Laparoscopic Banding

[coprolalia]

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In this ridiculously litigious environment in which we currently practice, a smart clinician is compelled to work it up.

There's no longer good old fashioned "doctoring" permitted. Where I draw the line is getting the psych consult, who probably won't help and only do nothing more than to likely further complicate the picture. This is a peri-operative problem, not a chronic one a noodle-shrinker can help fix... at least not yet.

Document everything, though. You're probably gonna get sued. And, maybe next time, go a little lighter on the anti-cholinergics. Rarely have I/do I ever need to give intra-op atropine. If I have a recurrent vagal reflex that won't ablate on repetitive stimulation, I'll give a tiny dose of glycopyrrolate. Quaternary amine. Doesn't cross the BBB.

-copro

 

[militarymd]

In this ridiculously litigious environment in which we currently practice, a smart clinician is compelled to work it up.

There's no longer good old fashioned "doctoring" permitted. Where I draw the line is getting the psych consult, who probably won't help and only do nothing more than to likely further complicate the picture. This is a peri-operative problem, not a chronic one a noodle-shrinker can help fix... at least not yet.

Document everything, though. You're probably gonna get sued. And, maybe next time, go a little lighter on the anti-cholinergics. Rarely have I/do I ever need to give intra-op atropine. If I have a recurrent vagal reflex that won't ablate on repetitive stimulation, I'll give a tiny dose of glycopyrrolate. Quaternary amine. Doesn't cross the BBB.

-copro

On the second day..the patient still has a constantly changing neuro exam......I would say it's not "anesthesia"...as the surgeon was saying....

Psych consult wasn't obtained until the 3rd day when all the testing was finally completed.

I don't think you can send someone home with an abnormal neuro exam....even if you SUSPECT malingering.

 

[urge]

Exactly! 👍
So you actually agree with me that this is Alice in wonderland syndrome?

Not really. I would just leave it as good ol' post op delirium from polypharmacy in a fatty that most likely already had depression and who knows what other mental disease.

 

[SleepIsGood]

In this ridiculously litigious environment in which we currently practice, a smart clinician is compelled to work it up.

There's no longer good old fashioned "doctoring" permitted. Where I draw the line is getting the psych consult, who probably won't help and only do nothing more than to likely further complicate the picture. This is a peri-operative problem, not a chronic one a noodle-shrinker can help fix... at least not yet.

Document everything, though. You're probably gonna get sued. And, maybe next time, go a little lighter on the anti-cholinergics. Rarely have I/do I ever need to give intra-op atropine. If I have a recurrent vagal reflex that won't ablate on repetitive stimulation, I'll give a tiny dose of glycopyrrolate. Quaternary amine. Doesn't cross the BBB.

-copro

Agreed with this.

I think atropine is usually for 'code' situations. Usually one can get away with using titrated doses of glycopyrollate and attenuate the tachycardia. To me, giving atropine is like throwing the 'kitchen sink' at the situation....way unnecessary intraop.

 

[urge]

So Mil, what happened to the patient? What did psych/neuro say?

 

[militarymd]

So Mil, what happened to the patient? What did psych/neuro say?

don't know...after being in the hospital for 3 days for a outpatient procedure....I stopped looking into her.

The last I heard was that neuro sent psych to her.

 

[Planktonmd]

So Mil, what happened to the patient? What did psych/neuro say?

I know what happened: She woke up and went home.

 

[Noyac]

don't know...after being in the hospital for 3 days for a outpatient procedure....I stopped looking into her.

The last I heard was that neuro sent psych to her.

Some dumbarse nurse gave her some benadryl and she went home.

 

[cchoukal]

On the second day..the patient still has a constantly changing neuro exam......I would say it's not "anesthesia"...as the surgeon was saying....

Psych consult wasn't obtained until the 3rd day when all the testing was finally completed.

I don't think you can send someone home with an abnormal neuro exam....even if you SUSPECT malingering.

Of course the surgeon said it was "anesthesia." I love that. You can explain 'til you're blue in the face about half-lives, clearance, and doses, and they'll nod like they agree, and as soon as you walk away, they're writing in the chart that they still think it's "anesthesia." They really just don't believe we're doctors.

Anyway...

People keep suggesting diphenhydramine, but without a diagnosis. Are you thinking dystonic reaction? I guess that's possible, but I would expect rigidity, not focal flaccidity.

