first day as CA-1 stories.

[RussianJoo]

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Had my first day as a CA-1 today, and it went well for the most part. The attendings at my program run multiple rooms so they mostly just spend 5min with you during induction and otherwise you have to call them to the room. So I guess our training comes mostly from the seniors, which sucks but at least the seniors are great. We do get the month of June to prepare us for July 1st.

So lucky for me the OR was very light today because of the holiday weekend. I had two cases Gyn... 1) Laparoscopic oopherectomy on a late 20's women with chronic abd pain. 2) eaxm under anesthesia with a pap-smear for a late 30's women with Congenital adrenal hyperplasia.

Case 1) very basic induction, with versed fentanyl propofol and sux. No this wasn't rapid sequence, it's just that the attendings don't like to wait around and are too cheap to use roc. I throw the tube into an easy airway, crank up the iso and we're off. I check twitches she got them all back, push 6mgs of vec and sit back and start my charting. bp is stable through the case peak pressures go up during insuflation so I switch the vent to pressure control. I give some zofran and toradol towards the end and in 45min they're closing skin and she has 4 strong twitches. I switch her to manual ventilation and voila she's breathing on her own. The curtain comes down i push the reversal because her tidal volumes weren't as high as i wanted them, and most of her receptors might still be blocked, at this time she's at 0.3 mac, we move her to the stretcher and a few min later she's consistently pulling volumes over 350 but still not following commands. The senior says she's ready asks me if she was an easy intubation as he pulls the tube. Once we pull into the PACU she's awake.

Case 2) I'll be doing this with an LMA, the attending tells me she likes very little to no fentanyl for these. I had 100mcgs drawn up for the case. Induction is once again quick and simple, I push 200mg of propofol and stick the LMA in, and crank up the sevo. She got two of versed pre-op. She's tachypnic in the 30's and both HR and BP are elevated from pre-induction, I turn up the O2 flow to get the MAC up quicker, and go slow with 25mcg of fentanyl. a few min later she's deeper but still tachypnic, and tachy, I give another 25mcg, and now she's breathing comfortably in the low 10's. They start the exam and a few min later she's tachypnic again in the high 20's, and what looks to me like moving her head slightly up and down. She's at one MAC exactly, i think 50% of people will move with surgical stimulus, I turn up the gas but to do something quickly because she's in lithotomy and the gyn docs ( i don't like calling them surgeons) got instruments in this woman's vagina. So I push 30mg of propofol and the other 50mcg of fentanyl.

A few min later I notice that she stopped breathing, but she's still satting 99%. maybe 20sec later I get up grab the bag and watching her peak pressures give her a breath here and there. At times I had to hyper ventilate her a bit because her pulse ox dropped to like 94 when i was checking to see if she would breath on her own. Anyway after like 10min of this apnea the gyn doc says he's done, and I think to myself are you sure? Cause we still have a few min before she'll breath. I ask the circulater to page one of the chiefs to come to the room, he's a good friend of mine. Of course by the time he gets to the room she's breathing on her own again. He takes over, we get her a little deeper and we do my first deep "extubation". I stick an oral airway in her we wait a few more min in the OR, she's breathing well and satting 98% on 10liters. And we're off to the pacu. Good tihng this was my last case cause I felt guilty just leaving her with a nurse., she was now satting 100% on 10L but still only arousable to stimuli. Oral air way still in her mouth. So I stick around. 10min later she's arousable to just touch, she's super comfortable, I ask her if she wants the oral airway out she nods her head no. i am like ok. I tell the nurse she'll take out the oral airway when she wants it out, otherwise she's comfortable, and leave to return my drugs and clean up the room.


Then one of the other seniors tells me i could have given her some naloxone. I felt kind of dumb for not thinking of that but in the end i am glad i didn't cause i probably would have given too much.


So please share your stories. I think they have great educational purpose and entertainment for us brand new CA-1's. My friends started cracking up when I told them about this. I do have to admit I was really scared for like 30 sec when I was bagging her but her O2 sat was going down.

 

[RussianJoo]

My classmate confessed to ignoring 1 Liter blood loss on a lady with a pre-op Hgb of 12.6. She noticed the blood loss but didn't think 1 liter was that much. She had fluid going and even drew up a fluid chart, but kept wondering why she had to use so much phenylephrine keep her bp up. Once the attending walked in he quickly bolused her with 500ml of hetastarch and drew an abg. The ended up giving her two units of PRBC in the pacu.

We're all meeting up later for drinks and more first day stories...

Happy 4th Everyone, I finally have a 3 day weekend!!!

 

[RxBoy]

First day is always the scariest. Nice smooth day. Few caveats I would add:
1) Sux is better to facilitate intubation. Trust me. When we had the sux shortage, I really missed the drug. Roc isn't as clean and a lot of times you don't get that nice loose moth opening you do with sux. Plus when it kicks in, it makes bagging so much easier
2) Always reverse. I mean if your TOF ratio is >0.9 its questionable but thats where it has to be for your pharyngeal constrictors to function properly (otherwise 0.7 to 0.9 only guarantees your diaphragm works and you'll still obstruct). 4 twitches is meaningless for extubation criteria and using TV to estimate how reversed someone is a really bad move. Neostig may increase some N/V the jury is still out because the studies swing both ways. I would take N/V over an awake panic patient that finds it difficult to breathe.
3) Never extubate on the stretcher so early in the game (unless your senior is there). Otherwise you'll get in a lot of trouble especially when they laryngospasm or severly desat and your EKG/BP monitors are all off and the circuit mask is no where to be found.
4) If you sense trouble, always call your seniors/attendings. Never second guess. Better to be safe then sorry which is good that you did that. With that said, if you have a properly seated LMA and using SV... some CPAP (5 to 10) and O2 flow is all you need (apneic oxygenation) unless of course BMI >40 but you shouldn't be putting LMA in them anyways . As the CO2 builds up, she will eventually start breathing again. Every now and then give a breathe to see where ETCO2 lies... If its in the upper 50's then I would start bagging. Nalaxone is your last ditch move. Problem is you completely destroyed her analgesia, and you are dropping a patient off in PACU who has the potential to renarcatize (nalaxone only works 20-30 minutes). And an Et MAC of 1 during a LMA case is not accurate, its usually an overestimation because her Fi Iso is mixing and making its way back during expiration. Usually I run them higher if I don't want them to move.

