Hey Noyac!!!!!

[jetproppilot]

How'd the spine case go today?

How'd you do it, specifically?

How'd the surgery go? How'd the patient do?

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[Noyac]

Dude it was awesome!!!!

The surgeon was really worried about the pt, the pt was scared sh*tless, and his wife the same.

The Details:
In the room with PIV and no sedation (I sedated him with my conversation). Induced with 140mg propofol, 50mg Roc and 20mcg sufenta. Placed the a-line , 2nd PIV and rolled prone. Started the precedex at 0.2 mcg/kg/hr (82 kg pt) and sufenta drips. Sevo stayed from 0.9-1.2 the whole case. Needed a neo drip for BP. His preop BP was 152/88 and with precedex/sufenta his Bp wanted to stay around 90/40. My spine surgeon takes off a unit of blood pre-op and we start way behind. Needed less and less neo as case went on. Lost 1000ml blood, gave 6L crystal, and 965 cell saver. Turned off the gas and rolled him supine. He opens his eyes and follows commands perfectly moving all ext's. Extubate and he says, no ****, "is it over MIke?" I said yep and your did great. To PCU pain free. Turned off the precedex and his wife and he are amazed. The surgeon said nothing of course, but he's a friend and he expected it this turnout anyway.

Great satisfying case.

 

[davvid2700]

what was the deal with the patient?

 

[zippy2u]

Sounds like a run-o'-tha-mill spine case to me as I thought it would be. Don't let all that psyche shiit that these pts throw at ya get ya all razzed up. Prop, vec, opiod and tube and go on down the road... Regards, ---Zip

 

[jetproppilot]

Dude it was awesome!!!!

The surgeon was really worried about the pt, the pt was scared sh*tless, and his wife the same.

The Details:
In the room with PIV and no sedation (I sedated him with my conversation). Induced with 140mg propofol, 50mg Roc and 20mcg sufenta. Placed the a-line , 2nd PIV and rolled prone. Started the precedex at 0.2 mcg/kg/hr (82 kg pt) and sufenta drips. Sevo stayed from 0.9-1.2 the whole case. Needed a neo drip for BP. His preop BP was 152/88 and with precedex/sufenta his Bp wanted to stay around 90/40. My spine surgeon takes off a unit of blood pre-op and we start way behind. Needed less and less neo as case went on. Lost 1000ml blood, gave 6L crystal, and 965 cell saver. Turned off the gas and rolled him supine. He opens his eyes and follows commands perfectly moving all ext's. Extubate and he says, no ****, "is it over MIke?" I said yep and your did great. To PCU pain free. Turned off the precedex and his wife and he are amazed. The surgeon said nothing of course, but he's a friend and he expected it this turnout anyway.

Great satisfying case.

And for that Dude, next year you're a free agent looking for the 20 mil signing bonus.

Very, very nice job.

 

[davvid2700]

Sounds like a run-o'-tha-mill spine case to me as I thought it would be. Don't let all that psyche shiit that these pts throw at ya get ya all razzed up. Prop, vec, opiod and tube and go on down the road... Regards, ---Zip

heh heh, sounds like a board answer..

Me:
Sir, I dont let any confusion get in the way of my anesthetic. I just ( say what zippy said ), and hope for the best, Sir.


Examiner: Thanks for coming (insert my name) shaking my hands


whispers to the other examiner.. we'll see this poor bastard in boston next year... I wonder if he has to fly a long way.

moral of the story: You are concerned about everything a patient tells you. If the patient tells you that his dog had a near death experience with anesthesia, You ask if you can see the records to double check.

 

[zippy2u]

It's all good David, I jumped through the BC hoop many moons ago. Regards, ---Zippy

 

[Noyac]

Ok let me clarify some things.

1. I wasn't "all that razzed up" I just thought it was interesting and that it hadn't been discussed here since I have been on this forum. POCD that is. Basically I was trying to put something on the forum that was different from the interview threads and the other stuff that appears more frequently.

