Mock oral case

[urgewrx]

This is a case one of my coworkers had during practice for this month's orals.

A bedridden (vegetable) pt with ALS is scheduled for a PEG. Pt has DNR/DNI orders. Orders were not withheld during peri-op period, per family's request.
Do you do the case?
If so, iv sedation? inhaled? local?
what if the pt stops brething?
should you mask ventilate? or watch him die? give reversal agents?
Let's say you fixed him, do you continue the case?

What do you guys think?

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[Noyac]

As many of you know, I'm not a fan of futile care but I am also not a fan of letting pts starve to death. I would do the case with IV sedation preferably. If they stop breathing, I would mask ventilate him until it reverses and I would explain this to the family since it would be caused by something I have given and would resolve shortly after. I would then continue. I would be sure that there was nothing in his stomach b/c aspiration would be a death sentence. Once the scope is passed then I would make sure the stomach was suctioned under direct visualization until completely cleaned out.
If this wasn't an option after reviewing the pt and his status then I would do it with an ETT without muscle relaxants. I think either way would be fine. If you paralyze him, he may be on the vent for some time which the family will not accept well and the pt may not benefit from at all.

 

[urgewrx]

Remember pt is DNR/DNI.

On discussion, the examiner said to toss in a line saying that you had an extensive conversation with the family. Do case with sedation. If pt stop breathing give reversal agent. If reversal agent does work and procedure not started cancel the case, pt will die from his disease. If reversal agent does not work, do not ventilate (even by mask) the pt as he is DNR/DNI.

I found some of this shocking. But the guy saying this is a senior aba examiner.

 

[Noyac]

Remember pt is DNR/DNI.

On discussion, the examiner said to toss in a line saying that you had an extensive conversation with the family. Do case with sedation. If pt stop breathing give reversal agent. If reversal agent does work and procedure not started cancel the case, pt will die from his disease. If reversal agent does not work, do not ventilate (even by mask) the pt as he is DNR/DNI.

I found some of this shocking. But the guy saying this is a senior aba examiner.

That's BS, I don't agree. You are doing a procedure on the pt so that his last few days or weeks are not total torture. I attempted to mention discussions with the family but my attempt was lame. I agree that you discuss everything with the family. I always tell the family that if I give something that causes the pt to stop breathing or BP to change dramatically that I will attempt to reverse it for the short period that it takes. I will not just let their family member die b/4 my eyes without doing anything if I caused it. Once the meds are worn off then I will let nature take its course. You will find that if you sedate this pt for this procedure you will very likely end his life right then if you do not assist him with respirations for a short time. This does not interfere with DNR/DNI if it is well explained to the family who will almost always agree to this.
Most importantly, remember when taking orals. There are more than one right answers. It all depends on how you answer and are you safe. Personally, I'm not going to practice euthanasia. I'll leave that to Kavorkian.

 

[Planktonmd]

That's BS, I don't agree. You are doing a procedure on the pt so that his last few days or weeks are not total torture. I attempted to mention discussions with the family but my attempt was lame. I agree that you discuss everything with the family. I always tell the family that if I give something that causes the pt to stop breathing or BP to change dramatically that I will attempt to reverse it for the short period that it takes. I will not just let their family member die b/4 my eyes without doing anything if I caused it. Once the meds are worn off then I will let nature take its course. You will find that if you sedate this pt for this procedure you will very likely end his life right then if you do not assist him with respirations for a short time. This does not interfere with DNR/DNI if it is well explained to the family who will almost always agree to this.
Most importantly, remember when taking orals. There are more than one right answers. It all depends on how you answer and are you safe. Personally, I'm not going to practice euthanasia. I'll leave that to Kavorkian.

Agree, 100%.
One option: do it with Precedex just keep an eye on the pressure.
This examiner is not being realistic, because airway management under anesthesia is part of the anesthetic technique, and has nothing to do with patient's wishes not to be resuscitated, or intubated. but after the anesthetic is gone, and if spontaneous breathing does not resume then it's up to the family to withdraw support.
I have done cases on similar patients under GA with ETT and most of the times extubated them post op, you just need to explain to the family that what you do is part of anesthesia and can not be avoided.