You'll learn all of this soon enough but be proud you made it through the first day.

 

[Ronin2258]

My first day as a CA-1 was mostly logistics. Finished off the last of the paperwork that needed to be done. Orientation was last Monday, but we had to wait for clearance from GME to even be allowed to start today, which took the full week and change. But for the most part, a fairly laid back day, to be quite honest.

We start simulation next week, and our first hands on with patients is the week after. To be quite honest, I actually like this approach. I haven't been hands-on procedures for such a long while, it would be nice screw things up on simulation. When we do have real, live patients, it will be two residents with one attending and we leapfrog over each other as the primary for the cases for the first month.

No call for 3 months, and M-F for at least the first month. But once on call, we will have no problems with numbers or procedures, despite how slow we are starting.

 

[RxBoy]

I push 200mg of propofol and stick the LMA in, and crank up the sevo. She got two of versed pre-op. She's tachypnic in the 30's and both HR and BP are elevated from pre-induction

Sorry one other thing to learn... I didn't catch that she was tachypenic before the start of the case meaning she was already SV. This is the time to hyperventilate the patient with high volatile concentration to get them deep. Don't let them breath themselves down with their own intrinsic Minute Vent after 200 of propofol (which will be severely diminished). They'll never be deep enough without assistance because of hypoventilation. Ideally you want them to not be breathing at all after insertion, hyperventilate with sevo until they are at a good MAC for their age. If your attending is insistent on getting them to SV early as possible, you can put them on the vent. SIMV with RR of 6 and PC of 15 works nice until they start breathing then switch to SV with some CPAP.

 

[Bertelman]

Sorry one other thing to learn... I didn't catch that she was tachypenic before the start of the case meaning she was already SV. This is the time to hyperventilate the patient with high volatile concentration to get them deep. Don't let them breath themselves down with their own intrinsic Minute Vent after 200 of propofol (which will be severely diminished). They'll never be deep enough without assistance because of hypoventilation. Ideally you want them to not be breathing at all after insertion, hyperventilate with sevo until they are at a good MAC for their age. If your attending is insistent on getting them to SV early as possible, you can put them on the vent. SIMV with RR of 6 and PC of 15 works nice until they start breathing then switch to SV with some CPAP.

Naw, that's too easy to just slam in some hypnotic. Why would you want to breathe for a patient perfectly willing to breathe for themselves? Give them as little propofol as you can get away with, like 120 or 150 (assuming slender and midaz on board). Slide the LMA in GENTLY. That's just enough stimulus to remind them to breathe. Turn on the sevo, let them do the work for you. You shouldn't need narcotic to insert an LMA.

When my LMA patients go apneic after insertion, I consider that a mild failure on my part. It was a revelation as a CA-1 after a few days on the cysto service to realize you didn't have to give everyone 200 of propofol and 50 of fentanyl with induction, especially those old guys. I don't understand why you would want to induce apnea if your goal for the procedure is to permit SV.

***Caveat for RJ*** Don't try this yet. As I mentioned, it requires some level of skill with inserting the LMA. If you muck around or bang up against stuff, you'll either stimulate them to start chewing or coughing, or even worse cause laryngospasm. You don't want that your first couple weeks. Find the right attending, tell them what you want to do, and have fun. Work on this when you've got a knee scope day, or some time when you bang out 4-5 LMAs in a day, to get some practice with different patients.

 

[RxBoy]

When my LMA patients go apneic after insertion, I consider that a mild failure on my part. It was a revelation as a CA-1 after a few days on the cysto service to realize you didn't have to give everyone 200 of propofol and 50 of fentanyl with induction, especially those old guys. I don't understand why you would want to induce apnea if your goal for the procedure is to permit SV.

I agree with that strategy but like you said it is a bit risky. With small amount of propofol and no opiates, there minute vent doesn't suffer too much and they probably would be able to breath themselves down if you cranked the gas high enough (especially with N20 on board). But I have had some cases where the patient was just not deep enough and they start bucking, kicking, ect so I like to make sure they are deep. Once the procedure begins, it usually stimulates them enough to breath on their own... If not I just let the CO2 build up. I also like small amount of opiate on board because it keeps them from getting tachypneic, and usually increases their TV (although opiates mildly decrease TV in theses cases its usually paradoxical because diminished pain changes those really short shallow breathes to just shallow breathes). All the volatiles except iso will increase your RR. But hey if you get away with no opiates, that means reduced incidence of N/V and quicker wake up.

