Did I really mess this up?

[Janedoedoctor]

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I recently butted heads with an anesthesiologist who accused me of mismanaging a case. I'm not in anes myself , but I'm on call for the surgical ICU occasionally. This is what happened:

79YO man with severe peripheral arterial disease. Was in internal medicine ward due other comorbidity, and threw a clot to his leg during his stay there. Was transferred to surgical ICU, and from there to OR for endovascular procedure.

The patient is returned to the ICU the same evening. Signout from PACU nurse to our team as follows: "did well postop but was slightly hypotensive and tachycardic. We gave 500cc of colloid, much better after that. Is somnolent, but rousable, probably still from GA. " 15 minutes later I am called urgently to the bedside. Guy is in florid hemorragic shock. 54/30, 120/min, stuporous. The abdomen is massively distended. To liven things up, the patients one and only peripheral iv just came out and none of the people present can manage a new one (which is saying something with our team!).

I did the following things:
1. Call vascular surgeon, tell him to have an OR prepped NOW
2. sent a nurse RUNNING for O neg blood
3. quickly inserted femoral DVC, fluids and blood wide open, small sprinkling of epinephine
4. Intubation (no induction meds needed)

These 4 things took me 15 minutes, max. We then RAN the patient to the OR. The patient did reasonably well afterwards.

The anethesiologist on call surprisingly tore me a new one when we arrived in the OR. In his opinion, I lost time with the DVC and the tube. I should have transported the patient to the OR (which is NOT close to the ICU!) without a line or a tube, in order to gain time.

In my humble opinion this is the most dimwitted suggestion I have ever heard. I would have smacked any med student who came up with it over the head. But this guy is 25 years my senior. Am I missing something here?
Please weigh in.

 

[BLADEMDA]

I recently butted heads with an anesthesiologist who accused me of mismanaging a case. I'm not in anes myself , but I'm on call for the surgical ICU occasionally. This is what happened:

79YO man with severe peripheral arterial disease. Was in internal medicine ward due other comorbidity, and threw a clot to his leg during his stay there. Was transferred to surgical ICU, and from there to OR for endovascular procedure.

The patient is returned to the ICU the same evening. Signout from PACU nurse to our team as follows: "did well postop but was slightly hypotensive and tachycardic. We gave 500cc of colloid, much better after that. Is somnolent, but rousable, probably still from GA. " 15 minutes later I am called urgently to the bedside. Guy is in florid hemorragic shock. 54/30, 120/min, stuporous. The abdomen is massively distended. To liven things up, the patients one and only peripheral iv just came out and none of the people present can manage a new one (which is saying something with our team!).

I did the following things:
1. Call vascular surgeon, tell him to have an OR prepped NOW
2. sent a nurse RUNNING for O neg blood
3. quickly inserted femoral DVC, fluids and blood wide open, small sprinkling of epinephine
4. Intubation (no induction meds needed)

These 4 things took me 15 minutes, max. We then RAN the patient to the OR. The patient did reasonably well afterwards.

The anethesiologist on call surprisingly tore me a new one when we arrived in the OR. In his opinion, I lost time with the DVC and the tube. I should have transported the patient to the OR (which is NOT close to the ICU!) without a line or a tube, in order to gain time.

In my humble opinion this is the most dimwitted suggestion I have ever heard. I would have smacked any med student who came up with it over the head. But this guy is 25 years my senior. Am I missing something here?
Please weigh in.

Good job. I would have preferred an U/S guided 8.5F catheter and triple lumen catheter in the Right IJ but a Femoral double lumen seems perfectly reasonable considering the situation.

Overall you did a fine job. Perhaps, you should have called the Anesthesiologist (and Tech or CRNA) to come assist you in order to speed things up?

 

[deleted126335]

Good job. I would have preferred an U/S guided 8.5F catheter and triple lumen catheter in the Right IJ but a Femoral double lumen seems perfectly reasonable considering the situation.

Overall you did a fine job. Perhaps, you should have called the Anesthesiologist (and Tech or CRNA) to come assist you in order to speed things up?

+1. If you did as the anesthesiologist advised, he would probably be bitching how poorly prepared this patient was.

 

[fabfive5]

Anyone think it is standard of care to transport a "stuporous" patient to the OR with one measily PIV?

Was he breathing when you intubated him? He OBVIOUSLY was hypoxic to some degree due to you not needing any induction medications. By introducing a patent airway, you enabled Oxygen to get to the brain...you should've explained this to the said Anesthesiologist. 😀

I think you did a good job for the situation you were in.

 

[Janedoedoctor]

He apparently considered the benefit of getting to the OR 15 mins earlier worth the risk of transporting this patient without a secure airway and without any venous access (PIV came out before the pt crashed).

