ER doesn't wait for npo time period for elective procedures.... Why do you?

[europeman]

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As a surgeon, I have on multiple occasions been rejected from doing a semi elective case because of npo status. ER patient that needs drainage of abscess for example.


So at my shop the ER are sorta cowboys. So rather than wait 6 hours after they had cream and coffee, I ask my Er colleagues to sedate them and it's always been great.

This year their guidelines back them up.... See below.

You think they are nuts? Or is anesthesia behind the game?


http://www.acep.org/workarea/DownloadAsset.aspx?id=93816

 

[gasdoc77]

As a surgeon, I have on multiple occasions been rejected from doing a semi elective case because of npo status. ER patient that needs drainage of abscess for example.


So at my shop the ER are sorta cowboys. So rather than wait 6 hours after they had cream and coffee, I ask my Er colleagues to sedate them and it's always been great.

This year their guidelines back them up.... See below.

You think they are nuts? Or is anesthesia behind the game?


http://www.acep.org/workarea/DownloadAsset.aspx?id=93816

"my" shop. Ladies and gentleman, we have ourselves a 'bater here.

 

[deleted171991]

As a surgeon, I have on multiple occasions been rejected from doing a semi elective case because of npo status. ER patient that needs drainage of abscess for example.


So at my shop the ER are sorta cowboys. So rather than wait 6 hours after they had cream and coffee, I ask my Er colleagues to sedate them and it's always been great.

This year their guidelines back them up.... See below.

You think they are nuts? Or is anesthesia behind the game?


http://www.acep.org/workarea/DownloadAsset.aspx?id=93816

The American Society of Anesthesiologists has always been conservative about precautions, hence anesthesia is a very safe business nowadays, compared to 50+ years ago. Also, the ASA sees every anesthetic as a potential general anesthetic.

For sedation, especially in individuals with no co-existing esophagogastric pathology, one could argue that maybe we are too conservative. As long as the patient's upper airway reflexes are maintained, the chances of aspiration are probably much smaller than when general anesthesia has been induced. I have seen situations where colleagues were more permissive about aspiration guidelines for modern cataract surgery (with the right surgeon), with no negative outcomes.

I think that we have already come a long way about NPO status and, in time, we will relax our guidelines even more, especially in relatively healthy patients, as evidence accumulates. I am not ashamed to let others be cowboys and experiment, as long as the patient is aware what he might be getting into (aspiration, pneumonia, even death). For bedside-level procedures, I think the intelligent alternative to waiting could be doing the procedure under a well-placed local anesthetic, with minimal/no sedation, as long as the patient is cooperative and his comorbidities permit it. I am much more appreciative of a surgeon who asks for that, versus heavily sedating the patient earlier than the guidelines would recommend.

As everything in medicine, this is a matter of probabilities; in this case, the probability of needing general anesthesia in the middle of the procedure, because of patient discomfort or surgical complications.

 

[urge]

As a surgeon, I have on multiple occasions been rejected from doing a semi elective case because of npo status. ER patient that needs drainage of abscess for example.


So at my shop the ER are sorta cowboys. So rather than wait 6 hours after they had cream and coffee, I ask my Er colleagues to sedate them and it's always been great.

This year their guidelines back them up.... See below.

You think they are nuts? Or is anesthesia behind the game?


http://www.acep.org/workarea/DownloadAsset.aspx?id=93816

Cannot read on the phone. What do their guidelines say?

 

[europeman]

Tks for the replies.

I'm not a "bater".... I have been consistent contributor to sdn for over a decade now.

Anyway, I hear you about what you say. Certainly the standard-of-care in anesthesia is like you say.

But the ER people, in part being a younger field, are pretty savy folks and use a lot of innovative ideas in heir field and are particular Stuarts of evidence. Us surgeons are the literal polar opposite!

My question is though.... His do you FEEL about their rational and evidence they cite?

Are they indeed cowboys?

 

[jwk]

Are they indeed cowboys?

Yes.

 

[Planktonmd]

We are held to much higher standard than anyone else when it comes to administering anesthesia since we are the anesthesia specialists.
If an ER physician gives general anesthesia to a full stomach patient and calls it "procedural sedation" and as a result the patient vomits and aspirates, this will be seen as an unavoidable complication with no standard of care violation since this is what most ER docs would have done.
If an anesthesiologist does the same exact thing he would be crucified by his peers and will be in violation of the standard of care.
Overtime the guidelines have been loosened, and as more data is accumulating we will see more change, but for now the ASA guidelines and the accepted practice of the majority of anesthesiologists are what forms the standard of care for anesthesia providers.