 

[Arch Guillotti]

First day is always the scariest. Nice smooth day. Few caveats I would add:
1) Sux is better to facilitate intubation. Trust me. When we had the sux shortage, I really missed the drug. Roc isn't as clean and a lot of times you don't get that nice loose moth opening you do with sux. Plus when it kicks in, it makes bagging so much easier
2) Always reverse. I mean if your TOF ratio is >0.9 its questionable but thats where it has to be for your pharyngeal constrictors to function properly (otherwise 0.7 to 0.9 only guarantees your diaphragm works and you'll still obstruct). 4 twitches is meaningless for extubation criteria and using TV to estimate how reversed someone is a really bad move. Neostig may increase some N/V the jury is still out because the studies swing both ways. I would take N/V over an awake panic patient that finds it difficult to breathe.
3) Never extubate on the stretcher so early in the game (unless your senior is there). Otherwise you'll get in a lot of trouble especially when they laryngospasm or severly desat and your EKG/BP monitors are all off and the circuit mask is no where to be found.
4) If you sense trouble, always call your seniors/attendings. Never second guess. Better to be safe then sorry which is good that you did that. With that said, if you have a properly seated LMA and using SV... some CPAP (5 to 10) and O2 flow is all you need (apneic oxygenation) unless of course BMI >40 but you shouldn't be putting LMA in them anyways . As the CO2 builds up, she will eventually start breathing again. Every now and then give a breathe to see where ETCO2 lies... If its in the upper 50's then I would start bagging. Nalaxone is your last ditch move. Problem is you completely destroyed her analgesia, and you are dropping a patient off in PACU who has the potential to renarcatize (nalaxone only works 20-30 minutes). And an Et MAC of 1 during a LMA case is not accurate, its usually an overestimation because her Fi Iso is mixing and making its way back during expiration. Usually I run them higher if I don't want them to move.

You'll learn all of this soon enough but be proud you made it through the first day.

huh, I understand and agree with about 50% of what you are saying. I think you might change your opinion over time, will be interested to hear.

 

[RxBoy]

huh, I understand and agree with about 50% of what you are saying. I think you might change your opinion over time, will be interested to hear.

Curious which parts? Granted I don't have 1% the experience some of the rockstar regulars have under their belts. You, Jet, Idio, pgg, ect A lot of times much more informative then anyone of my attendings could give. Thats why I like forum so much. Give some info, take some info.

 

[pgg]

Case 1) very basic induction, with versed fentanyl propofol and sux. No this wasn't rapid sequence, it's just that the attendings don't like to wait around and are too cheap to use roc.

1) Sux is better to facilitate intubation. Trust me. When we had the sux shortage, I really missed the drug. Roc isn't as clean and a lot of times you don't get that nice loose moth opening you do with sux. Plus when it kicks in, it makes bagging so much easier

No question, succ gives the best intubating conditions fastest.


But succinylcholine myalgias are real, and they really really suck.

As anesthesiologists we don't personally follow up with very many of our healthy outpatients, so I think as a group we don't really appreciate this side effect as much as we should.


When I had my radius/ulna ORIF about 15 years ago, my arm didn't really hurt afterwards. But the rest of me felt horrible. I honestly thought I'd coded on the table and they did CPR, my chest and arms hurt so much. I didn't really clue in to what happened until many years later when I got into the anesthesia world.

By sheer coincidence, one of our OB nurses today asked me why her neck and chest and arms and legs hurt so much after her endometrial ablation a couple days ago. She also wondered if she'd needed chest compressions during surgery. They used succ.


I don't use succinylcholine anymore unless I have a clear indication for a RSI. In those skinny easy-looking airways for short cases that I dont want a LMA for, I prefer to give about 20 mg of roc and WAIT a minute or two while mask ventilating them. The airways are still easy, and they're reversible within 15 or 20 minutes.

Succinylcholine myalgias are miserable ... just something to keep in the back of your head when reaching for it.

 

[Idiopathic]

Case 2) I'll be doing this with an LMA, the attending tells me she likes very little to no fentanyl for these. I had 100mcgs drawn up for the case. Induction is once again quick and simple, I push 200mg of propofol and stick the LMA in, and crank up the sevo. She got two of versed pre-op. She's tachypnic in the 30's and both HR and BP are elevated from pre-induction, I turn up the O2 flow to get the MAC up quicker, and go slow with 25mcg of fentanyl. a few min later she's deeper but still tachypnic, and tachy, I give another 25mcg, and now she's breathing comfortably in the low 10's. They start the exam and a few min later she's tachypnic again in the high 20's, and what looks to me like moving her head slightly up and down. She's at one MAC exactly, i think 50% of people will move with surgical stimulus, I turn up the gas but to do something quickly because she's in lithotomy and the gyn docs ( i don't like calling them surgeons) got instruments in this woman's vagina. So I push 30mg of propofol and the other 50mcg of fentanyl.

A few min later I notice that she stopped breathing, but she's still satting 99%. maybe 20sec later I get up grab the bag and watching her peak pressures give her a breath here and there. At times I had to hyper ventilate her a bit because her pulse ox dropped to like 94 when i was checking to see if she would breath on her own. Anyway after like 10min of this apnea the gyn doc says he's done, and I think to myself are you sure? Cause we still have a few min before she'll breath. I ask the circulater to page one of the chiefs to come to the room, he's a good friend of mine. Of course by the time he gets to the room she's breathing on her own again. He takes over, we get her a little deeper and we do my first deep "extubation". I stick an oral airway in her we wait a few more min in the OR, she's breathing well and satting 98% on 10liters. And we're off to the pacu. Good tihng this was my last case cause I felt guilty just leaving her with a nurse., she was now satting 100% on 10L but still only arousable to stimuli. Oral air way still in her mouth. So I stick around. 10min later she's arousable to just touch, she's super comfortable, I ask her if she wants the oral airway out she nods her head no. i am like ok. I tell the nurse she'll take out the oral airway when she wants it out, otherwise she's comfortable, and leave to return my drugs and clean up the room.