2. This was a pt that was very intelligent. Not one of those *******es that has problems with everything and allergies to every medicine under the sun. He was real. I spoke with the anesthesiologist that took care of him the last time and he confirmed the POCD and he said it scared the **** out of everyone involved. Well this got my attention as it would anybody.

3. When I spoke to the pt the day before surgery he was in tears from fear of going to sleep again. Generally, I would have said, there's nothing to worry about and that it was a rare occurrence that would be very unlikely to recur.

4. So I agree with Ol' Zip that there isn't much to really worry about but- it makes for an interesting conversation.

5. Oh, I forgot to mention something in the case. I used the BIS. I kept it at 50-60 the whole case. What do you guys think about that? Is it a good use of the BIS or is it just another monitor to tell me what I already knew?

 

[militarymd]

My 2 cents on the BIS....extra data that at this point in time appears relatively meaningless if you look at 30 day outcomes....Something that the lay public and lawyers are going ape s hit over. I used it a few times, and have decided that I'm not going to use it.....Sort of like CVP...I used it, learned its function, find it not useful...I don't use CVPs anymore.

As for POCD, a real phenomenon. I'm glad Noyac brought it up.

I had a patient from a few months back who had pretty bad Alzheimer's. I was consenting him for surgery through his son. His son expressed concern about GA and worsening mental state.

I agreed with him about the risks and we had a small discussion about POCD. The son actually told me that his whole family had problems after GA, and that he thought that his father's Alzheimer's started after a GA 10 years ago.

Anyways, at the end of the preop, the son told me he was an internist, and appreciated someone who accepts that we don't know everything and is willing to discuss topics like POCD with patients.

I thought the guy was kind of sly....but he was testing me to make sure I wasn't trying to pull anything over him by not discussing POCD, or trying to tell him that regional would be better.

This internist actually said that based on his reading, that he knew regional wasn't better, and just wanted to make sure that I agreed with him.

 

[zippy2u]

The BIS rep where I'm at is one helluva hottie. If I were single, I'd be using it regularly and attending the rep dinners frequently, preferably just the two of us. Since I'm married, I did the right thing and politely told the rep that if she brought that contraption to our facility, I would throw it out the window. I haven't heard hide nor hair from the BIS hottie. My wife would be proud of me. Regards, ----Zip

 

[Noyac]

The BIS rep where I'm at is one helluva hottie. If I were single, I'd be using it regularly and attending the rep dinners frequently, preferably just the two of us. Since I'm married, I did the right thing and politely told the rep that if she brought that contraption to our facility, I would throw it out the window. I haven't heard hide nor hair from the BIS hottie. My wife would be proud of me. Regards, ----Zip

Send her my way! I won't guarantee that I will use the thing.

 

[lvspro]

Ok let me clarify some things.

1. I wasn't "all that razzed up" I just thought it was interesting and that it hadn't been discussed here since I have been on this forum. POCD that is. POCD that is. Basically I was trying to put something on the forum that was different from the interview threads and the other stuff that appears more frequently.

2. This was a pt that was very intelligent. Not one of those *******es that has problems with everything and allergies to every medicine under the sun. He was real. I spoke with the anesthesiologist that took care of him the last time and he confirmed the POCD and he said it scared the **** out of everyone involved. Well this got my attention as it would anybody.

3. When I spoke to the pt the day before surgery he was in tears from fear of going to sleep again. Generally, I would have said, there's nothing to worry about and that it was a rare occurrence that would be very unlikely to recur.

4. So I agree with Ol' Zip that there isn't much to really worry about but- it makes for an interesting conversation.

5. Oh, I forgot to mention something in the case. I used the BIS. I kept it at 50-60 the whole case. What do you guys think about that? Is it a good use of the BIS or is it just another monitor to tell me what I already knew?

Much appreciated noy. I always look forward to all you seniors discussing interesting cases... it's just a matter of time b4 i run in to the same situation, so casual talk b/w pro's is nice for us onlookers.

 

[davvid2700]

My 2 cents on the BIS....extra data that at this point in time appears relatively meaningless if you look at 30 day outcomes....Something that the lay public and lawyers are going ape s hit over. I used it a few times, and have decided that I'm not going to use it.....Sort of like CVP...I used it, learned its function, find it not useful...I don't use CVPs anymore.