Patient was still breathing when I started the femoral line. When I was done it was more like gasping, which bought him the tube. I agree with the anesthesiologist that speed was extremely important here. But I am honestly convinced that we'd have wheeled a corpse into the OR if we had taken the 'scoop and run' approach to this situation.
Calling the anesthesiologist over and having him take these decisions would have made delays even longer.He'd first have to walk to the ICU from the OR (5 mins) before he could do anything for us.

 

[pgg]

Sounds like you did the right things under imperfect conditions.

Also sounds like the anesthesiologist was a clown. Getting pissy about someone's code management should be reserved for things like giving esmolol to treat a 23 year old hypotensive hypovolemic bleeding patient's tachycardia. (Recent M&M 'round these parts.)

Maybe he prefers to put in his lines in the elevator?

 

[periopdoc]

Assuming we have the entire story, I have no major critique of your management. I would be very critical if you brought an un-intubated guppy with no IV access to my OR. I would be very willing to come to the ICU to assist with stabilizing the patient for transport if called.

I do have a minor critique of your selection for IV access in this patient. Blade already mentioned it, but I would like to expand on the reasoning for any juniors that might be reading this.

In a patient like this, the integrity of femoral access is highly suspect. You have to have a high index of suspicion for physical disruption of the patency of the femoral vein and IVC either due to procedural damage or compression from the distended abdomen. Femoral access may do nothing but provide a abdominal conduit for your resuscitative fluids and medications.

A superior option is to access the circulation above the level of the problem (either internal jugular or subclavian) so that fluids and medications get to the heart and thus the circulation. It is also a good idea to choose a larger line that will support rapid fluid resuscitation. My personal choice would be an introducer either U/S guided into the IJ or blind subclavian.

A HUGE CAVEAT. You have to work with the skill set that you have. I am very comfortable with the two lines that I mentioned because I place them several times a month. If you are only comfortable placing femoral, don't flail around trying to establish "superior" access. Either get help or place the femoral and test it to ensure patency (either a fluid bolus or a pressor and look for BP changes) before relying on it for massive resuscitation.

Ultimately, you should establish either SC or IJ access as the femoral may go out at any time.

All in all you did a good job.

- pod

 

[Farmboy1]

You did a great job. I think that the doc that jumped down your throat likely is one of those 'low self-esteem therefore blames others for things gone wrong' kinda person. The only thing that I would have done differently is obtain the airway first (quickest way to die). I then would have obtained a line. I RESPECTFULLY disagree with periopdoc in that I feel a femoral line is the first choice in a hypotensive bleeding patient. The endovascular procedure that was performed was in the artery and that is where the bleeding is coming from, not a venous injury. The other issue is that placing an IJ line in a hypovolemic patient (even with ultrasound guidance) is not the first choice because you have increased risk of PTX and carotid arterial injury while you are trying to stick a deflated IJ and no matter how many you place, they take longer. The femoral line is the better intial temporary line to place as it is the quickest, has the least amount of complications and is faster...i.e. you can place it without sterile technique in an urgent scenerio as it will and should be replaced by an IJ or sublcavian once the patient is more stabilized. Taking the patient to the OR before doing the things that you did could easily have killed him (the time needed to transport is more than enough for a patient to lose their airway or code from hemorrhagic shock). This is just my OPINION based on years of trauma experience.

 

[pgg]

The femoral line is the better intial temporary line to place as it is the quickest, has the least amount of complications and is faster...i.e. you can place it without sterile technique in an urgent scenerio as it will and should be replaced by an IJ or sublcavian once the patient is more stabilized.

As pod said, individual skill set matters. Most of us in the anesthesia world can put an IJ in awfully quick ...

 

[Janedoedoctor]

You did a great job. I think that the doc that jumped down your throat likely is one of those 'low self-esteem therefore blames others for things gone wrong' kinda person. The only thing that I would have done differently is obtain the airway first (quickest way to die). I then would have obtained a line. I RESPECTFULLY disagree with periopdoc in that I feel a femoral line is the first choice in a hypotensive bleeding patient. The endovascular procedure that was performed was in the artery and that is where the bleeding is coming from, not a venous injury. The other issue is that placing an IJ line in a hypovolemic patient (even with ultrasound guidance) is not the first choice because you have increased risk of PTX and carotid arterial injury while you are trying to stick a deflated IJ and no matter how many you place, they take longer. The femoral line is the better intial temporary line to place as it is the quickest, has the least amount of complications and is faster...i.e. you can place it without sterile technique in an urgent scenerio as it will and should be replaced by an IJ or sublcavian once the patient is more stabilized. Taking the patient to the OR before doing the things that you did could easily have killed him (the time needed to transport is more than enough for a patient to lose their airway or code from hemorrhagic shock). This is just my OPINION based on years of trauma experience.

