Doing the costanza

[seinfeld]

---

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Ever been in a situation where the right clinical decision is the opposite of what you should do?

Get called STAT to the OR. When i arrive, a top notch CRNA is bagging the patient. "Doc I cant ventilate her! " He is trying harder and harder to bag. SBP 60, no ETCO2, HR ST120. I listen to the lung hear no breath sounds. I disconnect the circuit from the ETT and push on her chest, hear a rush of bubbling air come out. I suction for 30 seconds, get a bunch of junk out and everything gets better.

The situation reminds me of the Plane that crashed after leaving south america on its way to france. Co pilot wanted to gain altitude so he keep pulling up never realizing he was only creating more stall and therefore more loss of altitude.

Any other clinical situations out there you have encountered where do the opposite of your initial reaction is the right thing to do?

Moderators please dont allow this to turn into a CRNA bash fest, close the thread before that happens

 

[pgg]

Thought you were going to reach into the fish's mammal's blowhole and pull out a golf ball or something.

 

[excalibur]

Thought you were going to reach into the fish's mammal's blowhole and pull out a golf ball or something.

 

[RxBoy]

Case ill never forget.

Induced a heavy set fella. Drugs kick in, I start to bag. Unable to ventilate. Throw an oral airway in, unable to ventilate. Jaw thrust and practically lifting the guys head off the table. Unable to ventilate. Bag is blowing up like a balloon, no EtCO2. Severe laryngospasm?? can't be pushed sux. Severe bronchospasm? Maybe. Sats drop in the 30s within seconds. Panic sets in, attending tells me just try to intubate stat as he draws up epi. I ask should we LMA incase the tube worsens the bronchospasm. He says just throw the f'ing tube in. Grabe glide, grade 1 view. Intubate without a hiccup.

As I grab the circuit and detach the mask, I make the fateful discovery. I realize why this dude was so impossible to ventilate. A piece of plastic wrapping was wedged between the mask and elbow connector... Also dawned on me why he desatted so quick. Poor dude was sucking room air when I thought I was preoxygenating him.

 

[excalibur]

Case ill never forget.

Induced a heavy set fella. Drugs kick in, I start to bag. Unable to ventilate. Throw an oral airway in, unable to ventilate. Jaw thrust and practically lifting the guys head off the table. Unable to ventilate. Bag is blowing up like a balloon, no EtCO2. Severe laryngospasm?? can't be pushed sux. Severe bronchospasm? Maybe. Sats drop in the 30s within seconds. Panic sets in, attending tells me just try to intubate stat as he draws up epi. I ask should we LMA incase the tube worsens the bronchospasm. He says just throw the f'ing tube in. Grabe glide, grade 1 view. Intubate without a hiccup.

As I grab the circuit and detach the mask, I make the fateful discovery. I realize why this dude was so impossible to ventilate. A piece of plastic wrapping was wedged between the mask and elbow connector... Also dawned on me why he desatted so quick. Poor dude was sucking room air when I thought I was preoxygenating him.

I bet that piece of plastic was the stuff they wrap the masks in. This is not the first time I have heard of this scenario unfortunately. One of my attendings thought that plastic wrap around the mask was the devil for this reason. He felt masks should come in boxes or something to avoid this plastic wrap obstruction problem

 

[DrN2O]

Case ill never forget.

Induced a heavy set fella. Drugs kick in, I start to bag. Unable to ventilate. Throw an oral airway in, unable to ventilate. Jaw thrust and practically lifting the guys head off the table. Unable to ventilate. Bag is blowing up like a balloon, no EtCO2. Severe laryngospasm?? can't be pushed sux. Severe bronchospasm? Maybe. Sats drop in the 30s within seconds. Panic sets in, attending tells me just try to intubate stat as he draws up epi. I ask should we LMA incase the tube worsens the bronchospasm. He says just throw the f'ing tube in. Grabe glide, grade 1 view. Intubate without a hiccup.

