Imagine you were in my situation - #Case_01 / ERT 5 minutes

[DrAmir0078]

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Estimated Reading Time : 5 minutes

Hello Fellows,
I introduced myself earlier and this is my first post and I will title it always "Imagine you were in my situation", didn't want to use the informal way "if you were in my shoes"; beside what will make the title of the post changed, is only the case number with its hashtag (For future posts), and finally ERT means Estimated Reading Time for the post !

So today I am recalling a "Scary", did I said something wrong, yes scary case in my practice, as I witnessed it as a Senior House Officer last early August.
Ooops scroll down to my signature to read it first, never mind, I can copy and paste it:
(Being from Iraq, we struggle to learn) Be advised, my opinions are mine, reflecting our experience in Anesthesia. So please, follow your protocols and I am following my goal "Let's learn together !

Let's dive, let's learn together !
Before start - When I said "Imagine", that means, you are going to act according what things available handy in my current hospital : no ABG in the OR or near lab, no all the medicine available, tools are limited sometimes (Pre - Anesthesia history and examination are only done in the OR).

But, why I am talking about this case, because I am testing for the future about how this forum, and about my message in my first post, yet I am Iraqi and became American beside my years in the US about 8 of them, , , , etc

Let's go (if you have time)

48 years old female, presented for elective umbilical hernia repair, her weight is 95 kg, huge distended abdomen; unknown past medical or surgical history, except for having Allergic bronchitis as the patient said prior to the induction. Patient denies smoking!
My Senior Anesthsiologist agreed to proceed, and he managed her respiratory status by the following pre-medications:
Hydrocostison (HC) 100 mg/IV push
Dexamethasone (Decadron) 8 mg/IV push
Aminophylline 250 mg/IV infusion

Induction started, by Ketamine / kg (he used single agent anesthesia technique!), Atracurium (I believe), and intubation with 7" cuffed tube. I was there at the scene now, and got the info, and started to do my tube which was difficult, then the Senior arrived and he puts the tube!
Machine setting : he sets 600 Tidal Volume, I/E 1:2, Rate 11/min

Right after the intubation, chest was fully wheezy, coarse crepitation, the SPO2 starts to fall between 90-94% and never hits 95%!
We tried to increase the rate to 14/min and opened peep at 4 (just for a minute)--- SPO2 reached 98%!

Operation completed, and extuabtion done successfully (fully awake), but once we put the mask and the patient starts to breath with head-up, the SPO2 fell to 55%, all techniques done, jaw thrust, jet ventilation, no improvement just 10% and reached 65% SPO2 with full wheezy chest, beside when the patient regains his consciousness ,she became agitated!
Senior on scene again, he gave her additional :
1- 200 mg Hydrocortisone IV push
2- 1 Decadron 8mg IV push

He repeats the regimen 15 minutes later with additional Aminophylline !

No benefit, the patient still agitated, peripheral cyanosis was obvious, we put the patient in 45 degree, physical therapy (patting on the back of the chest)

No benefit, Senior repeats the Hydrocortisones 200 mg / IV push

Patient is still agitated, and finally said she is smoker, and with continuous mask ventilation, and her refusal, we managed to get her SPO2 to 78% after an hour and a half post repeated regimens !

ECG, lead II only, shows Tachycardia !

Drama, isn't it?

Senior agreed to moved the patient to the ICU, no PACU at facility !

Hypoxia freaked us out !

At the ICU, patient passed bowel on bed, bed was 45 degree up!

The Medicine team was consulted, and nebulizer was given there, repeated Aminophylline and steriods too ! no Mg sulfate !

At the end of my day (3 hours later), I've visited her, she was better, but the SPO2 was 88% !
At night, I've visited her again, she was walking fine in the ICU !


With such dropped SPO2, what do you expect of in term of consequences? (That was my question at that time!)

But, if it wasn't elective, how about if it was emergency, with such limited facilities !

Thanks a lot for reading me ....

I will answer any reply, because I might forget something and verify things !