Was there a repeat CT scan (the first was WNL, right?)?

 

[Eta Carinae]

but I would expect rigidity, not focal flaccidity.

Was there a repeat CT scan (the first was WNL, right?)?

This would probably be on the bottom of my list but in addition to post op delirium, in the setting of focal flaccidity, I wonder if brachial plexopathy is a concern...perhaps due to positioning during surgery.

should have worn off by day 2, though. I know scalenes are located away from the abd region. Just wondering.

 

[dhb]

I know scalenes are located away from the abd region.

Wow you need a post-doc for that! How dumb can you be. You add nothing to this forum and your repeat posts are a nuisance 👎

 

[Eta Carinae]

Patient refuses to turn to the left...and stares at her right hand screaming and crying.

Thoughts on what to do next.

Arm drop

Left arm is limp...and does not with draw to pain....but if you hold her left hand over her head and drop it...it does move enough to not land on her face.

I wonder if brachial plexopathy is a concern.

still. Very interesting case.

 

[geogil]

Eta, what does it imply if, when you drop a patient's arm over their face in such a way that it should hit, but that it doesn't? Put some of that post-doc power to work here.

 

[militarymd]

Of course the surgeon said it was "anesthesia." I love that. You can explain 'til you're blue in the face about half-lives, clearance, and doses, and they'll nod like they agree, and as soon as you walk away, they're writing in the chart that they still think it's "anesthesia." They really just don't believe we're doctors.

Anyway...

People keep suggesting diphenhydramine, but without a diagnosis. Are you thinking dystonic reaction? I guess that's possible, but I would expect rigidity, not focal flaccidity.

Was there a repeat CT scan (the first was WNL, right?)?

all repeat studies normal...with a changing neuro...weakness ...that changes sides...

sent to psych rehab.

 

[urge]

I doubt any of you has seen a dystonic reaction. I saw one as a resident. The patient was wide awake but could not stop dancing "electroboogie". Benadryl took care of it pretty quickly.

Mil's description in no way steers me towards dystonia.

For the younglings:
http://www.youtube.com/watch?v=9h6pcqC6wrI&feature=related
[YOUTUBE]9h6pcqC6wrI[/YOUTUBE]

 

[militarymd]

-scop patch off. give physostigmine.
-Additional history of med/druguse, or psych hx?
-wait.

you got it right away....it took us 4 days.

 

[veetz]

30 something year old overweight lady undergoes lap band under ga.

Preop Labs...normal.

PMHx: HTN being treated with hctz

NKDA

Concerned about PONV.

Given Scop patch and decadron preop...and zofran in OR.

Case was unremarkable...other than bradycardia during insufflation requiring atropine.

Post Op:

In recovery...over one hour before emergence from GA enough for OA to come out.

Vitals stable...Sats 99% on NC.

Patient refuses to turn to the left...and stares at her right hand screaming and crying.

Thoughts on what to do next.

Probably PTSD secondary to perineal burning/itching preop. JK

 

[Noyac]

Probably PTSD secondary to perineal burning/itching preop. JK

👍

I saw that and thought the same thing but didn't bother to reply.

 

[Noyac]

you got it right away....it took us 4 days.

What kind of psych history?

 

[deleted126335]

you got it right away....it took us 4 days.

It had to be some type of curveball or it wouldn't be worth your time posting.

 

[militarymd]

It had to be some type of curveball or it wouldn't be worth your time posting.

I don't know...I just know the consultants were scratching their heads.

 

[DrDre']

Arm drop test

Being a former paramedic, the arm drop test really really bothers me and makes me think psych which is always high on my list (for this reason, I always make it a diagnosis of exclusion- way last or I really favor it 🙂

How did lack of wakeup present in this young woman?


Did she pass the sternal rub, nasal airway? Almost no one can fake through the NPA. Although I have heard of true psych pros even being intubated...

This is a good case to review postop delirium, remind us how important a good workup can be (especially in the elderly) BUT to the less experienced, less jaded to see what behaviors are out there that we dont see often as anesthesiologists. I used to see this type of behavior nearly every day.

I would r/o life threats then start talking to my partner about nasal intubation. The seizure or coma usually resolved within seconds. Or as soon as the lido jelly squirted down their nare...