 

[deleted126335]

Guidelines from our respective specialty societies are conflicting with respect to NPO.

ASA NPO guidelines deal with ELECTIVE procedures. Anything that that gets done in the EMERGENCY ROOM can more than reasonably be argued to be an emergency.

Want us to go sooner than our guidelines call for? No problem whatsoever. Just call it an emergency when you book it. I will document the conversation preop and do the case.
Your original post referred to "semi elective". I get what that means. Unfortunately there is no good definition of "semi elective". As far as NPO goes it is either elective or emergent. You pick which.

 

[Mman]

the problem in the OR is that many surgeons post a case to be done under sedation and then they go ballistic if the patient so much as sneezes. If the case can be done with nothing more than 2 mg of IV versed they are probably fine as long as they don't have bad GERD. If the sedation the surgeon requests means I'm jaw thrusting the patient for 10 minutes than that's the same as a general anesthetic and the NPO guidelines are the same.

And medico-legally, if something bad happens and I didn't follow established national guidelines, well it's hard to defend yourself in court.

 

[seinfeld]

All it takes is one case of aspiration pneumonitis for one to change their mind on how urgent a case needs to go. Would you want your pilot not walking the exterior of plane before take off because the last 1000 times he did so he found nothing.

I cant tell you the number of times the ED screws around with a patient on bipap, or IV sedation and then they have to come up to the ICU for "aspiration pneumonia". It is sometimes not reported off as such but when you take a "good" history and do an investigation youll find it lurking in the shadows. I feel that diagnosis is used for so that way a DOC can blame the patient for the resultant illness

Overall, if its about your (anesthesia or surgical) schedule and not whats the least risky for the patient then I would question your morals

 

[Orin]

But the ER people, in part being a younger field, are pretty savy folks and use a lot of innovative ideas in heir field and are particular Stuarts of evidence. Us surgeons are the literal polar opposite!

My question is though.... His do you FEEL about their rational and evidence they cite?

Are they indeed cowboys?

I'd be the first one to agree that our NPO guidelines are very conservative. Looking at the ED evidence though, the adverse event rates they quote are in the 1-5% range. The largest study they quote is a pediatric one that has ~1500 patients where their adverse event rate is in the 10-15% range. None of their studies document any aspiration events, though I don't think any of them look as aggressively for aspiration as we do. Remember, the aspiration rate is somewhere beteen 1/1000 to 1/10000 depending on criteria and population. I would argue that they've got underpowered data and they aren't looking very carefully for what we worry about. Still, an AE rate of 5-15% is a little too high for me, but I'm not sure any of that is NPO related.

I agree with their rationale though, and I would wager that in most cases, 95% of the time things will be 100% okay, but 1-5% of the time the **** will hit the fan and then the question is how bad will it be.

 

[sevoflurane]

One bad aspiration to convince someone of the NPO guidelines is one too many.

 

[sevoflurane]

...and while we are on the topic. Check out your CT's/Xrays before you induce. Sometimes an NG tube is necessary before you drop in your paralytic.
Some surgeons are notoriously lazy about this. Adverse outcomes most certainly occur in the setting of a full stomach/ileus.

 

[Critical Mass REACHED]

We had a case in the OR where the patient aspirated, developed a severe sepsis as a result of aspiration pneumonia, and died 1 week later. I always thought it was kind of extreme until I witnessed the progression from aspiration to death. I've seen patients intubated in the ER and man it's sloppy, and makes me wonder after the 5 or 6th try why won't you just page the Anesthesiologist. This after they intubated the esophagus and started pumping the ambu bag and inflated the stomach, followed by massive vomiting and aspiration. Great work cowboys.

 

[sleepallday]

As a surgeon, I have on multiple occasions been rejected from doing a semi elective case because of npo status. ER patient that needs drainage of abscess for example.


So at my shop the ER are sorta cowboys. So rather than wait 6 hours after they had cream and coffee, I ask my Er colleagues to sedate them and it's always been great.

This year their guidelines back them up.... See below.

You think they are nuts? Or is anesthesia behind the game?


http://www.acep.org/workarea/DownloadAsset.aspx?id=93816

Anesthesiologists look at each case as a potential general anesthetic. These guidelines make it clear that they only apply to procedural sedation. Most surgeons assume that if the airway is not secured, then it must be a sedation case. This is absolutely incorrect. There is a fine line from when a sedation case crosses into the realm of a general anesthetic. And many anesthesiologists will tell you that they've done general anesthetic cases routinely with just a face mask on.