Best,

@DrAmir0078

 

[Planktonmd]

First thank you for sharing.
It seems to me that your patient had bronchospasm that started intraoperatively and continued pst-op. Aspiration might have been an unrecognized factor.
The anesthetic technique is a bit vague since you said that it was a "single agent anesthetic" with Ketamine, does that mean no opiates?
Also the use of Atracurium might have contributed to the bronchospasm (it causes histamine release).
And your treatment of the bronchospasm is s little unusual (Dexamethasone + Hydrocortisone + Aminophylline): you don't need to give hydrocortisone if you are using a potent steroid like Dexamethasone and since it sounds like you did not have access to inhaled bronchodilatorts (Albuterol or Salbutamol or Terbutaline) It would have been more useful to use Epinephrine.
Also moving an unstable patient with saturation in the 70% to the ICU is a bit brave and most people at that point would have reintubated the patient.
I agree with you this sounded very scary 🙂

 

[DrAmir0078]

First thank you for sharing.
It seems to me that your patient had bronchospasm that started intraoperatively and continued pst-op. Aspiration might have been an unrecognized factor.
The anesthetic technique is a bit vague since you said that it was a "single agent anesthetic" with Ketamine, does that mean no opiates?
Also the use of Atracurium might have contributed to the bronchospasm (it causes histamine release).
And your treatment of the bronchospasm is s little unusual (Dexamethasone + Hydrocortisone + Aminophylline): you don't need to give hydrocortisone if you are using a potent steroid like Dexamethasone and since it sounds like you did not have access to inhaled bronchodilatorts (Albuterol or Salbutamol or Terbutaline) It would have been more useful to use Epinephrine.
Also moving an unstable patient with saturation in the 70% to the ICU is a bit brave and most people at that point would have reintubated the patient.
I agree with you this sounded very scary 🙂

Thanks for reading me !
Definitely, she had bronchospasm !
Aspiration is questionable as you said !
My Senior and because in this hospital setting, and although it is teaching hospital, but not for Anesthesia, my Senior is an Anesthesia General Practitioner for over 10 years, and he learned this technique from his superiors during his SHO as he said to minimize the effects of other agents, and I agree too with you as vague!
No opiates, yes and although we have Fentanyl, but he didn't advise for it !
True, Atracurium has a histamine release issue, and could be a contributing factor, if we've used Recuroninum, could've be better ! (but I believe we were short)
True Dexamethasone is much potent, but regarding the thought of onset of action (lots of error here regarding the preference and potency)
I have epinephrine (I know, our formula to dilute the one ml of 1 mg into 10 ml and use 1ml diluted as it have 100 then diluted in another 20 ml and give one cc slowly IV) - please correct me, or if you have better formula ! Thanks ahead Doctor !
Yes, it was a brave decision of him, but in an Academic setting in Board Teaching hospital, It won't happen, but as long as I am here will update you with my cases, if you like to read our approach from where I live!
Honestly, different Senior Attendings have different taste, aren't true?
That's why, I had created my group with my residents and supervising Professors for my next 4 years residency started in October and also to share here the top trended articles, but not like this one !
Thanks a lot for your insight !

 

[anbuitachi]

Thanks for reading me !
Definitely, she had bronchospasm !
Aspiration is questionable as you said !
My Senior and because in this hospital setting, and although it is teaching hospital, but not for Anesthesia, my Senior is an Anesthesia General Practitioner for over 10 years, and he learned this technique from his superiors during his SHO as he said to minimize the effects of other agents, and I agree too with you as vague!
No opiates, yes and although we have Fentanyl, but he didn't advise for it !
True, Atracurium has a histamine release issue, and could be a contributing factor, if we've used Recuroninum, could've be better ! (but I believe we were short)
True Dexamethasone is much potent, but regarding the thought of onset of action (lots of error here regarding the preference and potency)
I have epinephrine (I know, our formula to dilute the one ml of 1 mg into 10 ml and use 1ml diluted as it have 100 then diluted in another 20 ml and give one cc slowly IV) - please correct me, or if you have better formula ! Thanks ahead Doctor !
Yes, it was a brave decision of him, but in an Academic setting in Board Teaching hospital, It won't happen, but as long as I am here will update you with my cases, if you like to read our approach from where I live!
Honestly, different Senior Attendings have different taste, aren't true?
That's why, I had created my group with my residents and supervising Professors for my next 4 years residency started in October and also to share here the top trended articles, but not like this one !
Thanks a lot for your insight !