As I grab the circuit and detach the mask, I make the fateful discovery. I realize why this dude was so impossible to ventilate. A piece of plastic wrapping was wedged between the mask and elbow connector... Also dawned on me why he desatted so quick. Poor dude was sucking room air when I thought I was preoxygenating him.

So you preoxygenated a guy without ever seeing the end tidal CO2?

 

[Doctor4Life1769]

Where I am the anesthesia techs help with turning over the anesthesia machine while we're wheeling the patient out to the PACU.

Usually, I just do a circuit check, set up my meds and airway equipment, etc.

So, I wheel in the next patient into the OR. hook up monitors and begin to preoxygenate. Well, the machine goes off. FiO2 = 0% and no EtCO2 being measured.

I immediately have the nurse contact the tech. I keep the mask over the patient's face. The tech shows up, he then swaps out the O2 sensor. Still, nothing. I immediately tell the nurse to hold the mask and I look at the EtCO2 sensor. The darn tech had hooked up the sensor to something else... so of course it wasn't sensing. I quickly fix it, and things are working as should be.

I was kinda annoyed. But, the tech was new. So, whatever. Now I always double check everything to ensure things are hooked up where they're supposed to be. I've had a situation where a tech accidentally turned off the scavenger and I did not know this until an attending brought it up. It's annoying because I always check that first thing in the morning.

 

[jetproppilot]

So you preoxygenated a guy without ever seeing the end tidal CO2?

Ummmmm.... I don't even know where to start with this so I'll just start:

1) Preoxygenation of a patient DOES NOT REQUIRE looking at a CO2 waveform

2) When preoxygenating a patient, I've NEVER looked back at the monitor for the CO2 waveform, like you've suggested should be done...

3) Dude, you're WAYYYYY OFF BASE CALLING SOMEONE OUT ON YOUR

MADE UP

STANDARD OF CARE.

You are speaking

WAYYYYYYY ABOVE YOUR KNOWLEDGE BASE.

And it shows.

 

[pgg]

So you preoxygenated a guy without ever seeing the end tidal CO2?

Not all preoxygenation is created equal, nor does it really need to be.

An airway or patient that concerns me gets meticulous preO2 with a good seal, and my end point is an expired O2 of ~80-85%+, which usually takes several minutes. Obviously if I'm looking at expired O2 I also see CO2.

But for the vast majority of my patients, my preoxygenation is less formal. It might be the OR nurse or even the patient holding the mask while I grab items from the cart, or a minute or two of supplemental oxygen via a simple facemask. In these cases with high flow O2 and an imperfect seal, not seeing CO2 is ordinary. I'm comfortable with that.

 

[inmyslumber]

While preoxygenating, it does not take much time to make sure the CO2 monitor is working.

Even if the OR nurse or patient is holding the mask, you can take the mask briefly and make a good seal just to confirm that there will CO2 waveform. Even just one wave will do.

DRN20 has the right idea although it was imperfectly stated.

 

[fakin' the funk]

3) Dude, you're WAYYYYY OFF BASE CALLING SOMEONE OUT ON YOUR

MADE UP

STANDARD OF CARE.

You are speaking

WAYYYYYYY ABOVE YOUR KNOWLEDGE BASE.

And it shows.

Huge overreaction to a belief/practice that you believe DrN2O stated explicitly...but didn't

But I'll defend this straw man anyway.

You can't trust your EtO2 (which is the standard that I was taught[ as an endpoint for preoxygenation unless you can trust that you are sampling alveolar gas, i.e., if you have a good CO2 waveform. We've all seen the EtO2 of (ex.) 104 and the Insp of (ex.) 98 -- that ain't alveolar gas, and a quick glance at the CO2 trace will confirm that.

 

[RxBoy]

n these cases with high flow O2 and an imperfect seal, not seeing CO2 is ordinary. I'm comfortable with that.