Then one of the other seniors tells me i could have given her some naloxone. I felt kind of dumb for not thinking of that but in the end i am glad i didn't cause i probably would have given too much.


So please share your stories. I think they have great educational purpose and entertainment for us brand new CA-1's. My friends started cracking up when I told them about this. I do have to admit I was really scared for like 30 sec when I was bagging her but her O2 sat was going down.

i dont preemptively give any fentanyl for my LMA cases, i agree with that. i will dose 25-50mcg after spontaneous ventilation has resumed, I never want to have an LMA on mechanical ventilation, and really dont like them on pressure support either but thats a little more tolerable.

dont be so concerned about patient movement. realize that with no paralytic on, and a stable anesthetic, some number of patients may move with stimulus. they wont remember, they wont come off the table, they arent "waking up". you got yourself in a little bit of a newbie trap by doing three things at once (if you had an ETT in you probably would have done the 4th thing, redose paralytic) and then "okay, were done". i recommend picking one thing, like maybe your propofol, and leaving your volatile alone and avoiding narcotic...but whatever you choose, remember you can always give a little more, and you can always add things. if you are confident that you have an acceptable anesthetic on board, realize that only very minor changes should be necessary to facilitate deepening of an anesthetic.

now, if your patient laryngospasms/bronchospasms with stimulation, it suggests that your anesthetic isnt deep enough, and you may need to do several things at once (#1, call attending; #2, push propofol; #3, attempt bag, etc...)

sounds to me like she was comfortable at the end of the case. i question the need to "deepen" her with an LMA in. you are worried about laryngospasm, which can happen with an LMA in place, so it seems reasonable to either take the LMA out or take her to PACU and let her pull it out herself, but success comes in many forms. you transported a stable postoperative patient with a patent airway, good vitals and good pain control to recovery. is there something else you think needed to be done? 👍

also, if this patient is the reference point for narcan use, then you will give a lot of narcan during your career. i wouldnt give it unless i made a gross error in judgement or calculation, or in the rare case where a patient just wont breathe.

 

[Idiopathic]

No question, succ gives the best intubating conditions fastest.


But succinylcholine myalgias are real, and they really really suck.

As anesthesiologists we don't personally follow up with very many of our healthy outpatients, so I think as a group we don't really appreciate this side effect as much as we should.


When I had my radius/ulna ORIF about 15 years ago, my arm didn't really hurt afterwards. But the rest of me felt horrible. I honestly thought I'd coded on the table and they did CPR, my chest and arms hurt so much. I didn't really clue in to what happened until many years later when I got into the anesthesia world.

By sheer coincidence, one of our OB nurses today asked me why her neck and chest and arms and legs hurt so much after her endometrial ablation a couple days ago. She also wondered if she'd needed chest compressions during surgery. They used succ.


I don't use succinylcholine anymore unless I have a clear indication for a RSI. In those skinny easy-looking airways for short cases that I dont want a LMA for, I prefer to give about 20 mg of roc and WAIT a minute or two while mask ventilating them. The airways are still easy, and they're reversible within 15 or 20 minutes.

Succinylcholine myalgias are miserable ... just something to keep in the back of your head when reaching for it.

one more reason to give lidocaine preinduction, and ive started giving a defasciculating dose of nondepolarizer with every induction now, assuming no airway issues. it either acts as a primer if i decide to continue with that drug or it eliminates fasciculations with sux, and it does reduce myalgias.

 

[cfdavid]

one more reason to give lidocaine preinduction, and ive started giving a defasciculating dose of nondepolarizer with every induction now, assuming no airway issues. it either acts as a primer if i decide to continue with that drug or it eliminates fasciculations with sux, and it does reduce myalgias.

Our PD is a big proponent of this. We're using 1mg/kg. What do you guys use?

Also, just curious to know what "go to" induction dose of Roc you guys are using? I've used from 0.5-1.0mg/kg but this really does seem attending specific. I'm aware of the pharmacokinetic issues. Just curious what most folks are using for "routine" (is there such a thing?) cases.

 

[Bertelman]

dont be so concerned about patient movement. realize that with no paralytic on, and a stable anesthetic, some number of patients may move with stimulus. they wont remember, they wont come off the table, they arent "waking up". you got yourself in a little bit of a newbie trap by doing three things at once (if you had an ETT in you probably would have done the 4th thing, redose paralytic) and then "okay, were done". i recommend picking one thing, like maybe your propofol, and leaving your volatile alone and avoiding narcotic...but whatever you choose, remember you can always give a little more, and you can always add things. if you are confident that you have an acceptable anesthetic on board, realize that only very minor changes should be necessary to facilitate deepening of an anesthetic.

👍

Nothing makes me laugh more than a surgeon or PA screaming, "Don't worry, we're just finishing up the surgery" at the patient with 0.5-1 MAC on board who just happened to twitch their leg a little because they chose to buzz a bleeder as I was emerging. There is a long path from reflex neural stimulation to patient recall. Of course you have to keep the patient safe and provide an acceptable surgical field, but don't presume that means complete absence of movement every single case.