If I could do one thing extra thing it'd be epinephrine .

 

[kmurp]

Sometimes I will take albuterol 2.5mg liquid and just dump the whole amount into the ET tube to treat bronchospasm.

 

[ProRealDoc]

Thanks for sharing

 

[deleted162650]

8% Sevo breaks bronchospasm pretty good.




I think the main problem here was not enough steroid.

 

[sbhfl]

The patient's severe bronchospasm happened after extubation? Sounds like aspiration or possibly negative pressure pulmonary edema. The treatment for both with sats in the 70s is intubation. Did the patient sit there with a sat in 70s for more than a couple minutes without tubing? Was the fear that tubing would worsen bronchospasm? I guess that's possible but if you hear wheezing you're hearing some gas movement-- and if they're satting in the 70s struggling to breath now and nothing you're doing is working imagine what they'll be like in 10 more minutes.

1. Reintubate. This patient should have been re-intubated immediately.
2. Albuterol. You need Beta2 agonism. Perhaps this wasn't available.
3. Epi, epi, epi. Was this not available for some reason? Even if the most austere locations stocking this needs to be a priority. Epi.
4. 1 dose of steroids was enough. Repeating the doses so often doesn't help and probably leads to worse wound healing, hyperglycemia, altered mental status. Adrenal suppression is obviously described for chronic steroids, so maybe that's not an issue. But that was a lot of steroids.

 

[DrAmir0078]

If I could do one thing extra thing it'd be epinephrine .

Thanks for reading,
So what is your dosage you rely on for epinephrine, sounds weird question, but honestly, everyone says different formula, I am gonna stick with eary formula 50mcg IV bolus !

 

[DrAmir0078]

Sometimes I will take albuterol 2.5mg liquid and just dump the whole amount into the ET tube to treat bronchospasm.

Thanks for reading me,
Are you a fan of NAVEL ? Opps, let's add Albuterol, so it will be NAAVEL !
Interesting ! !
Love to try, honestly !

 

[DrAmir0078]

Thanks for sharing

Thanks for reading 🙂

 

[DrAmir0078]

8% Sevo breaks bronchospasm pretty good.




I think the main problem here was not enough steroid.

Dr. SaltyDog
Thanks for reading me.
Interesting honestly, Sev can makes miracles; in my residency I will bring up this to my Professors and as you made me read an interesting article about that (Source: Respiratory Care Journal) - can't post a link {Forum policy - being newbie}

The other thing about not enough steriod, I believe you were sarcastic, weren't you?

 

[DrAmir0078]

The patient's severe bronchospasm happened after extubation? Sounds like aspiration or possibly negative pressure pulmonary edema. The treatment for both with sats in the 70s is intubation. Did the patient sit there with a sat in 70s for more than a couple minutes without tubing? Was the fear that tubing would worsen bronchospasm? I guess that's possible but if you hear wheezing you're hearing some gas movement-- and if they're satting in the 70s struggling to breath now and nothing you're doing is working imagine what they'll be like in 10 more minutes.

1. Reintubate. This patient should have been re-intubated immediately.
2. Albuterol. You need Beta2 agonism. Perhaps this wasn't available.
3. Epi, epi, epi. Was this not available for some reason? Even if the most austere locations stocking this needs to be a priority. Epi.
4. 1 dose of steroids was enough. Repeating the doses so often doesn't help and probably leads to worse wound healing, hyperglycemia, altered mental status. Adrenal suppression is obviously described for chronic steroids, so maybe that's not an issue. But that was a lot of steroids.

