Interesting case

[drrosenrosen]

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14 y/o girl for acute abd r/o ovarian torsion. The CT scan has showed no appendicitis, so the GYN folks take over to explore. Nothing exciting in her pre-op eval. No PMH, no meds, no allergies, never had anesthesia, good airway. We make kind of a soft-call for RSI because of the acute abdomen, even though we're thinking it's gyn pain. Versed 2mg, fentanyl 100 mcg (modified RSI), 150 prop, 120 sux (ca-1 kind of overdosed here, but not so much that anyone freaked out). Tube in easily, des/air/o2. Case took a while because the gyns got in there and found pus in the pelvis and a big nasty appendix, had to call in the surgeons. By the time the whole thing was over, case was about 2 hours. All along they were telling me that it wouldn't be much longer, so since I wasn't having any problems ventilating her, and we were running a nice BIS-titrated deep anesthetic, she got no vec. Tried to get her spontaneously breathing towards the end, but no luck. Didn't bother me too bad, just figured I'd breathe the des off for her and take the vent off when she started to wake up. Case over, des off, etdes 0.3, BIS 85, pt's not waking up. No coordinated respiratory efforts, no eye opening, nada. Tachy to 150, BP 160/90, still not breathing/moving. Que tal?

 

[Laurel123]

Could be a few things, but sounds like residual muscle relaxant. If you didn't give any vec/roc, then it could be pseudocholinesterase deficiency. The fact that she wasn't moving or waking up, but was tachy and hypertensive strongly points toward someone that is starting to wake up, but is very weak and still paralyzed.

At this point I would have cranked some Des back on, maybe a little propofol and checked her twiches.

 

[2ndyear]

I agree, pseudocholinesterase OR drug error. The "we didn't give her any vec" could mean, "we grabbed the wrong bottle and gave 10 of panc". Even then though, 2 hours and you would expect to see something unless you gave it near the end of the case.

 

[BLADEMDA]

I agree, pseudocholinesterase OR drug error. The "we didn't give her any vec" could mean, "we grabbed the wrong bottle and gave 10 of panc". Even then though, 2 hours and you would expect to see something unless you gave it near the end of the case.

During my younger days an anesthesia provider had a very weak patient in PACU. The guy need BiPap for a few hours after knee surgery. The provider said he gave ONLY sux for the case and no other NMB's. He wanted me to order all the usual crap for prolonged sux like dibucaine number, psuedocholinesterase level etc., After he left I went back to the operating room and checked the trash. It turned out he gave 7 cc of Pancuronium and NOT sux. I am not sure if he ever realized this mistake because the bottles look similar.

Also, I see med errors all the time. A provider recently gave Toradol instead of generic Zofran (the bottles look similar). My point is that when you hear hoof beats think horses; and, provider error is MUCH more common than you think.

Blade

 

[Noyac]

And I'll bet your next case post is an awareness case!😱

Just kiddng but I would be curious to know if she was conscious here.

 

[toughlife]

14 y/o girl for acute abd r/o ovarian torsion. The CT scan has showed no appendicitis, so the GYN folks take over to explore. Nothing exciting in her pre-op eval. No PMH, no meds, no allergies, never had anesthesia, good airway. We make kind of a soft-call for RSI because of the acute abdomen, even though we're thinking it's gyn pain. Versed 2mg, fentanyl 100 mcg (modified RSI), 150 prop, 120 sux (ca-1 kind of overdosed here, but not so much that anyone freaked out). Tube in easily, des/air/o2. Case took a while because the gyns got in there and found pus in the pelvis and a big nasty appendix, had to call in the surgeons. By the time the whole thing was over, case was about 2 hours. All along they were telling me that it wouldn't be much longer, so since I wasn't having any problems ventilating her, and we were running a nice BIS-titrated deep anesthetic, she got no vec. Tried to get her spontaneously breathing towards the end, but no luck. Didn't bother me too bad, just figured I'd breathe the des off for her and take the vent off when she started to wake up. Case over, des off, etdes 0.3, BIS 85, pt's not waking up. No coordinated respiratory efforts, no eye opening, nada. Tachy to 150, BP 160/90, still not breathing/moving. Que tal?

Did you happen to check twitches?

 

[milrisome]

BIS of 85 and no movement? Sounds supiciously like muscle relaxant effect. Not enough narcotic to cause it--and she wouldn't be tachy. Don't think there's anything else here to cause it. Check twitches, if it's a depolarizing block pattern, restart sedation and send to ICU. If it's a NDMB pattern, could try reversing.