You don't want to be known by the surgeons as the guy who always has moving bodies, but once they become comfortable with everything else you do, it is really not a big deal if they move a little with positioning, prep, or initial stimulus. I've seen a patient go from apneic to bucking with stimulus, so understand this is hard to predict. The best you can do is learn how to deal with the consequences, like Idio said, choose one agent to deepen.

 

[RussianJoo]

thanks for the feed back guys. I was hoping to hear stories from the other newly minted CA-1s.

 

[Idiopathic]

Our PD is a big proponent of this. We're using 1mg/kg. What do you guys use?

Also, just curious to know what "go to" induction dose of Roc you guys are using? I've used from 0.5-1.0mg/kg but this really does seem attending specific. I'm aware of the pharmacokinetic issues. Just curious what most folks are using for "routine" (is there such a thing?) cases.

i dose about 1mg/kg lidocaine for everyone, i still believe it augments the anesthetic and helps reduce a sympathetic surge. i also believe it helps with sux myalgias.

ive started using the low end for roc. i think you can get away with 0.3mg/kg and i typically use no more than 0.5. it sticks around a lot longer than vec, and since we have stopped using vec here, weve had many people need PACU ventilators for overdosing. (they were dosing it cc for cc with vec)

remember, your RSI dose is typically 1.2-1.5, so i think 1,g/kg is too much for routine cases.

 

[dhb]

. So I push 30mg of propofol and the other 50mcg of fentanyl.

He takes over, we get her a little deeper and we do my first deep "extubation". I stick an oral airway

As Idiopathic said you should choose just one drug to achieve your goal. I've been burned too by giving small doses of different drug which in the end results in an overdose (relatively speaking).

An LMA is just a fancy oral airway and i treat it as such. IMHO there is zero reason to deepen an anesthetic to pull an LMA and even worse to exchange it for an oral airway. Makes no sense to me. Not bashing you btw, learn with every case 👍

 

[WholeLottaGame7]

thanks for the feed back guys. I was hoping to hear stories from the other newly minted CA-1s.

I've got a week of orientation next week, then we hit the OR (doubling up CA-1s, very similar to Ronin's setup, it sounds like). I'll let you know a week from Monday 🙂

 

[Arch Guillotti]

An LMA is just a fancy oral airway and i treat it as such. IMHO there is zero reason to deepen an anesthetic to pull an LMA and even worse to exchange it for an oral airway. Makes no sense to me. Not bashing you btw, learn with every case 👍

huh, I like pulling them out deep and then putting in an oral airway.

 

[proman]

There's no real reason to exchange one supraglottic airway for another. We do it because our PACU nurses don't understand that and will freak about an LMA in place but scoff at not having an oral airway placed. We're treating the nurses not the patient.

 

[Arch Guillotti]

I have never had a problem with it and yes the PACU nurses would have a cow if a pt. with an LMA rolled in.

 

[fakin' the funk]

ive started using the low end for roc. i think you can get away with 0.3mg/kg and i typically use no more than 0.5. it sticks around a lot longer than vec, and since we have stopped using vec here, weve had many people need PACU ventilators for overdosing. (they were dosing it cc for cc with vec)

remember, your RSI dose is typically 1.2-1.5, so i think 1,g/kg is too much for routine cases.

I've gotten burned by rocuronium enough times during a single year of residency to shy away from it unless specificially indicated. Remember, the ED95 is 0.3mg/kg. So your "RSI dose" above is 4-5 times an ED95!

I also think the extra 30 seconds you may spend hand-ventilating waiting for a 1x ED95 dose to kick in, versus a 2x ED95 dose, is well worth avoiding any amount of postop ventilation a patient may need due to residual neuromuscular blockade. As others have said, you can always give more. And if you're near the end of a case and are keeping a patient weak on purpose, don't be reluctant to give 5mg of rocuronium as a maintenance dose. There is something funky about that drug and it is HARDER to reverse for a given level of TOF/twitch response.

To the OP -- you will learn this eventually, but there is NO clinically available objective or subjective test that will tell you if a pt's TOF ratio is greater than the 0.9 you need to NOT give reversal. To me, that means that your default clinical practice should be giving reversal. Maybe not the "full dose" 0.07mg/kg neostigmine. Maybe none if you gave 4mg vec to start a 4hr case and no NMBA since and they've had sustained 5s tetany for the last 2 hours.

 

[RussianJoo]

I've gotten burned by rocuronium enough times during a single year of residency to shy away from it unless specificially indicated. Remember, the ED95 is 0.3mg/kg. So your "RSI dose" above is 4-5 times an ED95!

I also think the extra 30 seconds you may spend hand-ventilating waiting for a 1x ED95 dose to kick in, versus a 2x ED95 dose, is well worth avoiding any amount of postop ventilation a patient may need due to residual neuromuscular blockade. As others have said, you can always give more. And if you're near the end of a case and are keeping a patient weak on purpose, don't be reluctant to give 5mg of rocuronium as a maintenance dose. There is something funky about that drug and it is HARDER to reverse for a given level of TOF/twitch response.

To the OP -- you will learn this eventually, but there is NO clinically available objective or subjective test that will tell you if a pt's TOF ratio is greater than the 0.9 you need to NOT give reversal. To me, that means that your default clinical practice should be giving reversal. Maybe not the "full dose" 0.07mg/kg neostigmine. Maybe none if you gave 4mg vec to start a 4hr case and no NMBA since and they've had sustained 5s tetany for the last 2 hours.