If it's an emergency, I'll do the case right away. But the patient gets a tube every time, even if the case normally doesn't require one. The other day, I had an OB that wanted to section a patient with a full stomach. He wasn't willing to call it an emergency but said it needed to go right away. That's his judgement call, so I said no problem but it's going to be a general anesthetic. Guess what? It turned out, the section could wait a few hour so that I could do a spinal.

 

[Libertas]

I was under the impression that a spinal is acceptable for an emergency c-section regardless of NPO status....and that the reason to do general anesthesia is lack of time to insert a spinal (crash section, as opposed to emergent)....no? I mean, with a spinal you aren't touching their airway reflexes.

 

[sevoflurane]

I was under the impression that a spinal is acceptable for an emergency c-section regardless of NPO status....and that the reason to do general anesthesia is lack of time to insert a spinal (crash section, as opposed to emergent)....no? I mean, with a spinal you aren't touching their airway reflexes.

This is why we are consultants.
There are risks and benefits to either spinal or GA for a stat C-Section. Both can be acceptable in an emergency. Depending on the situation sometimes it's better to go for GA. Other times it's better to do a spinal.

 

[sevoflurane]

🙄

 

[risnwb]

I was under the impression that a spinal is acceptable for an emergency c-section regardless of NPO status....and that the reason to do general anesthesia is lack of time to insert a spinal (crash section, as opposed to emergent)....no? I mean, with a spinal you aren't touching their airway reflexes.

It wasn't actually an emergency

 

[aneftp]

...and while we are on the topic. Check out your CT's/Xrays before you induce. Sometimes an NG tube is necessary before you drop in your paralytic.
Some surgeons are notoriously lazy about this. Adverse outcomes most certainly occur in the setting of a full stomach/ileus.

Colleague of mind just had huge aspiration case. Thank god patient was able to recover. Still bad infection. Incubated for days. She's only alive cause she's 38 years old. If she were 75 she would be dead.

Lots of figure pointing cause Ng tube wasn't place prior to induction. Orders were written in ER. Patient sat in ER for 8 hours no NG tube.

Even with RSI patient aspirated.

Only saving grace is chest x ray down in ER did show a developing pneumonia prior to transfer to OR.

But nevertheless. Patient further aspiration 200 cc down trachea into lungs of junk. Had to bronch patient intraop just to clean her up to get sats above 80%.

 

[sevoflurane]

Colleague of mind just had huge aspiration case. Thank god patient was able to recover. Still bad infection. Incubated for days. She's only alive cause she's 38 years old. If she were 75 she would be dead.

Lots of figure pointing cause Ng tube wasn't place prior to induction. Orders were written in ER. Patient sat in ER for 8 hours no NG tube.

Even with RSI patient aspirated.

Only saving grace is chest x ray down in ER did show a developing pneumonia prior to transfer to OR.

But nevertheless. Patient further aspiration 200 cc down trachea into lungs of junk. Had to bronch patient intraop just to clean her up to get sats above 80%.

Yup. 👍

 

[sevoflurane]

It wasn't actually an emergency

It is perfectly acceptable to do a spinal in an emergency with a patient that looks like the patient in picture #1. Going for a GA in a patient that looks like picture #1 can mean death to the mother AND unborn child if you don't do it correctly.

CONCLUSION:
Difficult airway management during general anaesthesia, inadequate supervision of trainee anaesthetists and a lack of appropriate monitors were the major anaesthetic reasons for maternal mortality. Recommendations have been made to ensure that parturients and the unborn child receive the best anesthetic care attainable in the hospital.

http://www.ncbi.nlm.nih.gov/pubmed/16430543

 

[sevoflurane]

It depends on the patient, the risks vs benefit and the feasibility of different approaches.

 

[pgg]

As a surgeon, I have on multiple occasions been rejected from doing a semi elective case because of npo status. ER patient that needs drainage of abscess for example.


So at my shop the ER are sorta cowboys. So rather than wait 6 hours after they had cream and coffee, I ask my Er colleagues to sedate them and it's always been great.

This year their guidelines back them up.... See below.

You think they are nuts? Or is anesthesia behind the game?


http://www.acep.org/workarea/DownloadAsset.aspx?id=93816

I think they're sort of nuts, and here's why:

In their discussion of "does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration" they note

Any adverse events (vomiting or adverse respiratory event) occurred in 12.0% in the 0- to 2-hour group, 16.4% in the 2- to 4-hour group, 14.0% in the 4- to 6-hour group, 14.6% in the 6- to 8-hour group, and 14.5% in the greater than 8 hours group.