Preciously... I usually position the mask so it sits above the face while being held on the christmas tree/fingers/circuit holder or whatever you want to call it. Preoxegenate by flow by, not a perfect fit. Then I finish attaching monitors and load syringes to stop cocks. (I used to use the mask straps for tight fit but realized it made a lot of pts anxious and the straps were always cumbersome getting in the way) In a high turnover room, attendings walk in and push drugs. This was one of those situations.

If its a bad airway or mega obese pt, I take more precautions. Sit them up, air tight fit, use a little cpap and wait for the EtO2 to hit 85+ before induction. Although ideal, its impractical to do this for all the pts especially in a fast turnover room.

 

[W222]

My moment went something like this: I was in a gym room with a surgeon who is very fast and all the cases were TAH-BSOs and debulkings. I get done with a case and I already was set up for my next case before I leave the room with the patient I just woke up. I am back in the room ten minutes later ready to induce the next one, a crazy 50 something with about 20 drug allergies chronic abdominal pain, morbid obesity, OSA, Cad and COPD. I pre oxygenate for five minutes while I am throwing monitors on this fine specimen. I have a glide there just in case it's tough. Well I go with an RSI and push propofol and sux. I intubation and then hook up my circuit and can't generate any positive pressure, there is a massive leak. I look down and someone has removed my entire co2 absorption container, not just the cartridge but the plastic holders also. Wtf? I luckily had a Jackson Reese on hand and hooked it to supplemental o2 and bagged her until my tech brought me a new assembly. Turns out there was a new tech on duty and he threw the entire thing away.

 

[DrN2O]

Ummmmm.... I don't even know where to start with this so I'll just start:

1) Preoxygenation of a patient DOES NOT REQUIRE looking at a CO2 waveform

2) When preoxygenating a patient, I've NEVER looked back at the monitor for the CO2 waveform, like you've suggested should be done...

3) Dude, you're WAYYYYY OFF BASE CALLING SOMEONE OUT ON YOUR

MADE UP

STANDARD OF CARE.

You are speaking

WAYYYYYYY ABOVE YOUR KNOWLEDGE BASE.

And it shows.

Look at the case, buddy. I get the impression that he had at least some concern with the airway (see glidescope and sux). In which case, checking the seal and the end tidal would be advisable. Whatever, my tone was probably a little too judgemental to Rxboy. I do hate the plastic wrap though.

Hey jet, easy on the font size, no need to compensate.

 

[jetproppilot]

Look at the case, buddy. I get the impression that he had at least some concern with the airway (see glidescope and sux). In which case, checking the seal and the end tidal would be advisable. Whatever, my tone was probably a little too judgemental to Rxboy. I do hate the plastic wrap though.

Hey jet, easy on the font size, no need to compensate.

1) I'm not your buddy.

2) FONTS ARE MY GIG, Slim. Don't like it?

I COULD REALLY CARE LESS.

 

[jetproppilot]

Huge overreaction to a belief/practice that you believe DrN2O stated explicitly...but didn't

But I'll defend this straw man anyway.

You can't trust your EtO2 (which is the standard that I was taught[ as an endpoint for preoxygenation unless you can trust that you are sampling alveolar gas, i.e., if you have a good CO2 waveform. We've all seen the EtO2 of (ex.) 104 and the Insp of (ex.) 98 -- that ain't alveolar gas, and a quick glance at the CO2 trace will confirm that.

Hey FAKE, you can spout your "science" as you see it..

we're talking about preoxygenation, dude....not verification of appropriate endotracheal tube placement...no....we're talking about preoxygenation.

REALLY DUDE??

I stand by my post.