I always plan to reverse, I read somewhere, that even with all 4 twitches and no fade you can still have up to 70% of the receptors blocked.

 

[Bertelman]

I always plan to reverse, I read somewhere, that even with all 4 twitches and no fade you can still have up to 70% of the receptors blocked.

This has been discussed elsewhere for certain, but if the patient has had 4 full twitches for >30 min, pulling good Vt, I often don't reverse, unless I suspect there is some reason they may have difficulty ventilating, e.g. post-thoracotomy, big belly case, etc.

Overall, I probably reverse maybe 60-70% of my general cases, but I'm also one that doesn't redose unless absolutely necessary, and I give a lighter dose up front. When I do, I give maybe 1-2 cc neostig.

 

[cfdavid]

Anyone using a lot of succ on hard to ventilate (or likely) patients? fatties, osa's, bearded dudes?

Not quite RSI with cricoid pressure etc., but just preoxygentating for 4-5 minutes at tidal volume, inducing with propofol and succ., and then straight to intubation.

 

[DrBeaker]

Long-time lurker, first-time poster. We start on Tuesday. Ready to get started...

 

[RussianJoo]

Long-time lurker, first-time poster. We start on Tuesday. Ready to get started...

great, welcome!

 

[Idiopathic]

I've gotten burned by rocuronium enough times during a single year of residency to shy away from it unless specificially indicated. Remember, the ED95 is 0.3mg/kg. So your "RSI dose" above is 4-5 times an ED95!

I also think the extra 30 seconds you may spend hand-ventilating waiting for a 1x ED95 dose to kick in, versus a 2x ED95 dose, is well worth avoiding any amount of postop ventilation a patient may need due to residual neuromuscular blockade. As others have said, you can always give more. And if you're near the end of a case and are keeping a patient weak on purpose, don't be reluctant to give 5mg of rocuronium as a maintenance dose. There is something funky about that drug and it is HARDER to reverse for a given level of TOF/twitch response.

To the OP -- you will learn this eventually, but there is NO clinically available objective or subjective test that will tell you if a pt's TOF ratio is greater than the 0.9 you need to NOT give reversal. To me, that means that your default clinical practice should be giving reversal. Maybe not the "full dose" 0.07mg/kg neostigmine. Maybe none if you gave 4mg vec to start a 4hr case and no NMBA since and they've had sustained 5s tetany for the last 2 hours.

probably closer to 2 minutes, but thats why there are different doses for standard induction and rapid sequence induction.

 

[pgg]

Anyone using a lot of succ on hard to ventilate (or likely) patients? fatties, osa's, bearded dudes?

Not quite RSI with cricoid pressure etc., but just preoxygentating for 4-5 minutes at tidal volume, inducing with propofol and succ., and then straight to intubation.

Not sure exactly what you're asking. I'm not a fan of giving the induction agent, seeing if I can ventilate the patient, and then deciding if I want to try the relaxant. Usually I flush the propofol in with the relaxant in order to give myself the best ventilating and intubating conditions as quickly as possible.

So not an RSI with cricoid, but a rapid induction including relaxant.

 

[secretasianman]

Not sure exactly what you're asking. I'm not a fan of giving the induction agent, seeing if I can ventilate the patient, and then deciding if I want to try the relaxant. Usually I flush the propofol in with the relaxant in order to give myself the best ventilating and intubating conditions as quickly as possible.

So not an RSI with cricoid, but a rapid induction including relaxant.

if you have an unanticipated difficult to ventilate patient, you've dl'ed x1 and unable to intubate, and LMA does not improve ventilation, what would your next step be?

 

[Arch Guillotti]

if you have an unanticipated difficult to ventilate patient, you've dl'ed x1 and unable to intubate, and LMA does not improve ventilation, what would your next step be?

he chooses wisely

 

[secretasianman]

he chooses wisely

yeah that's why i said unanticipated 🙂. I've heard of 2 different opinions to this topic before so just wanted to hear you guys think.

 

[pgg]

if you have an unanticipated difficult to ventilate patient, you've dl'ed x1 and unable to intubate, and LMA does not improve ventilation, what would your next step be?

Yell for help, glidescope, semi-blind bougie feeling for the bumpbumpbump of tracheal rings, cut the neck.

Thankfully unanticipated difficult intubations are very rare (the tossed-around figure I remember is something like 1:2500), and of those unanticipated can't ventilate patients are even rarer.



I'm not saying I do this with ALL comers. Pent/sux/tube isn't the answer to everything. 🙂

But in general, if I'm comfortable enough to induce a patient, I'm going to paralyze him immediately too. If I unexpectedly find myself in a can't intubate / can't ventilate situation, I don't have much hope that the induction agent is going to wear off fast enough for the patient to save himself - especially in fat people who desat like anchors tossed out of airplanes.

I don't see any practical advantage to testing ventilation between induction agent and muscle relaxant, especially since the relaxant is likely to greatly improve ventilating conditions, but isn't guaranteed to not ruin them either.

In those cases, as long as you've induced the patient and committed yourself to establishing some kind of ventilation no matter what, I think it's best to have optimal conditions quickly.

I just try to choose wisely when it comes to who simply gets induced, and who gets another plan.

 

[michigangirl]

My first day as a CA-1 I:

1. Sprayed myself with vecuronium in the eye when diluting it and pulling it into the syringe. Then freaked out cause I thought I might absorb enough ocularly to have a systemic effect. Hilarious now. Not hilarious then.