In the anesthesia world none of these adverse event rates would be acceptable. Seriously, a 12 - 15% adverse event rate? Really? They're pointing at the fact that an adverse event rate of 12% in the non-fasted 0-2h group isn't much different than the 14.5% rate in the >8h group ... hooray? Don't you think that an adverse event rate over 1 in 10 just isn't acceptable at all? (They do go on to claim 0 aspiration events in 1555 patients.)

No wonder they think we're too conservative, if adverse events in a tenth of their patients are part of their normal daily practice.

Next up, "257 pediatric patients undergoing procedural sedation with ketamine" showed emesis rates of 6.6% in the <1h, 14.0% in 1-2h, and 15.7% in >3h fasting groups. It's a total puke-o-rama. Whatever they're doing, they're making an awful lot of their patients throw up.



I think the reason the ER gets away with ignoring NPO guidelines has a lot to do with their sedation (aka general anesthesia) technique, which typically doesn't involve airway instrumentation. In truth, they probably aren't causing many really bad aspiration injuries; we on the other hand really can't cause any given our standards. Plankton nailed it with his post in this thread - our standard of care is different than theirs. We don't tolerate aspiration injuries as the normal cost of doing business.

Furthermore, I think they get away with playing loose with NPO guidelines because of ER culture ...
1) ER complications are tolerated and explained away as "well it was an emergency, the patient was really sick" ... I've seen this often, especially with "difficult" intubations. I truly, genuinely believe that the ER manufactures an unacceptable number of their adverse airway events out of nothing.
2) ER complications are not detected because the sick patients leave the ER pretty quickly ... aspiration isn't always immediately catastrophic, it evolves, and we see it when we take these patients to the OR or ICU

Yes, I am painting with a broad brush, and I don't really mean to malign our EM colleagues ... but it's a different world down there. They have a fundamentally different attitude toward risk, complications, and safety.

The reason anesthesia is as safe as it is today is because we (as a specialty) took a very hard line toward safety a couple decades ago. You won't see the ASA change NPO guidelines because the ER thinks they're getting away with an acceptably low adverse event rate.

 

[Arch Guillotti]

The other day, I had an OB that wanted to section a patient with a full stomach. He wasn't willing to call it an emergency but said it needed to go right away. That's his judgement call, so I said no problem but it's going to be a general anesthetic. Guess what? It turned out, the section could wait a few hour so that I could do a spinal.

So how long do you wait on a (presumably laboring) woman until you do the case? When will her stomach be empty enough for you to do a spinal.

Unless the circumstances were extraordinary I would have just done a spinal like every other c/s and called it a day.

 

[Arch Guillotti]

Colleague of mind just had huge aspiration case. Thank god patient was able to recover. Still bad infection. Incubated for days. She's only alive cause she's 38 years old. If she were 75 she would be dead.

Lots of figure pointing cause Ng tube wasn't place prior to induction. Orders were written in ER. Patient sat in ER for 8 hours no NG tube.

Even with RSI patient aspirated.

Only saving grace is chest x ray down in ER did show a developing pneumonia prior to transfer to OR.

But nevertheless. Patient further aspiration 200 cc down trachea into lungs of junk. Had to bronch patient intraop just to clean her up to get sats above 80%.

The point about placing an ng tube prior to induction is an interesting one. What if the patient refuses?

There is an interesting document the ASA put out when they revoked the board certification of a member for bad testimony during a malpractice case. Google "Zucker summary of actions and findings 2011" for the actual document.

The case is a full stomach that turns out to be a difficult airway and subsequent aspiration.

We find that Dr. Katz’s testimony on the placement of a nasogastric tube violates Guideline B2 because he condemns performance that clearly falls within generally accepted practice standards. Dr. Katz testified that the standard of care mandated the placement of a nasogastric tube because the patient had a full stomach. He told the jury that placing a nasogastric tube in a patient with a full stomach was elementary; it was “Anesthesia 1-A.” We do not agree. Placing a nasogastric tube in a patient with a full stomach is a judgment call, and we find that anesthesiologists could reasonably differ on whether to place a nasogastric tube under the circumstances...

 

[Arch Guillotti]

the problem in the OR is that many surgeons post a case to be done under sedation and then they go ballistic if the patient so much as sneezes. If the case can be done with nothing more than 2 mg of IV versed they are probably fine as long as they don't have bad GERD. If the sedation the surgeon requests means I'm jaw thrusting the patient for 10 minutes than that's the same as a general anesthetic and the NPO guidelines are the same.