 

[Gern Blansten]

My moment went something like this: I was in a gym room with a surgeon who is very fast and all the cases were TAH-BSOs and debulkings. I get done with a case and I already was set up for my next case before I leave the room with the patient I just woke up. I am back in the room ten minutes later ready to induce the next one, a crazy 50 something with about 20 drug allergies chronic abdominal pain, morbid obesity, OSA, Cad and COPD. I pre oxygenate for five minutes while I am throwing monitors on this fine specimen. I have a glide there just in case it's tough. Well I go with an RSI and push propofol and sux. I intubation and then hook up my circuit and can't generate any positive pressure, there is a massive leak. I look down and someone has removed my entire co2 absorption container, not just the cartridge but the plastic holders also. Wtf? I luckily had a Jackson Reese on hand and hooked it to supplemental o2 and bagged her until my tech brought me a new assembly. Turns out there was a new tech on duty and he threw the entire thing away.

Had a tech decide to change the CO2 absorber between routine overnight cases at 4 AM. When the resident went to try to ventilate, no positive pressure. The first place I looked was the CO2 absorber, but it looked completely normal even with removal and close inspection. Ventilated with a Jackson-Reese until we could get another machine. Once the machine was out of the room and the patient was stable, I was able to take a closer look. After several minutes, I saw it. There was a crack in the canister, right in the seam around the rim (almost invisible). The tech had not fit the two together before closing them and forced it shut. That created a hairline crack that made it impossible to generate positive pressure.

 

[pgg]

Had a tech decide to change the CO2 absorber between routine overnight cases at 4 AM. When the resident went to try to ventilate, no positive pressure. The first place I looked was the CO2 absorber, but it looked completely normal even with removal and close inspection. Ventilated with a Jackson-Reese until we could get another machine. Once the machine was out of the room and the patient was stable, I was able to take a closer look. After several minutes, I saw it. There was a crack in the canister, right in the seam around the rim (almost invisible). The tech had not fit the two together before closing them and forced it shut. That created a hairline crack that made it impossible to generate positive pressure.

Teaching moment for the resident, trust no one, do your own machine checks. There are ninjas and assassins everywhere.

 

[RxBoy]

Ummmmm.... I don't even know where to start with this so I'll just start:

1) Preoxygenation of a patient DOES NOT REQUIRE looking at a CO2 waveform

2) When preoxygenating a patient, I've NEVER looked back at the monitor for the CO2 waveform, like you've suggested should be done...

3) Dude, you're WAYYYYY OFF BASE CALLING SOMEONE OUT ON YOUR

MADE UP

STANDARD OF CARE.

👍👍👍

 

[Gern Blansten]

Teaching moment for the resident, trust no one, do your own machine checks. There are ninjas and assassins everywhere.

Very true!

 

[dhb]

There was a crack in the canister, right in the seam around the rim (almost invisible).

Has happened to me too amazing how an invisible crack can cause a massive leak

 

[BobBarker]

Happens enough at our place that if you have a leak and run the circuit quickly and everything looks good everyone just automatically changes the absorbent. You can also ventilate with it disconnected completely but not with a crack.

 

[deleted171991]

So you preoxygenated a guy without ever seeing the end tidal CO2?

With all due respect to the "old-timers" that practiced safe anesthesia way before the CO2 monitors, not using the ETCO2 when available is like not using ultrasound for central lines or nerve blocks. I love the O2/CO2 monitors, I even look at the volumes my patient is moving during preoxygenation, even if it's the airway from heaven on a Miss Universe body. Those extra 2-3 minutes I might waste on being cautious make me less "slick" but way safer.

I have to concur with DrN2O. Not seeing the ETCO2 should raise some serious flags. Not seeing a properly rising end-tidal O2 should raise serious flags. Not checking the monitors before inducing a patient is the mark of a bad, not bad-ass, anesthesiologist.

The ASA motto, and hence the "standard of care", is vigilance. Even if I could induce most of my ASA 1/2 patients with just my pocket pulse-ox on, it doesn't mean that I should.

 

[Mman]

I never induce without seeing something on the CO2 waveform. If I'm worried about the airway I make sure I see the end tidal O2 to assess the effectiveness of my preoxygenation.