Thank You Dr. Sbhfl,
You are talking pearls, jewels.
Let's answer each question:

The patient's severe bronchospasm happened after extubation?
I was hearing coarse crackles the entire operation time, worsen to audible Wheeze right after extubation!

Sounds like aspiration or possibly negative pressure pulmonary edema. The treatment for both with sats in the 70s is intubation. Did the patient sit there with a sat in 70s for more than a couple minutes without tubing?
I thought rapidly of this scary Negative Pressure Pulmonary Edema as the Peak Inspiratory Pressure Pip was hitting 30s cmH2O, shouting there is obstruction!
Yes, the patient once we extubated her, sat for almost two hours with air hunger (struggling to breath), puffy dusky Face (Like Status Asthmaticus) for almost 2 hours with SPO2 (60s in the first hour, 70s in the second hour), with Peripheral Cyanosis !
I was honestly fearing of Brain Insult, but I believe the patient is COPD, and since I don't have ABG, and again just SHO whose words in such freaky situation will be unhearible by superiors !

I guess that's possible but if you hear wheezing you're hearing some gas movement-- and if they're satting in the 70s struggling to breath now and nothing you're doing is working imagine what they'll be like in 10 more minutes.
What I was hearing was continuing with the breathing Sir, It wasn't gas, but thinking of her huge hollymolly abdomen, could've some gases remixed with sounds I was hearing!
How about we were giving mostly steriods and repeating Aminophylline for the next almost 2 hours?


1. Reintubate. This patient should have been re-intubated immediately.
2. Albuterol. You need Beta2 agonism. Perhaps this wasn't available.
3. Epi, epi, epi. Was this not available for some reason? Even if the most austere locations stocking this needs to be a priority. Epi.
4. 1 dose of steroids was enough. Repeating the doses so often doesn't help and probably leads to worse wound healing, hyperglycemia, altered mental status. Adrenal suppression is obviously described for chronic steroids, so maybe that's not an issue. But that was a lot of steroids

Thanks for this guidelines, yes true, the patient had to be re-intubated; Albuterol, can be managed to be brought from the ER, but as I said being an SHO doctor, I follow the orders of my Seniors ! (it is not an excuse); Epinephrine is available too in the OR, and in the ER, but there is fear of using it by some Seniors, and never had seen once safe practice of Epinephrine (probably in my next weeks residency, I will address such deficits!
Saying 1 dose of steroids was enough ( I take off my hat for you ), since Dexamethasone is 15 - 25 stronger than Hydrocostisone beside there is a myth over here about Hydrocortisone acts faster than Dexamethasone and increasing the steroids will strengthen the potency ! ! I truly need to make a Seminar or presentation about Gluccorticoids (Myths and Facts) !


Many thanks again !

Peace

 

[vector2]

For bronchospasm, dose epi 5-10 mcg IV at a time every 2-3 min until it breaks. 50-200 mcg is appropriate for a SC or IM dose.

Also, you should not tolerate a sat in 70s for as long as you did. Pts with severely decompensated status asthmaticus like your pt need immediate intubation and epinephrine (followed by continuous nebulizer, aminophylline infusion, scheduled steroids, magnesium, ketamine, anticholinergics etc). Other pts with a normal baseline sat and undifferentiated hypoxemia need immediate intervention (either intubation, noninvasive PPV, high flow nasal cannula) with 100% fio2 once you have a sustained sat under 88% for more than 5 minutes with conservative measures.

 

[DrAmir0078]

For bronchospasm, dose epi 5-10 mcg IV at a time every 2-3 min until it breaks. 50-200 mcg is appropriate for a SC or IM dose.

Also, you should not tolerate a sat in 70s for as long as you did. Pts with severely decompensated status asthmaticus like your pt need immediate intubation and epinephrine (followed by continuous nebulizer, aminophylline infusion, scheduled steroids, magnesium, ketamine, anticholinergics etc). Other pts with a normal baseline sat and undifferentiated hypoxemia need immediate intervention (either intubation, noninvasive PPV, high flow nasal cannula) with 100% fio2 once you have a sustained sat under 88% for more than 5 minutes with conservative measures.

