Informed consent while on nitrous

[narcusprince]

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Many times I am consulted to place epidural catheters in moms on inhaled nitrous. Given that the nitrous is a sedative/analgesic is mom technically not consentable due to being under sedation?

 

[Mman]

Many times I am consulted to place epidural catheters in moms on inhaled nitrous. Given that the nitrous is a sedative/analgesic is mom technically not consentable due to being under sedation?

Personally I'd wait a few minutes for them to breathe it off and then consent them.

 

[Monty Python]

Many times I am consulted to place epidural catheters in moms on inhaled nitrous. Given that the nitrous is a sedative/analgesic is mom technically not consentable due to being under sedation?

I asked a similar question about a year ago at a Risk Management committee meeting where our legal counsel was in attendance. At least once or twice weekly we face a situation on L&D where a primip unknown to us, whose birth plan stated their intent to deliver "all natural," and who had refused to see us in preop clinic while in their 3rd trimester, is now screaming for an epidural. Upon our arrival at bedside we find the primip relatively gorked out on recent IV administration of fentanyl/nubain/stadol as ordered by the OB. How "informed" is informed anesthesia consent under those conditions? According to our legal counsel, it's up to us to decide the patient's ability to comprehend what's being discussed with them at that precise point in time, regardless of their current medication or overall mental status. If our professional judgment feels the patient is comprehending the R/B/A of what's being discussed with them even with Rx on board, then their signature on the consent has legal standing. Part of me feels that's a legal cop-out. But, it goes along with a parallel problem: the patient with no Rx on board, but who is screaming for you to do "something" immediately upon your arrival, and who is in such obvious pain that you wonder if they're even listening (or able to comprehend through their pain) as you discuss R/B/A of labor analgesia options. Speaking as a non-lawyer I feel it puts us in a grey area, and is akin to obtaining a signature on a bogus confession after torture. To add to the discussion: one of my brothers-in-law is ordained clergy. He cannot and will not perform a marriage ceremony if he detects alcohol on either the bride's or groom's breath. The wedding parties are told this during their pre-marriage counseling and also during the wedding planning. Yet we're OK getting informed consent for a neuraxial procedure with recent narcotic on-board. That's clear as mud.

 

[Random Anesthesiologist]

There have been studies that show women in painful labor without narcs can make appropriate informed consent decisions. Psych history could be a confounder. Just sayin.

 

[deleted162650]

Is anyone aware of any case in the history of modern medicine where an anesthesiologist was sued or charged with assault for placing an epidural in a laboring woman who requested it??

Honestly asking here. Just wanna know what degree of mental masturbation we're practicing.

 

[pgg]

I'd just have her put the mask down for a couple minutes. Nitrous comes off pretty fast.

 

[narcusprince]

Is anyone aware of any case in the history of modern medicine where an anesthesiologist was sued or charged with assault for placing an epidural in a laboring woman who requested it??

Honestly asking here. Just wanna know what degree of mental masturbation we're practicing.

I could see a scenario where a patient gets an epidural and complications occur with the epidural ie Wet Tap, bleeding, infection. Then some slick lawyer says how could she consent to the epidural she was sedated from the nitrous. Pgg you may be aware but nitrous falls under the conscious sedation protocol. A slick lawyer would look at errors in the process, its not what you did its what they can prove.

 

[Mman]

I could see a scenario where a patient gets an epidural and complications occur with the epidural ie Wet Tap, bleeding, infection. Then some slick lawyer says how could she consent to the epidural she was sedated from the nitrous. Pgg you may be aware but nitrous falls under the conscious sedation protocol. A slick lawyer would look at errors in the process, its not what you did its what they can prove.

Nitrous is also an anesthetic gas and dose is measured under the same MAC category as things like sevoflurane and isoflurane. If a patient was exhaling 1% sevoflurane, would you consider them able to be consented?

 

[deleted162650]

I could see a scenario where a patient gets an epidural and complications occur with the epidural ie Wet Tap, bleeding, infection. Then some slick lawyer says how could she consent to the epidural she was sedated from the nitrous. Pgg you may be aware but nitrous falls under the conscious sedation protocol. A slick lawyer would look at errors in the process, its not what you did its what they can prove.

Yes, we could all dream up such scenarios. Is anyone out there actually aware of a similar case that's ever actually been filed??

 

[pgg]

I could see a scenario where a patient gets an epidural and complications occur with the epidural ie Wet Tap, bleeding, infection. Then some slick lawyer says how could she consent to the epidural she was sedated from the nitrous. Pgg you may be aware but nitrous falls under the conscious sedation protocol. A slick lawyer would look at errors in the process, its not what you did its what they can prove.

Nitrous has very predictable on and off times. We as anesthesiologists are uniquely skilled and knowledgeable about the kinetics of inhaled anesthetics. Who better to judge when or whether a patient is under the influence or not?

As long as she hasn't been huffing away at the nitrous for a few minutes, I think you're fine.

 

[narcusprince]

Of course I can make a decision whether they are consentable and understand r/b/a but legally its a dicey situation. Rarely do I enter the labor room and mom isnt sucking on nitrous. And when nitrous stops helping the pain its a rapid tolerance to its analgesic effect. Many cases the patients say they want to go natural, and use nitrous then you get called into the room mom screaming wanting an epidural. At that point we have mental duress combined with nitrous, vice just mental duress. Whats needed is early epidural placement and education. Skip the nitrous.......

 

[pgg]

Of course I can make a decision whether they are consentable and understand r/b/a but legally its a dicey situation.

That's just it though, I don't think it's legally dicey at all.

You take away the nitrous and five minutes later give her the spiel and a paper to sign.

What's the problem?

 

[narcusprince]

Just wait until you see a patient after they have given up on nitrous and request an epidural. These patients are jumping off the bed. I like the approach of early epidural placement which is the standard at your hospital. And you get rid of all the nitrous bs consent and tachyphlaxis. I have found nitrous just bridges patients but does not cover them anywhere close to a well placed labor epidural.

 

[pgg]

Just wait until you see a patient after they have given up on nitrous and request an epidural. These patients are jumping off the bed.

I believe you. But again ... so what? A woman experiencing agonizing labor pain can consent for an epidural.

I like the approach of early epidural placement which is the standard at your hospital. And you get rid of all the nitrous bs consent and tachyphlaxis. I have found nitrous just bridges patients but does not cover them anywhere close to a well placed labor epidural.

OK, so you don't like nitrous for labor analgesia. If you just stopped there, I wouldn't argue the point. 🙂

But what you argued above - that nitrous makes a woman unconsentable for an epidural, or somehow raises your legal liability - I can't get on board with that. I think it's wrong.

 

[Mman]

But what you argued above - that nitrous makes a woman unconsentable for an epidural, or somehow raises your legal liability - I can't get on board with that. I think it's wrong.

If the nitrous is out of their system, sure they are consentable. But if they are on a 1/2 MAC of gas, consent probably isn't legal (or shouldn't be).

 

[pgg]

If the nitrous is out of their system, sure they are consentable. But if they are on a 1/2 MAC of gas, consent probably isn't legal (or shouldn't be).

Of course, that's what I wrote above. Take away the nitrous. Wait a few minutes. Proceed.