But even in the skinny slam dunk ASA 1, I want to see something on the CO2 tracing to confirm it's working. Can't tell you how much of a pain in the butt it is to put the tube in and get nothing on the CO2 trace and then have to trouble shoot back until you figure out it's the monitor and not the patient. Last time it happened to me was on a case in radiology where we were so far from the machine during the case we had extensions on the circuit and the Anes Tech put 2 gas sample lines together with a stopcock connecting them. Stopcock was turned the wrong way and so it was sampling room air.

Terribly annoying to deal with...

 

[jetproppilot]

With all due respect to the "old-timers" that practiced safe anesthesia way before the CO2 monitors, not using the ETCO2 when available is like not using ultrasound for central lines or nerve blocks. I love the O2/CO2 monitors, I even look at the volumes my patient is moving during preoxygenation, even if it's the airway from heaven on a Miss Universe body. Those extra 2-3 minutes I might waste on being cautious make me less "slick" but way safer.

I have to concur with DrN2O. Not seeing the ETCO2 should raise some serious flags. Not seeing a properly rising end-tidal O2 should raise serious flags. Not checking the monitors before inducing a patient is the mark of a bad, not bad-ass, anesthesiologist.

The ASA motto, and hence the "standard of care", is vigilance. Even if I could induce most of my ASA 1/2 patients with just my pocket pulse-ox on, it doesn't mean that I should.

Agreed.

I'm a generation beyond that. I've always had CO2 monitors at my beckon call.

That being said,

YOU DON'T NEED A CO2 MONITOR TO PREOXYGENATE.

Digressing,

I'm an anesthesiologist. I'm also a pilot.

The two fields have a lot in common.

Buddy of mine years ago went for his ATP Checkride... he passed, but with a caveat:

The FAA Check Pilot told my buddy he was too

GPS DEPENDENT.

(Global Positioning System)

GPS has revolutionized navigation in an airplane

much like ETCO2 has revolutionized anesthesia.

That being said,

like the FAA examiner told my buddy on his ATP checkride,

"Don't just depend on your GPS. Your other navigational instruments and your knowledge are important."

The same can be said concerning ETCO2 monitoring in our profession.

 

[Arch Guillotti]

I always look for the end tidal tracing. Most of the time when it isn't there it's because the nurse has the pop off valve closed all the way.

When I am concerned about an airway, I insist on a tight fitting mask seal for at least a couple of minutes with a good tracing. I don't pay much attention to the expired fraction of O2 for some reason.

 

[jetproppilot]

I always look for the end tidal tracing.

Metaphorically speaking,

YOU ARE GPS DEPENDENT.

 

[lord_jeebus]

Although I take the 0.2 seconds to recognize an ETCO2 tracing...

I think it's one thing to preoxygenate a patient without checking the ETCO2, but knowing that one personally did a thorough machine check, and using some other means of confirming that preoxygenation is indeed happening -- much as a pilot might check his equipment and be able to navigate without GPS.

It's another to "preoxygenate" without checking the ETCO2, and also fail to employ any method of confirming oxygen delivery prior to induction of anesthesia, allowing for the apneic anesthetized non-preoxygenated difficult airway patient -- the parallel is not a pilot who can navigate without GPS, but a pilot who omits routine pre-flight safety checks because he knows he can navigate without GPS, and succeeds in landing the plane safely after a failure only because he was able to fix the problem before crashing the plane.

In other words,

Plantiff attorney: "Doctor, did you confirm that the patient was being preoxygenated? Did you look at your ETCO2 before inducing anesthesia and paralyzing my client?"

Answer A: "I did not check the ETCO2, but delivered oxygen by simple facemask, which was audible with visible fogging and defogging. I had personally checked my anesthesia equipment and verified that gas flowed properly through the circuit during inspiration and exhalation, per the standards of my profession."

vs.

Answer B: "No, but that's how I always do it and how was I supposed to know that there was a piece of plastic occluding my circuit?"

 

[Pooh & Annie]

Metaphorically speaking,

YOU ARE GPS DEPENDENT.