Love it when a surgeon swears on a holy bible that a case can truly be done with small amount of sedation and lots of local anesthetic. Of course the patient invariably starts wailing and the surgeon is cursing because the patient won't hold still.

 

[Planktonmd]

So how long do you wait on a (presumably laboring) woman until you do the case? When will her stomach be empty enough for you to do a spinal.

Unless the circumstances were extraordinary I would have just done a spinal like every other c/s and called it a day.

Agree!
I don't think there is a point in time when you can consider a pregnant woman "empty stomach" and there are no real guidelines in this population on how to approach the NPO status.
For all non elective C sections I proceed based on the OBGYN's preference regardless of the NPO status.
For elective scheduled C sections they need to be NPO like all elective surgeries.

 

[deleted126335]

The point about placing an ng tube prior to induction is an interesting one. What if the patient refuses?

There is an interesting document the ASA put out when they revoked the board certification of a member for bad testimony during a malpractice case. Google "Zucker summary of actions and findings 2011" for the actual document.

The case is a full stomach that turns out to be a difficult airway and subsequent aspiration.

The ASA did not "revoke his certification" He was censured (reprimanded) by the ASA for violating the guidelines for expert witness testimony.
The ABA was not involved.

 

[sleepallday]

So how long do you wait on a (presumably laboring) woman until you do the case? When will her stomach be empty enough for you to do a spinal.

Unless the circumstances were extraordinary I would have just done a spinal like every other c/s and called it a day.

True. All pregnant women can be considered as a full stomach. But there is a difference between a pregnant patient that has been NPO > 8 hours and a lady that just had a breakfast burrito a few hours ago. In my case, the patient was not laboring and it was not an emergency. So why rush to do the case?

But, for the sake of argument, lets say it was a true emergency and had to go right away. I would still prefer to do a GA and secure the airway rather then deal with her likely vomiting post spinal or, even more dangerous, deal with a high spinal.

 

[Libertas]

But isn't the mortality rate during c-section many times higher with GA than regional? And the mortality secondary to airway (mis)management? (I'm forgetting the exact paper, but I know there was one on a similar topic). It would seem to me that unexpected airway problems pose a greater danger than for example a high spinal.

 

[IanMcGalt]

But isn't the mortality rate during c-section many times higher with GA than regional? And the mortality secondary to airway (mis)management? (I'm forgetting the exact paper, but I know there was one on a similar topic). It would seem to me that unexpected airway problems pose a greater danger than for example a high spinal.

Only in obese parturients/more likely difficult airways

 

[Bostonredsox]

I am not sure I completely follow the logic europeman. if the case/procedure is not emergent, and we know that intubation on a full stomach increases the chance for asiration with subsequent pneumonitis, sepsis and death, why wouldnt it be delayed? I mean almost everyone I intubate has a full stomach, as they are all codes, rapid responses or impending collapses. they all get RSI'd and all though I have rarely had a true aspiration, I know it can happen, but as they are emergent airways theres nothing I can do about it. the idea of a pre-indution NGT seems plausible to me. If the pt is failing bipap and Im heading to tube them, if I have the nurse quickly shove an ng in while im getting ready to induce how long should I then be waiting before induction? of course he has to comne off bipap to put the ng in so this may not be feasible but I admit I hadnt thought of it. but back to my original question, if any of my airways were not emergent, I would most definitely slip in an ng and decompres the stomach before induction. even if the data shows the risk of aspiration is low, whatever that risk is, it has to be lowered furthur by putting in an ngt. why would the er docs prefer to just induce the pts on a full stomach knowing it increases the aspiration chances or even if it doesnt increase them, 2 min for an ngt would decrease them?

EDIT I just reread your OP and realised you were talking about awake procedural sedation in the ed on a full stomach. not sure about this. again the only procedural sedation I do is for an emergent cardioversion so poor example. but I have seen pts aspirate during bronchs, colonoscopies, etc from just the versed. rare but when they do, they all code. so if the procedure is elective in the ed, say a abscess drainage, and the stomach is full...why not place ngt, then sedate? im sure you guys have data on ngt affecting aspiration rates, i doubt its 100% but it has to be better than doing nothing.

 

[jwk]

True. All pregnant women can be considered as a full stomach. But there is a difference between a pregnant patient that has been NPO > 8 hours and a lady that just had a breakfast burrito a few hours ago. In my case, the patient was not laboring and it was not an emergency. So why rush to do the case?