Thanks for reading me Dr. Vector2
Interesting formula (5-10 mcg IV) every 2-minutes
(That means take 1mg ampl, diluted in 10 cc, 1 cc = 100 mcg, then dilute 1 cc in 20cc ampl, 1 cc = 5 mcg/cc and will give 1cc - 2 cc every 2-3 minutes) not 50mcg at once (which is used for Anaphylaxis) --- now I know the right dosage ... Many thanks

Pts with severely decompensated status asthmaticus like your pt need immediate intubation and epinephrine (followed by continuous nebulizer, aminophylline infusion, scheduled steroids, magnesium, ketamine, anticholinergics etc).

Definitely will keep that in my mind next time!

Honestly, I was truly the facilities I witnessed in the US regarding PPVs and I was telling them, hopefully in my next weeks residency, things will be different than this hospital!

 

[pgg]

I don't have a whole lot to add.

Yes, SaltyDog is a sarcastic snorkeler and this patient got plenty of steroids. 🙂

elective umbilical hernia repair, her weight is 95 kg, huge distended abdomen

I was there at the scene now, and got the info, and started to do my tube which was difficult, then the Senior arrived and he puts the tube!

You said it was elective, but you've also described some signs consistent with obstruction. Or does "huge distended abdomen" just mean the patient was obese? (Usually when we describe an abdomen as "distended" we're implying some kind of pathologic intra-abdominal process, not just an excess of fat.)

With a small bowel obstruction, and prolonged/difficult laryngoscopy for intubation, I would be especially concerned about the risk of an aspiration event. This would be one possible reason for the bronchospasm.


Additionally, it's not clear to me how you maintained anesthesia during this case. You used ketamine for induction, and said your senior used a single agent technique. Do you mean it was the only agent used for induction, or was it also used for maintenance of anesthesia during the surgery? Inadequate anesthesia could also have been a contributing factor.

Operation completed, and extuabtion done successfully (fully awake), but once we put the mask and the patient starts to breath with head-up, the SPO2 fell to 55%, all techniques done, jaw thrust, jet ventilation, no improvement just 10% and reached 65% SPO2 with full wheezy chest, beside when the patient regains his consciousness ,she became agitated!

Also confusing - you said the patient was extubated awake, but then said she became agitated after she regained consciousness.

Was she really awake at extubation? If not, another explanation for the rapid desaturation immediately after extubation is laryngospasm. And if this led to negative pressure pulmonary edema, it would also explain her prolonged hypoxia (though I'd be surprised that a 48 yo female could inflict that upon herself, that's more of a young muscular man kind of problem).

Was the patient's neuromuscular blockade reversed?

As for her agitation, hypoxia, hypercarbia, and residual neuromuscular blockade are high on that differential. 🙂

 

[DrAmir0078]

Thanks for reading me Dr. Pgg

You said it was elective, but you've also described some signs consistent with obstruction. Or does "huge distended abdomen" just mean the patient was obese? (Usually when we describe an abdomen as "distended" we're implying some kind of pathologic intra-abdominal process, not just an excess of fat.)

With a small bowel obstruction, and prolonged/difficult laryngoscopy for intubation, I would be especially concerned about the risk of an aspiration event. This would be one possible reason for the bronchospasm.

She was obese as I mentioned her weight as 95 kg, beside my description of her abdomen was hugely distended as like Central obesity (You can imagine the intra abdominal pressure) like a camel dome!

True, she was difficult to intubate her, we tried twice but the Senior succeeded!

Very informative explanation of the possibility of aspiration - loved it!

Also confusing - you said the patient was extubated awake, but then said she became agitated after she regained consciousness.

Was she really awake at extubation? If not, another explanation for the rapid desaturation immediately after extubation is laryngospasm. And if this led to negative pressure pulmonary edema, it would also explain her prolonged hypoxia (though I'd be surprised that a 48 yo female could inflict that upon herself, that's more of a young muscular man kind of problem).

Yes, she awoke fully as she was annoyed from tube and she was moving her head left and right with SPO2 above 95%.
We didn't hear any stridor like as a sign of laryngospasm, but what freaked us out her rapid desaturation.