That's bush league anesthesia you're espousing.
Not checking for a good seal with ETCO2 tracing and adequately de-nitrogenating a difficult airway is sloppy anesthesia practice at best. I hope the residents reading this know better.

 

[jetproppilot]

That's bush league anesthesia you're espousing.
Not checking for a good seal with ETCO2 tracing and adequately de-nitrogenating a difficult airway is sloppy anesthesia practice at best. I hope the residents reading this know better.

No, dudette.

It's knowing when I have to rely on my monitors to know I'm right,

which ALSO means there are certain situations where I am not

MONITOR DEPENDENT

and I'm still right.

PREOXYGENATION IS NOT

AND NEVER SHOULD BECOME

A MONITOR DEPENDENT SKILL.

As a pilot,

I DON'T NEED GAUGES FOR A VISUAL APPROACH, NOR WILL I EVER.

My pilot Visual Approach is a parallel to my Preoxygenation as an Anesthesiologist.

Pooh, I hope you are teaching your residents to be

DOCTORS.

Not monitor dependent

ROBOTS.

Dear Reading Residents, there is a certain

STICK AND RUDDER SKILL

to our craft, much like pilots need to maintain a certain STICK AND RUDDER SKILL to their flying, despite the technologic advancement.

Don't ever let anyone tell you otherwise.

 

[Pooh & Annie]

No, dudette.

It's knowing when I have to rely on my monitors to know I'm right,

which ALSO means there are certain situations where I am not

MONITOR DEPENDENT

and I'm still right.

PREOXYGENATION IS NOT

AND NEVER SHOULD BECOME

A MONITOR DEPENDENT SKILL.

As a pilot,

I DON'T NEED GAUGES FOR A VISUAL APPROACH, NOR WILL I EVER.

My pilot Visual Approach is a parallel to my Preoxygenation as an Anesthesiologist.

Pooh, I hope you are teaching your residents to be

DOCTORS.

Not monitor dependent

ROBOTS.

Dear Reading Residents, there is a certain

STICK AND RUDDER SKILL

to our craft, much like pilots need to maintain a certain STICK AND RUDDER SKILL to their flying, despite the technologic advancement.

Don't ever let anyone tell you otherwise.

I dont even know where to start. You sound like someone who only sees shapes and numbers on their monitors, not an anesthesiology SPECIALIST who truly knows all the information they can get from those monitors. And it becomes second nature if you actually practice it.

What I teach my residents is that they should use every tool at their disposal to provide their patient's the safest anesthetic possible. It's laughable for an anesthesiologist to suggest you can't focus on a patient and take a look at a monitor.

You think confirming ETCO2 prior to induction of a potential difficult airway is monitor relying. I think it ensures a tight seal, so inhaled nitrogen doesn't decrease the time to potential desats, and more importantly, to avoid the type of post-induction confusion that can happen when there are issues with the circuit or CO2 detector. There are other reasons. Not checking these things with a difficult airway is a recipe for disaster.

In a hypothetical practice where everyone knew you weren't checking end-tidal gasses, I don't know if anyone would say anything to you but a legit group would protect themselves by not scheduling you with the difficult airways.

Once again, I hope residents are learning to use everything they've got to keep patient's safe.

 

[jetproppilot]

I dont even know where to start. You sound like someone who only sees shapes and numbers on their monitors, not an anesthesiology SPECIALIST who truly knows all the information they can get from those monitors. And it becomes second nature if you actually practice it.

What I teach my residents is that they should use every tool at their disposal to provide their patient's the safest anesthetic possible. It's laughable for an anesthesiologist to suggest you can't focus on a patient and take a look at a monitor.

You think confirming ETCO2 prior to induction of a potential difficult airway is monitor relying. I think it ensures a tight seal, so inhaled nitrogen doesn't decrease the time to potential desats, and more importantly, to avoid the type of post-induction confusion that can happen when there are issues with the circuit or CO2 detector. There are other reasons. Not checking these things with a difficult airway is a recipe for disaster.