 

[drrosenrosen]

So we checked twitches when it looked like she should have been awake but wasn't - nothing. When the HR and BP shot up a minute or two later, we talked to her, told her she was waking up but still weak, and slammed in some versed/fentanyl. Took her to the PACU, where she remained intubated. Started making purposeful movements, but still weak, after three-four hours. Finally extubated after about five hours. Drug error was first thing I thought of too, even though I did the whole case myself. But she definitely fasciculated after induction, and I didn't even have vec drawn up. We sent off a dibucaine number and I gave her a letter to carry around saying she's got atypical pseudocholinesterase.

 

[jwk]

So we checked twitches when it looked like she should have been awake but wasn't - nothing. When the HR and BP shot up a minute or two later, we talked to her, told her she was waking up but still weak, and slammed in some versed/fentanyl. Took her to the PACU, where she remained intubated. Started making purposeful movements, but still weak, after three-four hours. Finally extubated after about five hours. Drug error was first thing I thought of too, even though I did the whole case myself. But she definitely fasciculated after induction, and I didn't even have vec drawn up. We sent off a dibucaine number and I gave her a letter to carry around saying she's got atypical pseudocholinesterase.

Have you confirmed that it was in fact an atypical pseudocholinesterase or just assuming that waiting for the results?

I'm with ya - I think it was the sux as well, but blade's point about drug error should be well-heeded. One of our M&M's many years ago was a patient that got "10cc of pavulon" but never relaxed. Four twitches, sustained tetanus, etc. The attending got suspicious and rooted around in the trash and found an empty vial of heparin. They ran an ACT on the patient - wayyyy prolonged. OOPS! 10k units of heparin instead of pavulon - just what you want prior to a bloody total joint case!

Come in to let someone out for a break and that syringe of fentanyl just ain't doing the job despite repeated doses? Then you have another problem - but that's another thread.

 

[Planktonmd]

So we checked twitches when it looked like she should have been awake but wasn't - nothing. When the HR and BP shot up a minute or two later, we talked to her, told her she was waking up but still weak, and slammed in some versed/fentanyl. Took her to the PACU, where she remained intubated. Started making purposeful movements, but still weak, after three-four hours. Finally extubated after about five hours. Drug error was first thing I thought of too, even though I did the whole case myself. But she definitely fasciculated after induction, and I didn't even have vec drawn up. We sent off a dibucaine number and I gave her a letter to carry around saying she's got atypical pseudocholinesterase.

They can now measure Pseudo-cholinesterase level, more sensitive than the Dibucaine number.

 

[epidural man]

So we checked twitches when it looked like she should have been awake but wasn't - nothing. When the HR and BP shot up a minute or two later, we talked to her, told her she was waking up but still weak, and slammed in some versed/fentanyl. Took her to the PACU, where she remained intubated. Started making purposeful movements, but still weak, after three-four hours. Finally extubated after about five hours. Drug error was first thing I thought of too, even though I did the whole case myself. But she definitely fasciculated after induction, and I didn't even have vec drawn up. We sent off a dibucaine number and I gave her a letter to carry around saying she's got atypical pseudocholinesterase.

given the numbers quoted in our text books about frequency of this disorder, I am surprised that we don't see it more often. Actually, a wise attending told me to always check twitches after sux dose - he said he alone has had it happen to him (pseudocholinesterase) 4 times in his career. Also, for me I always check twitches because I want to know if they are twitchless before I cram the NG/OG in. Too many times I have had them buck (or sit up on the table as happened once) on me because I took to long to get the thing in -

Certainly, if you use sux and then give a non-depolarizer it is good practice to make sure twitches have returned before giving vec/cis/roc.

How many people check twitches before pushing any paralytic for a baseline?

 

[VentdependenT]

given the numbers quoted in our text books about frequency of this disorder, I am surprised that we don't see it more often. Actually, a wise attending told me to always check twitches after sux dose - he said he alone has had it happen to him (pseudocholinesterase) 4 times in his career. Also, for me I always check twitches because I want to know if they are twitchless before I cram the NG/OG in. Too many times I have had them buck (or sit up on the table as happened once) on me because I took to long to get the thing in -

Certainly, if you use sux and then give a non-depolarizer it is good practice to make sure twitches have returned before giving vec/cis/roc.

How many people check twitches before pushing any paralytic for a baseline?

I only check after having gave sux....and if things aren't busy (putting in a-line/central line/gotta go surgery).

With a NDMB I dont wait until the patient is induced then check twitches. I wanna go. The paralytic goes in after the patient no longer opens eyes to verbal command (if not a RSI with ROC).