As for POCD, a real phenomenon. I'm glad Noyac brought it up.

I had a patient from a few months back who had pretty bad Alzheimer's. I was consenting him for surgery through his son. His son expressed concern about GA and worsening mental state.

I agreed with him about the risks and we had a small discussion about POCD. The son actually told me that his whole family had problems after GA, and that he thought that his father's Alzheimer's started after a GA 10 years ago.

Anyways, at the end of the preop, the son told me he was an internist, and appreciated someone who accepts that we don't know everything and is willing to discuss topics like POCD with patients.

I thought the guy was kind of sly....but he was testing me to make sure I wasn't trying to pull anything over him by not discussing POCD, or trying to tell him that regional would be better.

This internist actually said that based on his reading, that he knew regional wasn't better, and just wanted to make sure that I agreed with him.

how do you get achance to see the bis you are never in the room to see it work. get off your ass get in the room and see the bis in action and then get back to us about your thoughts. I have not used the bis in a while but when i was in training i thought it was great.

 

[militarymd]

how do you get achance to see the bis you are never in the room to see it work. get off your ass get in the room and see the bis in action and then get back to us about your thoughts. I have not used the bis in a while but when i was in training i thought it was great.

I guess your idea of working with CRNAs and my idea are 2 different ones.

I trained residents for 5 years before this job. I taught residents about the BIS. I attended in the ICU 1 week in 4...I brought the BIS to the ICU and used it in the ICU...and taught the ICU nurses how to use it.

I think it is a piece of crap.

 

[davvid2700]

I think it is a piece of crap.

I think you are one of those old timers that likes things to be just like they were in the good old days.. When there was no affirmative action, no bis monitor, etc.. I knew a guy like you he was my attending at the VA. You cant be dogmatic.. you are too black white on things..


plus.. the bis is not a peice of crap.. it may be a monitor that you choose not to use.. and truthfully... we dont need the bis monitor. but it is a monitor just like any and gives us information.. I bet you cried for weeks( probably still are) when they implemented IV catheter that guard against needlesticks, touting. " i cant start an IV now. Where are my old catheters?" and you went to administration to have them send back the 10,000 Iv catheters that they bought because you cant adapt the new technology..

dude, when are you retiring?

 

[jetproppilot]

I think you are one of those old timers that likes things to be just like they were in the good old days.. When there was no affirmative action, no bis monitor, etc.. I knew a guy like you he was my attending at the VA. You cant be dogmatic.. you are too black white on things..


plus.. the bis is not a peice of crap.. it may be a monitor that you choose not to use.. and truthfully... we dont need the bis monitor. but it is a monitor just like any and gives us information.. I bet you cried for weeks( probably still are) when they implemented IV catheter that guard against needlesticks, touting. " i cant start an IV now. Where are my old catheters?" and you went to administration to have them send back the 10,000 Iv catheters that they bought because you cant adapt the new technology..

dude, when are you retiring?

David, what level are you?

Just curious.

 

[davvid2700]

Ive been in practice 18 months

 

[Noyac]

I bet you cried for weeks( probably still are) when they implemented IV catheter that guard against needlesticks, touting. " i cant start an IV now. Where are my old catheters?" and you went to administration to have them send back the 10,000 Iv catheters that they bought because you cant adapt the new technology..


I think you have me and Military mixed up. I was the one crying. But I have adapted.

 

[Noyac]

Also David. I am on the same side of the fence as Mil on the BIS. Except that I use it from time to time because it is there. Why? I don't know yet. But It hasn't given me any useful info yet.

 

[VentdependenT]

Our department is against the BIS for the same reasons I've heard from MIL. Aside from some case reports the slippery BIS rep dropped on us its not useful. In fact our dept got into it with the BIS guy and it got ugly real fast.

I think there is one floating around the surgicenter but I haven't been there yet.

We are taught to ask "whats the last thing you remember before going to sleep, whats the first thing you remember about waking up, and do you recall anything from the surgery."