Was the patient's neuromuscular blockade reversed?

As for her agitation, hypoxia, hypercarbia, and residual neuromuscular blockade are high on that differential

We gave her (neostigmine 2.5 mg and atropine 1.2 mg). Although she was on Atracurium (metabolism through Hoffman)

True, as your last sentence!

My pleasure

Amir

 

[anbuitachi]

Thanks for reading,
So what is your dosage you rely on for epinephrine, sounds weird question, but honestly, everyone says different formula, I am gonna stick with eary formula 50mcg IV bolus !

Like someone else said, i start at 10 mcg bolus. not sure why your seniors would be afraid to use epinephrine. id be much more concerned with a patient satting 70% for a hour. epinephrine is a useful drug and is commonly used for many things

 

[DrAmir0078]

Like someone else said, i start at 10 mcg bolus. not sure why your seniors would be afraid to use epinephrine. id be much more concerned with a patient satting 70% for a hour. epinephrine is a useful drug and is commonly used for many things

Dr. Anbuitachi,
Thanks for giving me a good formula, as 10 mcg bolus and as other said (5-10 mg) every 2 to 3 minutes until bronchospasm breaks; so I will abandon that 50 mcg (which is for Anaphylaxis) !

To be honest, in my 15 months of practice as SHO in Anesthesia, I had lots of discussion with Senior Attendings and one of them said "If I didn't learn how to use it, I won't use it in my practice", It could've be the cause of fear. Other said this "I had bad experience with blah medicine, so either will be cautious with it, or will never use it". It looks like, they have PTSD from certain items!
Do you agree with such says?

I have this today for example; For Austin-Moore procedure for 90 years old man, my Senior did Neuroaxial Anesthesia - Spinal, and the blood pressure kept drooping, we didn't have ephidrine or any Vasopressor drugs, while we have epinephrine handy and my Senior said "Yes, I know we can use it, but why to get into problems of stimulation of Alpha, Beta and then Cardiac arrhythmias"
See Dr 🙁

Hopefully, such things will be cleared up in the future in my residency !

Thanks for reading me !

 

[Mman]

Sometimes I will take albuterol 2.5mg liquid and just dump the whole amount into the ET tube to treat bronchospasm.

5 mls of 2% lidocaine down the endotracheal tube will also break it nicely

 

[DrAmir0078]

5 mls of 2% lidocaine down the endotracheal tube will also break it nicely

Many thanks,
I just read about it, never thought of it, although I know what's NAVEL means... This is awesome!
Lidocaine is handy here

Dear Fellow, I am an SHO in Anesthesia, next October PGY1 (Iraqi Board Residency program in Anaesthesia and Critical Care), so just sharing my own experience, please be advised to follow your proctols, we learn together!

 

[anbuitachi]

Dr. Anbuitachi,
Thanks for giving me a good formula, as 10 mcg bolus and as other said (5-10 mg) every 2 to 3 minutes until bronchospasm breaks; so I will abandon that 50 mcg (which is for Anaphylaxis) !

To be honest, in my 15 months of practice as SHO in Anesthesia, I had lots of discussion with Senior Attendings and one of them said "If I didn't learn how to use it, I won't use it in my practice", It could've be the cause of fear. Other said this "I had bad experience with blah medicine, so either will be cautious with it, or will never use it". It looks like, they have PTSD from certain items!
Do you agree with such says?

I have this today for example; For Austin-Moore procedure for 90 years old man, my Senior did Neuroaxial Anesthesia - Spinal, and the blood pressure kept drooping, we didn't have ephidrine or any Vasopressor drugs, while we have epinephrine handy and my Senior said "Yes, I know we can use it, but why to get into problems of stimulation of Alpha, Beta and then Cardiac arrhythmias"
See Dr 🙁

Hopefully, such things will be cleared up in the future in my residency !

Thanks for reading me !

your only vasopressor is epinephrine?

 

[DrAmir0078]

your only vasopressor is epinephrine?