But, for the sake of argument, lets say it was a true emergency and had to go right away. I would still prefer to do a GA and secure the airway rather then deal with her likely vomiting post spinal or, even more dangerous, deal with a high spinal.

Scheduled C-sections (for repeats or whatever) are NPO 8 hrs. Non-scheduled C-Sections, whether emergent or "urgent", it doesn't matter because we do them when the OB says it's indicated. ALL are treated as full-stomach's if we go the GA route.

If we can get an epidural or SAB in an emergent C-section, we will, regardless of their NPO status ,because we always consider regional preferable to GA.

 

[Arch Guillotti]

The ASA did not "revoke his certification" He was censured (reprimanded) by the ASA for violating the guidelines for expert witness testimony.
The ABA was not involved.

My error.

 

[Arch Guillotti]

True. All pregnant women can be considered as a full stomach. But there is a difference between a pregnant patient that has been NPO > 8 hours and a lady that just had a breakfast burrito a few hours ago. In my case, the patient was not laboring and it was not an emergency. So why rush to do the case?

But, for the sake of argument, lets say it was a true emergency and had to go right away. I would still prefer to do a GA and secure the airway rather then deal with her likely vomiting post spinal or, even more dangerous, deal with a high spinal.

So what were the circumstances that required a c/s? Was there any urgency at all? Might make it easier for all the armchair quarterbacks here to understand your circumstances.

A true crash emergency c/s usually gets a tube because there isn't time for anything else. The rest get a spinal. Unless an epidural has failed dosing I am not worried about a high spinal. I am not worried about puking either since sometimes they do this anyway.

 

[sevoflurane]

The only AW I've not been able to secure in 5 years of PP was a morbidly obese OB AW for stat C/S.
I was lucky that day as I could adequately ventilate with an LMA. If she had under GA...it could have been a disaster.

 

[seinfeld]

I was under the impression that a spinal is acceptable for an emergency c-section regardless of NPO status....and that the reason to do general anesthesia is lack of time to insert a spinal (crash section, as opposed to emergent)....no? I mean, with a spinal you aren't touching their airway reflexes.

You havnt done enough csections with spinal to have had a high spinal yet, when that happens youll understand.

Medicine is risk/benefit game, knowing your liklihood of risk and your assumed benefit is the key to deciding how to proceed.

 

[pgg]

But isn't the mortality rate during c-section many times higher with GA than regional? And the mortality secondary to airway (mis)management? (I'm forgetting the exact paper, but I know there was one on a similar topic). It would seem to me that unexpected airway problems pose a greater danger than for example a high spinal.

There's a lot to be said on this subject, and we've had a number of threads before ...

The center of that debate is whether or not the incidence of unexpected difficult airways is really so much higher in pregnant women than non-pregnant women, how clinically relevant that is today, and to what degree prudent anesthesiologists should try to avoid general anesthesia in parturients. The usual (mostly academic) position on that debate is that the incidence of unexpected difficult airway in term pregnant women (ie, you DL and can't intubate) is 10x that in non-pregnant women. IIRC, one of the figures thrown around in the literature was 1:2500 normal population to 1:250 in pregnant women.

I had some attendings in residency go to lengths that (in my current view and opinion) were excessive to avoid general anesthesia. Too much time spent screwing with difficult spinals when the baby looked so-so. Too many flakey epidurals tolerated and painful sections endured by patients, because of reluctance to convert to GA. Even a case with a known percreta with IR-placed balloon catheters inserted preop, where my attending chose neuraxial anesthesia (and the accompanying sympathectomy) to avoid GA in a pregnant woman.


I think a lot of us here don't really agree that 1:250 pregnant women without outward indicators of a difficult airway will turn out to have an unexpected difficult airway making intubation via direct laryngoscopy impossible. The prevailing opinion over the years on SDN leans toward the stance that general anesthesia for c-section should be approached with somewhat elevated caution, but not the extreme apprehension / fear that seems to be taught in many residency programs. IE, when general anesthesia is indicated, just do it.

I think the dogma survives for a couple reasons -
1) The ASA's difficult airway algorithm is behind the times. Video laryngoscopy really ought to be a central part of that algorithm, but it's not, yet.
2) Academic bias stemming from the hazards of inexperienced residents operating, inexperienced residents anesthetizing, and (maybe) more genuinely abnormal patients.


Obviously a patient with a known or suspected difficult airway is an entirely different debate.