2. Cut myself on the glass fentanyl vial. Then proceeded on with my day, bandaid on. Known HIV positive guy in outpatient center for melanoma resection. His IV started backing up and the stopcock wasn't turned all the way closed, so it was spilling on the floor. I got all skittish about the mess I was making and went to grab the IV- forgot to put gloves on. bloody fluid in cut. Combivir X 1 month. Worst months of my life waiting for a negative test.

So my first day of CA-1 year blew a#s. But I learned extremely important lessons. Always wear gloves. No mess is worth getting a communicable disease. Take your time drawing up meds. The actual anesthetics were fine. It was the stupid crap that made it horrible.

 

[proman]

if you have an unanticipated difficult to ventilate patient, you've dl'ed x1 and unable to intubate, and LMA does not improve ventilation, what would your next step be?

Yell for help, glidescope, semi-blind bougie feeling for the bumpbumpbump of tracheal rings, cut the neck.

I think a fiberoptic attempt would be warranted before surgical airway. If needed, I'd rather do a needle cric to oxygenate before resorting to a surgical airway.

Unanticipated difficult intubation is much more common than unanticipated difficult mask ventilation. Kheterpal 2009 paper in Anesthesiology, Prediction and Outcomes of Impossible Mask Ventilation, a review of 50,000 anesthetics.
4 years, 53,041 attempts at mask. 77 (0.15%) were difficult, neck radiation, male, sleep apnea, MP 3 or 4, beard were independent predictors. A quarter of those were also difficult intubations. 15/17 were successfully intubated, 12 alternate intubation technique, 2 surgical airways, 2 patients awakened -> fiberoptic.

 

[pgg]

I think a fiberoptic attempt would be warranted before surgical airway. If needed, I'd rather do a needle cric to oxygenate before resorting to a surgical airway.

I thought about putting fiberoptic in that list, but where I work getting one in the room is a multi-minute endeavor, assuming help is available. I think it's unlikely that in an unanticipated difficult airway I'd be able to get my hands on one quickly.

Needle cric and jet ventilation is a good thought.

 

[Idiopathic]

how quickly can you get a fiberoptic scope in the room loaded with a tube and ready to go? i could probably have it ready in 2 minutes at the best, and thats after 1 minute minimum of DL/bag/LMA. Not a good emergency device, IMO. if you cant ventilate with an LMA in place i think its highly unlikely that you will have a quick and easy FO view, anyway.

also, big difference between difficult and impossible

 

[Idiopathic]

My first day as a CA-1 I:

1. Sprayed myself with vecuronium in the eye when diluting it and pulling it into the syringe. Then freaked out cause I thought I might absorb enough ocularly to have a systemic effect. Hilarious now. Not hilarious then.

2. Cut myself on the glass fentanyl vial. Then proceeded on with my day, bandaid on. Known HIV positive guy in outpatient center for melanoma resection. His IV started backing up and the stopcock wasn't turned all the way closed, so it was spilling on the floor. I got all skittish about the mess I was making and went to grab the IV- forgot to put gloves on. bloody fluid in cut. Combivir X 1 month. Worst months of my life waiting for a negative test.

So my first day of CA-1 year blew a#s. But I learned extremely important lessons. Always wear gloves. No mess is worth getting a communicable disease. Take your time drawing up meds. The actual anesthetics were fine. It was the stupid crap that made it horrible.

i demand that all my residents/students wear gloves in the OR and I chastise nurses who dont do it.

 

[secretasianman]

how quickly can you get a fiberoptic scope in the room loaded with a tube and ready to go? i could probably have it ready in 2 minutes at the best, and thats after 1 minute minimum of DL/bag/LMA. Not a good emergency device, IMO. if you cant ventilate with an LMA in place i think its highly unlikely that you will have a quick and easy FO view, anyway.

also, big difference between difficult and impossible

Yeah same here in my institution it woudl probably take 2min at best to get FO including loading and setting up. Would probably be much faster to get a glidescope set up and ready to go.

Faced with rapidly declining sats in a difficult to intubate/ventilate scenario like this I would probably think about busting out the crich kit (and dread having to do so), maybe page ent to the room stat. I'm not familiar with how to hook up a 16g angiocath to a high pressure oxygen delivery system so i wouldn't be able to go that route...

thanks for the article proman, should be an interesting read.

 

[secretasianman]

My first day as a CA-1 I:

1. Sprayed myself with vecuronium in the eye when diluting it and pulling it into the syringe. Then freaked out cause I thought I might absorb enough ocularly to have a systemic effect. Hilarious now. Not hilarious then.

2. Cut myself on the glass fentanyl vial. Then proceeded on with my day, bandaid on. Known HIV positive guy in outpatient center for melanoma resection. His IV started backing up and the stopcock wasn't turned all the way closed, so it was spilling on the floor. I got all skittish about the mess I was making and went to grab the IV- forgot to put gloves on. bloody fluid in cut. Combivir X 1 month. Worst months of my life waiting for a negative test.

So my first day of CA-1 year blew a#s. But I learned extremely important lessons. Always wear gloves. No mess is worth getting a communicable disease. Take your time drawing up meds. The actual anesthetics were fine. It was the stupid crap that made it horrible.

those vials are serious safety hazards... i've sliced my thumb with the fentanyl vials and the even smaller ones in the spinal kits. needless to say it didnt look very slick when doing a spinal with a 4x4 wrapped thumb the size of a lollipop.

 

[pgg]

I'll add that the last time I tried to get a fiberoptic scope into an OR in a hurry to help someone out, the cart was actually locked. I ended up using one of those ortho cast-spreader pry tools to break into the difficult airway cart. Not cool.