Dear Dr. Anbuitachi,
You know where am I from?
So, it depends on where exactly too the hospital, so my hospital in the mid-east south of Iraq, so supplies run out fast and also there is a governmental austerity campaign (so, not all medicines available unfortunately).
Anyway, Good Anesthesiologists buy their medicines like Ephedrine, Midazolam, even spinal needles ...etc
You can imagine ! (Some postgrad interns buy their own specific ER medicines, so they won't get in trouble with patients' relatives) ... it happens and the life meant to be like this ... no complaint !
But, we have very outstanding private hospital, they supply everything, but also this is the responsibility of the Anesthesiologists to buy from the market - sometimes !
Also, there some world class private hospitals too, with EMR too and they invite world class doctors to perform operation like Pediatric Cardiovascular surgeries by American team, or Ortho French, Russian, , , etc (All their Anesthesiologists are well Iraqi trained ones)

 

[pgg]

I have this today for example; For Austin-Moore procedure for 90 years old man, my Senior did Neuroaxial Anesthesia - Spinal, and the blood pressure kept drooping, we didn't have ephidrine or any Vasopressor drugs, while we have epinephrine handy and my Senior said "Yes, I know we can use it, but why to get into problems of stimulation of Alpha, Beta and then Cardiac arrhythmias"
See Dr 🙁

This is a problem.

You may not have the authority to fix this problem now, but read this well and resolve to fix it when you can.

Performing spinal anesthesia when you don't have vasopressors immediately available to treat hypotension is malpractice. I really can't say it any clearer than that: it is malpractice that will eventually kill people.

Yes, epinephrine can be arrhythmogenic. In 5-10 mcg boluses, it usually isn't.

You know what's really arrhythmogenic? Ischemic myocardium, because the blood pressure is 75/30.

Phenylephrine, norepinephrine, ephedrine, or even vasopressin are usually better first line vasopressors for post-spinal hypotension than epinephrine. (Except when bradycardia is present, or a high spinal is developing, then epinephrine is always first line.)


I spent part of this year as a guest at a hospital in a developing country, and there was a totally avoidable death in the OR after a spinal for an elective procedure. I won't go into all of the details, but the patient became hypotensive after a spinal, developed some ischemia, chest pain, diaphoresis, and then about 15 minutes later suffered a vfib arrest and died after unsuccessful CPR. Vasopressors were not given to correct the hypotension (until the attempted resuscitation was in progress). IV fluids were not effective in preventing or treating the pre-arrest hypotension. This was a clean kill. Avoidable. Malpractice.

Of course, this wasn't the only spinal that had severe hypotension that went untreated, merely the only one that resulted in a death while I was there. They routinely just let patients ride with systolic pressures in the 70s or 80s for a while after a spinal.


In my travels to several developing countries where I've practiced anesthesiology with the locals, the aversion to using vasopressors to treat expected anesthesia related hypotension is common, and mysterious to me. It usually isn't a cost or supply issue. Most of these hospitals actually have at least norepinephrine available, and all have epinephrine.

Most anesthetic agents - IV drugs, volatile anesthetics, neuraxial local - cause a reduction in systemic vascular resistance and thus hypotension. It is logical and necessary to treat this hypotension, and drugs with alpha agonist effects are usually the best answer, along with judicious use of IV fluids, and downward titration of the anesthetic itself (if possible).

You, your seniors, and others in your hospital need to fix this aversion to using vasopressors. They are a necessary part of many anesthetic techniques.

Don't be afraid to use epinephrine.

 

[pgg]

Dear Dr. Anbuitachi,
You know where am I from?
So, it depends on where exactly too the hospital, so my hospital in the mid-east south of Iraq, so supplies run out fast and also there is a governmental austerity campaign (so, not all medicines available unfortunately).
Anyway, Good Anesthesiologists buy their medicines like Ephedrine, Midazolam, even spinal needles ...etc
You can imagine ! (Some postgrad interns buy their own specific ER medicines, so they won't get in trouble with patients' relatives) ... it happens and the life meant to be like this ... no complaint !
But, we have very outstanding private hospital, they supply everything, but also this is the responsibility of the Anesthesiologists to buy from the market - sometimes !
Also, there some world class private hospitals too, with EMR too and they invite world class doctors to perform operation like Pediatric Cardiovascular surgeries by American team, or Ortho French, Russian, , , etc (All their Anesthesiologists are well Iraqi trained ones)

I understand - really, I do. And I sincerely respect the work you're doing in that difficult environment.