 

[seinfeld]

I would also add to the list of why the dogma lives on is that many (not all) Academic Attendings are too scared of their own shadow from time spent away from the OR and actually doing their own cases.

I posted previously of an academic OB attending who told me she would never induce a pregnant patient by herself, I did that 2xs in my first 6 months of practice, without issue. (my last GA in OB was done with LMA though )

 

[sleepallday]

So what were the circumstances that required a c/s? Was there any urgency at all? Might make it easier for all the armchair quarterbacks here to understand your circumstances.

A true crash emergency c/s usually gets a tube because there isn't time for anything else. The rest get a spinal. Unless an epidural has failed dosing I am not worried about a high spinal. I am not worried about puking either since sometimes they do this anyway.

So full story - Lady is not in labor presents for a repeat section. Both current and previous pregnancy complicated by just thrombocytopenia (>100k). All major diseases of pregnancy with thrombocytopenia have been ruled out (eg. eclampsia, HELLP). Platelets have been consistently >100k throughout pregnancy and last CBC was just done now. She has had full breakfast 5 hours ago. OB would like to section her but I say we have to wait another 3 hours. OB then says we have to go now because he is concerned that platelets may suddenly drop to dangerously low levels over the next 3 hours. ( I can only roll my eyes here because platelets have consistently been >100k, including the value from just a few minutes ago). This is his call, so I agree to proceed with a GA because of the full stomach. Not to mention that I wouldn't put a needle in her back if the platelets really were as low as the OB was claiming. OB insists on a spinal and starts making a big fuss about it by claiming all the other partners would have done it. Case ends by us doing the section 3 hours later with a spinal.

I agree with some of the posts above and there is no such thing as cookie cutter anesthesia. In this particular case, if we really needed to section before > 8 hours NPO, I believe GA would be the best course of action. For some reason, as others have also mentioned, some academic attendings have instilled this fear of GA for sections in the residents. I even remember during residency, some attendings would have us attempt spinals in true STAT sections.

 

[BobBarker]

Makes more sense now. Don't disagree at all with your line of thinking.

 

[jwk]

So full story - Lady is not in labor presents for a repeat section. Both current and previous pregnancy complicated by just thrombocytopenia (>100k). All major diseases of pregnancy with thrombocytopenia have been ruled out (eg. eclampsia, HELLP). Platelets have been consistently >100k throughout pregnancy and last CBC was just done now. She has had full breakfast 5 hours ago. OB would like to section her but I say we have to wait another 3 hours. OB then says we have to go now because he is concerned that platelets may suddenly drop to dangerously low levels over the next 3 hours. ( I can only roll my eyes here because platelets have consistently been >100k, including the value from just a few minutes ago). This is his call, so I agree to proceed with a GA because of the full stomach. Not to mention that I wouldn't put a needle in her back if the platelets really were as low as the OB was claiming. OB insists on a spinal and starts making a big fuss about it by claiming all the other partners would have done it. Case ends by us doing the section 3 hours later with a spinal.

I agree with some of the posts above and there is no such thing as cookie cutter anesthesia. In this particular case, if we really needed to section before > 8 hours NPO, I believe GA would be the best course of action. For some reason, as others have also mentioned, some academic attendings have instilled this fear of GA for sections in the residents. I even remember during residency, some attendings would have attempt spinals in true STAT sections.

I'm not clear on what the indication is for C-Section at this point besides "I want to do it now". Platelets >100k is not thrombocytopenia in my book, and neuraxial anesthesia would not be contraindicated. I haven't heard of a diagnosis of "impending thrombocytopenia". 😉 However, we would probably let our OB's make that call - and document that it's urgent in the medical record - and we would do an epidural like we do on 99.5% of our other C-section cases and not think twice about it. We do epidurals on patients who present in labor that were scheduled C-Sections in all the time - usually about two hours after they hit the door - long enough to get them admitted, get labs and an IV, get a liter + of fluid on board, etc. Except for your "not in labor" comment, this wouldn't raise an eyebrow at our place.

 

[Mman]

You havnt done enough csections with spinal to have had a high spinal yet, when that happens youll understand.

Medicine is risk/benefit game, knowing your liklihood of risk and your assumed benefit is the key to deciding how to proceed.

I'm too lazy to look, but what's the incidence of a high spinal requiring intubation during c-section? How many thousands do you need to do to have a 50% chance of experiencing one? In my experience the chances of a high spinal are dependent on what sort of spinal dose you like to give. I have several colleagues that give the full 2 mls of 0.75% bupivicaine with every spinal. I'm more of a 1.4 ml kinda guy. If the patient has had an epidural running I'm more of a 0.8 to 1.0 ml kinda guy.