In a hypothetical practice where everyone knew you weren't checking end-tidal gasses, I don't know if anyone would say anything to you but a legit group would protect themselves by not scheduling you with the difficult airways.

Once again, I hope residents are learning to use everything they've got to keep patient's safe.

SOOOO..based on your response, let's take this to another level,

DOCTOR.

Since you think it's soooooo important to see an ETC02 tracing when preoxygenating,

DO YOU THINK IT'S

STANDARD OF CARE?

To see an ETCO2 tracing when preoxygenating?

(yes or no)

Do you think it is a BREACH of Standard of Care if there is no ETC02 tracing during preoxygenation?

(yes or no)

On a more pragmatic stance,

Would you cancel a case if you looked back at your monitor and didn't see an ETC02 tracing while preoxygenating?

DOCTOR?

(Pretty simple answer... YES or NO.)

 

[pgg]

Would you cancel a case if you looked back at your monitor and didn't see an ETC02 tracing while preoxygenating?

What kind of ridiculous question is this?

Of course no one would cancel the case. If they thought seeing etCO2 was an important part of their pre-induction checklist for that case, and didn't see it, they'd fix the monitor. Not throw up their hands and cancel.


I wrote earlier that I don't always look for etCO2 when preoxygenating. If it's not an airway I'm concerned about, I'll often pre-O2 with a simple facemask, or by having the periop nurse or patient hold the mask. They rarely get a perfect seal and with high flow O2 it's not unusual to see no etCO2. I'm OK with that. (If I'm not OK with it, I hold the mask myself +/- some CPAP and we sit there and wait until etO2 is in the 80s.)


You're not really suggesting that it isn't standard of care to preO2 patients with concerning airways or other hints of badness, are you? And if you're going to do that, shouldn't there be some objective measure that the patient really is getting denitrogenated? Some objective end point of completeness?


I also think there's value, when teaching new residents - who do not yet have the experience or a good feel for assessing who really needs complete and thorough denitrogenation and who doesn't - to instruct them to always look for etCO2 or etO2. In time, they will learn when it's critical and when it's not.

There's little harm in teaching excessive caution to trainees. The opposite is not true.

 

[jwk]

For those of you who EXPECT to see, and are anxiously awaiting the arrival of, an EtCO2 waveform while you're pre-oxygenating, by all means - if you don't see one, you should find out why.

Most of the time when I pre-oxygenate, I'm letting the mask attached to the circuit sit on the patient's face while I'm grabbing my syringes, etc. If I'm more than slightly concerned about really pre-oxygenating, then I'm just as likely looking for big bag movements as I am to look at the monitors, since I do like to know I have a good mask seal - that and making sure I actually turned on the O2 flowmeter - which c'mon, admit it, some of you will forget to do from time to time. We're big fans of the 4-5 maximal breaths for pre-oxygenation for the most part, so we're not looking at the gas/volume monitors anyway. Looking for high expired O2 readings? Nah. And according to some of my old Emory professors, the goal was not pre-oxygenation but de-nitrogenation.

 

[Pooh & Annie]

SOOOO..based on your response, let's take this to another level,

DOCTOR.

Since you think it's soooooo important to see an ETC02 tracing when preoxygenating,

DO YOU THINK IT'S

STANDARD OF CARE?

To see an ETCO2 tracing when preoxygenating?
E
(yes or no)

Do you think it is a BREACH of Standard of Care if there is no ETC02 tracing during preoxygenation?

(yes or no)

On a more pragmatic stance,

Would you cancel a case if you looked back at your monitor and didn't see an ETC02 tracing while preoxygenating?

DOCTOR?

(Pretty simple answer... YES or NO.)

Goodness, that is a whole 'nother level!

