and their CRNA colleagues would agree.
 
I’ve had a colleague do this before, and it was not well-received (not that any of us really care). Some CRNAs are pretty clueless, and their CRNA colleagues would agree.

Yeah I also don't think "taking over" the case is a great idea.....assuming you work with a generally good group of CRNAs who you like and trust. Carrot before stick, massage their ego, make it sound like it was their idea to keep an adult's MAP higher than a neonate's, etc.

But when I said "malignant" in my prior post, I meant really, really malignant. For example, my job is much better than it was a few years ago when I started, but way back when I remember asking the chief CRNA if she could ask the CRNAs to maybe give me a heads-up if I'm busy in another room when they're transporting/getting started on a sick ICU pt even if they're intubated, and she flat-out said "what do they need you for?" That was also around the time a couple of the "cardiac" CRNAs whose main mantra was that all open heart anesthetics are the same complained that my TEE machine was getting in the way of their setup.

When you're in a practice where some CRNAs are so malignant that the carrot's not gonna work, that's the type of situation I'm talking about where you just have to do what's best for the patient while the CRNA stands there.
 
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Yeah I also don't think "taking over" the case is a great idea.....assuming you work with a generally good group of CRNAs who you like and trust. Carrot before stick, massage their ego, make it sound like it was their idea to keep an adult's MAP higher than a neonate's, etc.

But when I said "malignant" in my prior post, I meant really, really malignant. For example, my job is much better than it was a few years ago when I started, but way back when I remember asking the chief CRNA if she could ask the CRNAs to maybe give me a heads-up if I'm busy in another room when they're transporting/getting started on a sick ICU pt even if they're intubated, and she flat-out said "what do they need you for?" That was also around the time a couple of the "cardiac" CRNAs whose main mantra was that all open heart anesthetics are the same complained that my TEE machine was getting in the way of their setup.

When you're in a practice where some CRNAs are so malignant that the carrot's not gonna work, that's the type of situation I'm talking about where you just have to do what's best for the patient while the CRNA stands there.
That's one reason to leave a job.

One should not stay in any job where CRNAs are more important than the anesthesiologists. Sooner or later it will bite one in the butt.
 
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Intriguingly low diastolic pressure for a NIBP.
I wonder what it read before induction. Without knowing what that patients pre-induction pressures were when awake, mentating normally, and not complaining of crushing substernal chest pain, I don't know if there's malpractice afoot. Maybe induction was at 14:23? Or maybe induction was at 14:03 and the first NIBP was 152/73?

NIBP readings sometimes come up at the intersection of cuff size, arm size, position, and algorithmic voodoo. When I see a cuff tell me the diastolic is 25 my first though isn't Oh no the LV perfusion pressure is 15.
 
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I wonder what it read before induction. Without knowing what that patients pre-induction pressures were when awake, mentating normally, and not complaining of crushing substernal chest pain, I don't know if there's malpractice afoot. Maybe induction was at 14:23? Or maybe induction was at 14:03 and the first NIBP was 152/73?

NIBP readings sometimes come up at the intersection of cuff size, arm size, position, and algorithmic voodoo. When I see a cuff tell me the diastolic is 25 my first though isn't Oh no the LV perfusion pressure is 15.
Ultimately, the diastolic isn't the problem though. The map is what is actually measured on the machine correct? I would imagine one would have a hard time arguing in court that keeping a pt with a map of 40's-50's for 40 minutes intraop is not the standard of care.
 
Ultimately, the diastolic isn't the problem though. The map is what is actually measured on the machine correct? I would imagine one would have a hard time arguing in court that keeping a pt with a map of 40's-50's for 40 minutes intraop is not the standard of care.
Sure

I'm just saying that if that NIBP measured a baseline MAP of 50 I'd be less concerned. NIBPs can be quirky. For example I think of the large-adult cuff on the forearm of a 50-BMI'er with conical "biceps" as more a tool for trend watching than a provider of accurate numbers.

All that said I just plug in phenylephrine infusions on an awful lot of patients, in an effort to keep them where they live.
 
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