If phenylephrine and norepinephrine are unavailable and cost prohibitive, get comfortable using small doses of epinephrine.

Norepinephrine comes in very concentrated vials. Consider preparing (under sterile conditions) multiple syringes of dilute norepinephrine so that one vial can be safely used for multiple patients.

Be diligent about fluid preloading, when it is appropriate to do so.

What you can't do is just let these patients be hypotensive and hope for the best.

 

[DrAmir0078]

This is a problem.

You may not have the authority to fix this problem now, but read this well and resolve to fix it when you can.

Performing spinal anesthesia when you don't have vasopressors immediately available to treat hypotension is malpractice. I really can't say it any clearer than that: it is malpractice that will eventually kill people.

Yes, epinephrine can be arrhythmogenic. In 5-10 mcg boluses, it usually isn't.

You know what's really arrhythmogenic? Ischemic myocardium, because the blood pressure is 75/30.

Phenylephrine, norepinephrine, ephedrine, or even vasopressin are usually better first line vasopressors for post-spinal hypotension than epinephrine. (Except when bradycardia is present, or a high spinal is developing, then epinephrine is always first line.)


I spent part of this year as a guest at a hospital in a developing country, and there was a totally avoidable death in the OR after a spinal for an elective procedure. I won't go into all of the details, but the patient became hypotensive after a spinal, developed some ischemia, chest pain, diaphoresis, and then about 15 minutes later suffered a vfib arrest and died after unsuccessful CPR. Vasopressors were not given to correct the hypotension (until the attempted resuscitation was in progress). IV fluids were not effective in preventing or treating the pre-arrest hypotension. This was a clean kill. Avoidable. Malpractice.

Of course, this wasn't the only spinal that had severe hypotension that went untreated, merely the only one that resulted in a death while I was there. They routinely just let patients ride with systolic pressures in the 70s or 80s for a while after a spinal.


In my travels to several developing countries where I've practiced anesthesiology with the locals, the aversion to using vasopressors to treat expected anesthesia related hypotension is common, and mysterious to me. It usually isn't a cost or supply issue. Most of these hospitals actually have at least norepinephrine available, and all have epinephrine.

Most anesthetic agents - IV drugs, volatile anesthetics, neuraxial local - cause a reduction in systemic vascular resistance and thus hypotension. It is logical and necessary to treat this hypotension, and drugs with alpha agonist effects are usually the best answer, along with judicious use of IV fluids, and downward titration of the anesthetic itself (if possible).

You, your seniors, and others in your hospital need to fix this aversion to using vasopressors. They are a necessary part of many anesthetic techniques.

Don't be afraid to use epinephrine.

You made my whole day (although it reaching mid night here) Dr. pgg
Wow what informative speech, it rings in my head, your advice is like an ice on my heart !
Seriously it is Malpractice not having Vasopressors handy while performing Neuraxial Anesthesia !

Don't be afraid to use epinephrine.

I will Dr.Pgg

My respect to every single letter my teacher !

Amir

 

[DrAmir0078]

I understand - really, I do. And I sincerely respect the work you're doing in that difficult environment.

If phenylephrine and norepinephrine are unavailable and cost prohibitive, get comfortable using small doses of epinephrine.

Norepinephrine comes in very concentrated vials. Consider preparing (under sterile conditions) multiple syringes of dilute norepinephrine so that one vial can be safely used for multiple patients.

Be diligent about fluid preloading, when it is appropriate to do so.

What you can't do is just let these patients be hypotensive and hope for the best.

Many thanks Dr. Pgg

I salute you !