 

[seinfeld]

yeah i was talking more about "higher" than normal spinals associated with dosing after a labor epidural was in place. I also have colleagues who give the whole 2 mls but I noticed they tend to let their patients sit a bit longer than I do.

 

[fakin' the funk]

Currently in ICU fellowship. Aspiration pneumonia is everywhere. Everywhere. The strokey demented pure medical patients, those are obvious. And perioperatively I'm not talking about macro-event aspiration pneumonitis, fortunately and appropriately rare.

I'm talking micro-aspiration when no one's looking. We see it all the time. Seinfeld mentioned the borderline-awake BiPap'd patient. We see a lot of postop aspiration pneumonia in surgical patients with no predisposing upper GI pathology. My conclusion after seeing it enough is that properly NPO'd patients still have micro-aspiration of ?oral contents or ?micro-regurgitation, whether peri-induction, intra-op, peri-extubation, or in PACU. Who knows if this is just unavoidable, due to excess opioid, residual NMB, or whatever.

But after seeing what can happen even with "empty" stomachs, I'm glad we have rules about keeping them as empty as possible. 8 hours, yo.

 

[fakin' the funk]

There's a lot to be said on this subject, and we've had a number of threads before ...

The center of that debate is whether or not the incidence of unexpected difficult airways is really so much higher in pregnant women than non-pregnant women, how clinically relevant that is today, and to what degree prudent anesthesiologists should try to avoid general anesthesia in parturients. The usual (mostly academic) position on that debate is that the incidence of unexpected difficult airway in term pregnant women (ie, you DL and can't intubate) is 10x that in non-pregnant women. IIRC, one of the figures thrown around in the literature was 1:2500 normal population to 1:250 in pregnant women.

I had some attendings in residency go to lengths that (in my current view and opinion) were excessive to avoid general anesthesia. Too much time spent screwing with difficult spinals when the baby looked so-so. Too many flakey epidurals tolerated and painful sections endured by patients, because of reluctance to convert to GA. Even a case with a known percreta with IR-placed balloon catheters inserted preop, where my attending chose neuraxial anesthesia (and the accompanying sympathectomy) to avoid GA in a pregnant woman.

Couldn't agree more. Those data are before the DAA, the Glidescope, widespread fear of the pregnant airway, the intubating LMA, etc, etc.

 

[periopdoc]

Those data are base on the fact that OB anesthesia used to be thought of as scut work and when a c-section was called the least-favored, brand new CA-1 was sent up to do the anesthesia solo. Surprise, surprise, surprise there were more airway disasters on OB than in the general OR where it was senior residents and attendings managing the airways.

Unpredictable difficult laryngoscopy is no more common in the parturient than in the general population. They do desaturate faster and might be more likely to have gastric content to regurgitate. Due to engorgement, the breasts can sometimes get in the way if you don't position the patient in a back up or reverse-t position. The best OB anesthesiologists that I have ever met offered elective GA to all their patients. I don't.

- pod

 

[deleted171991]

I haven't done OB since my residency, but I have done solo a lot of obese patients since. Looking back to my residency, my possibly ignorant feeling is that, as long as the patient is NPO and one is good at glidescope use, the non-morbidly obese OB airway is not more difficult than the regular BMI 45+ female airway. Same reduced functional capacity and time constraint that does not allow messing around too much, so basically every intubation is a (modified) RSI.

I have a feeling that a lot of the "data" comes from the dark ages before videolaryngoscopy, and/or from academic centers where the main intubators were trainees. The academia is such an ivory tower, full of theoreticians who have lost a ton of manual skills, not daily practitioners.

 

[emergentmd]

I have no clue if there is a big difference from what we do for moderate/deep procedural sedation vs what anesthesiology does. I do hear alot of complaints about delayed cases from the ED b/c Anesthesiology had to wait their 6-8 hrs.

But There is No way we can run an ED if we had to wait that long. We use Propofol, etomidate, etc all day long in my ED. I don't even ask when they last ate b/c they are never NPO x 6-8 hrs.

What am I to do with my dislocated shoulders, hips, ankles? What am I to do with Pediatric pts that won't hold still for me to suture their lips? What am I to do with my open fractures?

Should i admit all of my shoulder dislocations to the hospital to wait their 6-8 hrs and let the orthos do the procedure? Good luck on this

Should I keep them in my ED for 6-8 hrs until they are past the time limit? Good luck on this.

I have no choice but to do it without waiting.