Once the patient is under a GA, ETCO2 monitoring IS a standard of care for GOOD REASON. So I certainly would delay a case and troubleshoot if my monitors weren't working, particularly during a potential difficult airway! Good Lord I hope you wouldn't suggest to the residents that they do otherwise. You yourself can do whatever you'd like, but there are more than enough experts in the field that would describe you as negligent if god forbid you had a poor outcome. This isn't 1950.

 

[pgg]

And according to some of my old Emory professors, the goal was not pre-oxygenation but de-nitrogenation.

What?

Are you de-nitrogenating with argon or some other gas that isn't oxygen?

 

[Gern Blansten]

What?

Are you de-nitrogenating with argon or some other gas that isn't oxygen?

Methane? The last remaining flammable anesthetic gas in the OR?

 

[jwk]

What?

Are you de-nitrogenating with argon or some other gas that isn't oxygen?

😱 Holy crap Batman - so that's the problem!

 

[jetproppilot]

MAN I"VE GOT EVERYONE ON THE WARPATH!!!!

PGG wants to kick my a ss,

Pooh and Annie is BREATHING DOWN MY THROAT,

LOL

Know what this reminds me of?

That Allen Iverson video DJ STEVE PORTER made that went viral on YouTube...

You know, the one where Iverson says

"WE SITTIN' HERE, I'M SPOSED TO BE A FRANCHISE PLAYA, AND WE TALKIN' BOUT

PRACTICE

NOT A GAME NOT A GAME NOT A GAME

WE TALKIN' BOUT

PRACTICE"

HAHAHAHAHHAHAHAHAHAHAHHAHAHAHAHAA!!!!!!!

Such parallels man.

I should make a video like DJ Steve Porter did !!!

Doesn't FLOW as well tho: (EH HEMMM....jet clears throat and RAPS THE MIKE)

WE SITTIN' HERE, I'M SPOSED TO BE A FRANCHISE PLAYA

AND WE TALKIN' BOUT

PREOXYGENATION

NOTTA CASE NOTTA CASE NOTTA CASE

WE TALKIN' BOUT

PREOXYGENATION

Nahhhh.....

Don't think Dr Dre is gonna be ringin' my cell, YEARD ME??

 

[Gern Blansten]

 

[jetproppilot]

[YOUTUBE][YOUTUBE]http://www.youtube.com/watch?v=exOxUAntx8I[/YOUTUBE][/YOUTUBE]


LOLLLLLLLLLLL!!!!!!!

WE TALKIN' BOUT

PREOXYGENATION

 

[jetproppilot]

CASTMEMBERS:


ALLEN IVERSON: JET


JIM MORA: POOH and ANNIE


MIKE GUNDY: PGG

 

[leviathan]

I'm not sure if you're reading their argument correctly, Jet. Either that or I'm not. I don't think people are saying you need to specifically see an ETCO2 to ensure they're getting good preoxygenation. What they're saying is that you should verify your monitors work, including your capnography, before inducing a patient. Verifying a good ETCO2 waveform after intubation IS standard of care (right?), and if you have a monitor that's not working, it just adds one extra layer of troubleshooting to your situation if you tube the patient and don't see a waveform. Failing to see an ETCO2 waveform before you induce isn't going to be the end of the world, but it does help remove one piece of uncertainty from the situation.

 

[pastafan]

So much vitriol in this thread. I find it most interesting that only two posts correctly refer to de-nitrogenation. Speaking of teaching residents, what happened to the basics?

 

[Pooh & Annie]

CASTMEMBERS:


ALLEN IVERSON: JET


JIM MORA: POOH and ANNIE


MIKE GUNDY: PGG

That is some well placed comic relief... You seen any of the clips of Iverson's mama? Pretty classic. He'll always be her baby.

 

[jetproppilot]

That is some well placed comic relief... You seen any of the clips of Iverson's mama? Pretty classic. He'll always be her baby.

Pooh I'm gonna look her up on YouTube!!

Btw I noticed your post count in the 300s... did your count roll over at 100,000 or something?😀