This was my reasoning also. Although I regularly place SC and IJ lines, I don't do as many as the anesthesiologists and I am not comfortable doing them in code situations, especially not with such hypovolemia.
It is right that the VCI might get compressed by the abdominal hematoma, but but sometimes the enemy of good is better....

 

[dA pilot]

He apparently considered the benefit of getting to the OR 15 mins earlier worth the risk of transporting this patient without a secure airway and without any venous access (PIV came out before the pt crashed).
Calling the anesthesiologist over and having him take these decisions would have made delays even longer.He'd first have to walk to the ICU from the OR (5 mins) before he could do anything for us.

The only thing I would like to add is that it is never too early to call for help or get the nurses to do it.

If you would have called me earlier, I could have help secure the airway while you worked on the line, mobilize people to get the OR completely ready, help with transport, or just get an eyeball on the patient to know what I was really dealing with.

 

[Idiopathic]

Ive got no problem with the preop management. If you had brought the patient to me as described prior to the interventions, our conversation would not have been pleasant and there would have been formal follow up afterwards.

i also would have welcomed a call asking for recommendations or assistance if so desired, but this is what I would have suggested.

 

[mocdoc]

Assuming we have the entire story, I have no major critique of your management. I would be very critical if you brought an un-intubated guppy with no IV access to my OR. I would be very willing to come to the ICU to assist with stabilizing the patient for transport if called.

I do have a minor critique of your selection for IV access in this patient. Blade already mentioned it, but I would like to expand on the reasoning for any juniors that might be reading this.

In a patient like this, the integrity of femoral access is highly suspect. You have to have a high index of suspicion for physical disruption of the patency of the femoral vein and IVC either due to procedural damage or compression from the distended abdomen. Femoral access may do nothing but provide a abdominal conduit for your resuscitative fluids and medications.

A superior option is to access the circulation above the level of the problem (either internal jugular or subclavian) so that fluids and medications get to the heart and thus the circulation. It is also a good idea to choose a larger line that will support rapid fluid resuscitation. My personal choice would be an introducer either U/S guided into the IJ or blind subclavian.

A HUGE CAVEAT. You have to work with the skill set that you have. I am very comfortable with the two lines that I mentioned because I place them several times a month. If you are only comfortable placing femoral, don't flail around trying to establish "superior" access. Either get help or place the femoral and test it to ensure patency (either a fluid bolus or a pressor and look for BP changes) before relying on it for massive resuscitation.

Ultimately, you should establish either SC or IJ access as the femoral may go out at any time.

All in all you did a good job.

- pod

I second this.

In the future, also call the anesthesiologist on call for backup, help transporting, spread the blame around, etc.

 

[nitroglycerine]

I recently butted heads with an anesthesiologist who accused me of mismanaging a case. I'm not in anes myself , but I'm on call for the surgical ICU occasionally. This is what happened:

79YO man with severe peripheral arterial disease. Was in internal medicine ward due other comorbidity, and threw a clot to his leg during his stay there. Was transferred to surgical ICU, and from there to OR for endovascular procedure.

The patient is returned to the ICU the same evening. Signout from PACU nurse to our team as follows: "did well postop but was slightly hypotensive and tachycardic. We gave 500cc of colloid, much better after that. Is somnolent, but rousable, probably still from GA. " 15 minutes later I am called urgently to the bedside. Guy is in florid hemorragic shock. 54/30, 120/min, stuporous. The abdomen is massively distended. To liven things up, the patients one and only peripheral iv just came out and none of the people present can manage a new one (which is saying something with our team!).

I did the following things:
1. Call vascular surgeon, tell him to have an OR prepped NOW
2. sent a nurse RUNNING for O neg blood
3. quickly inserted femoral DVC, fluids and blood wide open, small sprinkling of epinephine
4. Intubation (no induction meds needed)

These 4 things took me 15 minutes, max. We then RAN the patient to the OR. The patient did reasonably well afterwards.

The anethesiologist on call surprisingly tore me a new one when we arrived in the OR. In his opinion, I lost time with the DVC and the tube. I should have transported the patient to the OR (which is NOT close to the ICU!) without a line or a tube, in order to gain time.

In my humble opinion this is the most dimwitted suggestion I have ever heard. I would have smacked any med student who came up with it over the head. But this guy is 25 years my senior. Am I missing something here?
Please weigh in.

Well done, Doc. Don't worry about the other guy. The first anesthetist should not probably have brought this patient to you in such a condition. At least should have been kept intubated and with a good IV access. Good job. I would have thanked you if I was the other guy.

 

[CrazyJake]

Everybody is a quarterback and it's super easy to critique someone while you're not in the situtation. I see this especially in the ICU.