 

[Hamhock]

I would probably think about busting out the crich kit (and dread having to do so), maybe page ent to the room stat. I'm not familiar with how to hook up a 16g angiocath to a high pressure oxygen delivery system so i wouldn't be able to go that route....

Although I think the best part of this thread and the OP's intent was for descriptions of day 1 of CA-1, I must add:

I find it concerning that a (presumable) anesthesia resident is "not familiar" with "hook[ing] up a 16g angiocath to a high pressure oxygen delivery system".

What amount of training is typical for anesthesia residents in cric and "jet ventilation" (which, for adults is questionable)?

Is this a required skill? Practiced on models/sim/cadavers? Is this regulated by the anesthesiology governing bodies?

HH

 

[RxBoy]

I find it concerning that a (presumable) anesthesia resident is "not familiar" with "hook[ing] up a 16g angiocath to a high pressure oxygen delivery system".]

Only know one attending that has ever did an emergency cric (used the scalpel in the central line kit). Saved the patients life. I know some that attempted Jet Vent and usually by the time that it gets to that point, never good outcomes.

One was because the CRNA didn't call the attending until very late in the game. Pt LMA was accidently extubated middle of the case, she didn't pick it up but she thought the pulse ox was faulty because she couldn't get a read. So she kept trying to fiddle with the pulse ox for 5 minutes until the patient turned blue. By the time the she called the attending in, patient was practically dead. CI/CV fast enough due to upper airway edema. Pt coded. Last ditch resort jet vent and that didn't help.


As for the whole angio cath to Jet vent. Some resident taught me 16 gauge>screw on 3 cc syringe with plunger taken out->7 or 7.5 tube connector tip to syringe->connector to anesthesia circuit then oxygen flush pushed if jet vent isn't readily available yet. Practiced putting it together, never had to use it.

 

[RussianJoo]

we just had a morning lecture on emergency airways.. We found that the flush valve on all our machines didn't deliver enough pressure to oxygenate the pt. However, when the auxiliary oxygen supply was cranked to the max (above 15l/min) it delivered sufficient pressure. We only had one actual jet ventilation apparatus in the hospital and even that most of the attendings had no clue how to use. To Macgyver an angiocath jet ventilation we use a 14gauge attached to a 3cc syringe with a end piece from a 6.5 ET tube. They showed us a video on how to use a percutanouse cric kit but i doubt we'll have any sort of simulator training with it. Seems like it would be a huge mess if we couldn't get an airway and had to do an emergency airway. I am sure my program isn't the only program that doesn't teach this or emphasize it's importance.

 

[Bertelman]

we just had a morning lecture on emergency airways.. We found that the flush valve on all our machines didn't deliver enough pressure to oxygenate the pt. However, when the auxiliary oxygen supply was cranked to the max (above 15l/min) it delivered sufficient pressure. We only had one actual jet ventilation apparatus in the hospital and even that most of the attendings had no clue how to use. To Macgyver an angiocath jet ventilation we use a 14gauge attached to a 3cc syringe with a end piece from a 6.5 ET tube. They showed us a video on how to use a percutanouse cric kit but i doubt we'll have any sort of simulator training with it. Seems like it would be a huge mess if we couldn't get an airway and had to do an emergency airway. I am sure my program isn't the only program that doesn't teach this or emphasize it's importance.

You've got to hook up to the wall supply (50 psi) to deliver jet vent effectively, or at least split off the supply on the back of the ventilator. Everything on the front of the gas machine is a low-pressure system, and won't give enough pressure. Each of our ORs had a bag on the back of the machine with a coiled green O2 hose with a DISS, a handle regulator to regulate the flow, and a 14g angiocath.

 

[proman]

Each of our ORs had a bag on the back of the machine with a coiled green O2 hose with a DISS, a handle regulator to regulate the flow, and a 14g angiocath.

I think this is very important. It's hard enough doing the connections right when all the equipment is there, you shouldn't have to think if you have the right connector etc. Every anesthetic machine should have the ability to do jet ventilation.

 

[pgg]

To Macgyver an angiocath jet ventilation we use a 14gauge attached to a 3cc syringe with a end piece from a 6.5 ET tube.

This won't work. Like Bertelman said, you need the high pressure source. Jet ventilation relies on entrainment of room air via the Venturi effect and for that high pressure high flow is needed. You might squeeze a few cc of O2 in with that setup, but that gas wont go into the lungs (the low resistance path is back out the mouth/nose).

I was taught the same 3cc syringe ETT connector trick in residency ... this pearl needs to die.

 

[RussianJoo]

You've got to hook up to the wall supply (50 psi) to deliver jet vent effectively, or at least split off the supply on the back of the ventilator. Everything on the front of the gas machine is a low-pressure system, and won't give enough pressure. Each of our ORs had a bag on the back of the machine with a coiled green O2 hose with a DISS, a handle regulator to regulate the flow, and a 14g angiocath.

I'll have to look closely at the hose on the back and loot at some of the DISS connections but we definitely don't have anything close to what you're describing on the back of our machines.. Might be a nice little project to make up a bunch of emergency airways and figure out how to connect them to the high pressure circui.

 

[Arch Guillotti]

I for one am surprised that jet ventilators aren't readily available

 

[RussianJoo]

yeah as a med student i just thought they were pre-installed on the backs of the anesthesia machines automatically. But the only one I've seen at my hospital is the one that they showed us during the morning report.