In your situation, non-OR environment, I'd have as above put in an IJ, tubed'em, and rolled. Have someone call ahead to the Anesthesia team..but no major faults on your part. When the **** hits the fan, you do what ya gotta do...which ya did.

Nice work.
CJ

 

[G-Man82]

I'm still an Intern and so my mode of thinking is still pretty much about protocols, but even in a situation like what the OP presented with a crashing patient, it's still ABCs (or rather CABs now) before anything else, like transport, right? At least that's what I remember from these kinds of case scenarios presented by Attendings during my Surgery, Medicine, and then later on Anesthesiology rotations in med school. It's also what I have seen done this year in our medical ICUs before a patient went for urgent imaging or even to the OR for anything. The last thing I wanted was to be in the elevator as the MD in the critical care transport team, with a patient who then proceeds to code in front of my eyes, with me being the most senior on the transport team.

 

[Idiopathic]

I'm still an Intern and so my mode of thinking is still pretty much about protocols, but even in a situation like what the OP presented with a crashing patient, it's still ABCs (or rather CABs now) before anything else, like transport, right? At least that's what I remember from these kinds of case scenarios presented by Attendings during my Surgery, Medicine, and then later on Anesthesiology rotations in med school. It's also what I have seen done this year in our medical ICUs before a patient went for urgent imaging or even to the OR for anything. The last thing I wanted was to be in the elevator as the MD in the critical care transport team, with a patient who then proceeds to code in front of my eyes, with me being the most senior on the transport team.

you are right on the money. regardless of your feelings on ABC vs CAB (Ill argue that in a hospital setting with skilled providers, ABC is often more valuable), NEVER transport a meta-stable patient without taking certain variables out of the equation (access, ETT, drugs, etc,). Think of all the stuff you get ready to transport a stable patient to the ICU (i get neo, ephedrine, epi, atropine, sux, propofol, Mac 4/7.5 ETT, 4 LMA, stylet, flush syringes for every trip with a patient). the elevator is a terrifying place with an agonal, cyanotic patient in whom you cant push meds.

 

[CambieMD]

Well done, Doc. Don't worry about the other guy. The first anesthetist should not probably have brought this patient to you in such a condition. At least should have been kept intubated and with a good IV access. Good job. I would have thanked you if I was the other guy.

I agree that you did a good job in caring for the patient,as you described. Your actions were appropriate. A call to the second anesthesiologist early on may have still resulted in a tongue lashing. Smetimes ,you just can't win.

Cambie

 

[Sergio99]

...Calling the anesthesiologist over and having him take these decisions would have made delays even longer.He'd first have to walk to the ICU from the OR (5 mins) before he could do anything for us.

I think Blademda was being sarcastic when he suggested that, meaning that the attending anesthesiologist would not have done better himself.

 

[C.P.]

Assuming we have the entire story, I have no major critique of your management. I would be very critical if you brought an un-intubated guppy with no IV access to my OR. I would be very willing to come to the ICU to assist with stabilizing the patient for transport if called.

I do have a minor critique of your selection for IV access in this patient. Blade already mentioned it, but I would like to expand on the reasoning for any juniors that might be reading this.

In a patient like this, the integrity of femoral access is highly suspect. You have to have a high index of suspicion for physical disruption of the patency of the femoral vein and IVC either due to procedural damage or compression from the distended abdomen. Femoral access may do nothing but provide a abdominal conduit for your resuscitative fluids and medications.

A superior option is to access the circulation above the level of the problem (either internal jugular or subclavian) so that fluids and medications get to the heart and thus the circulation. It is also a good idea to choose a larger line that will support rapid fluid resuscitation. My personal choice would be an introducer either U/S guided into the IJ or blind subclavian.

A HUGE CAVEAT. You have to work with the skill set that you have. I am very comfortable with the two lines that I mentioned because I place them several times a month. If you are only comfortable placing femoral, don't flail around trying to establish "superior" access. Either get help or place the femoral and test it to ensure patency (either a fluid bolus or a pressor and look for BP changes) before relying on it for massive resuscitation.

Ultimately, you should establish either SC or IJ access as the femoral may go out at any time.

All in all you did a good job.

- pod

+1
management was fine.
learning point is to think of where your vascular lesion is to avoid pumping further products into the abdomen.

 

[seinfeld]

Communication, lack there of, is the root cause many adverse outcomes. Always remember that although the surgeon will be doing the operating the handoff of medical management of the patient will be done by the Anesthesiologist. You did the right things, add to your thought process a call to the anesthesiologist.

 

[jetproppilot]

+1. If you did as the anesthesiologist advised, he would probably be bitching how poorly prepared this patient was.

I agree. You did a great job.👍