 

[urgewrx]

You know how oral boards go. They'll say "family is adamant about DNR/DNI". What are you going to do?
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[Noyac]

You know how oral boards go. They'll say "family is adamant about DNR/DNI". What are you going to do?
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You will get in a debate with the examiner but do not be resistant or hostile. If you give the impression that you are not flexible and that you think you know it all, you will fail. Yes, the examiner will force you to make a decision and whatever decision you make will get you in trouble. But if you have adequately explained your point and concerns you will skate by. I would tell the examiner exactly how I would explain things to the family and emphasizing how DNR/DNI isn't appropriate it this juncture but will be reinstated immediately after the procedure. THen as the examiner forces me to make a decision without allowing me to convince the family, I would come up with my best sedation technique and proceed. The precedex is a thought. I'd probably use ketamine mostly with a little versed depending on how alert and "with it" the pt is.

 

[johankriek]

am i the only one, if i were to do the case, i would standby and give him oxygen and nothing else OR an endotracheal tube (cuffed), using a rapid sequence induction to avoid aspiration. Aspiration is the main concern with this guy, prolly sure mortality if he does. he has depressed airway reflexes already, with unknown gastric motility.... iw ould treat him like full stomach.

I would have a conversation with the endoscopist and tell him to do it under local if he can... then i would have a conversatin with the family stating that if he does indeed get into an airway situation that i would reverse it becase it is due to the medications and things that i have done.... IF they dont want me to,.,... then I am not the anesthesiologist to do the case.. I would take myself away from the case after securing appropriate referrals.

 

[urgewrx]

IF they dont want me to,.,... then I am not the anesthesiologist to do the case.. I would take myself away from the case after securing appropriate referrals.

Are you sure you want to do that on the oral board?
Smells like failure to me.

 

[johankriek]

Are you sure you want to do that on the oral board?
Smells like failure to me.

why does it smell like failure? after explaining to the patient's family that if the patient goes into resp arrrest that it most likely is due to the medications which is easily reversible and that i would have a responsibility as i would for any patient. If a patient asks you .. hey listen dont wake me up.. i wanna die.. would you do it?

i would also secure professional consult from my collleague and withdraw myself from the care.. I wouldnt withdraw myself until my colleague took over.. a peg is not an emergency.. they could place a OG or NG tube and feed through there if i cannot find anyone..

 

[urgewrx]

You cannot dump cases on another anesthesiologist in your oral board.
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[johankriek]

You cannot dump cases on another anesthesiologist in your oral board.
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thats not the point..

the point is, the family cant tell me how to do the case... I happen to think I have some judgement..

OK i wont dump it on someone else.. GOOD POINT

Ill change my answer

i would discuss it with the endoscopist and tell him that I dont feel comfortable doing the case the way the family wants me to do it.. That right there I have not achieved consent. So legally, if i did anything it would be battery. So at that point. you can let nature take its course OR place a NG or OG tube to feed the patient.. Forget getting another anesthesiologist.. I DONT HAVE CONSENT. So legally i cannot do anything

 

[johankriek]

this reminds me of a patient i had about 6 months ago for a I think it was for a breast biopsy. and she was overweight. She says you can sedate me, but under NO circumstances will I let you put me to sleep. as in GA. i told her there is a fine line and in the event of an emergency i may have to place an airway.. tube lma etc.. She would not consent.. So i went home early that day.. I dont have consent

 

[Noyac]

am i the only one, if i were to do the case, i would standby and give him oxygen and nothing else OR an endotracheal tube (cuffed), using a rapid sequence induction to avoid aspiration. Aspiration is the main concern with this guy, prolly sure mortality if he does. he has depressed airway reflexes already, with unknown gastric motility.... iw ould treat him like full stomach.

You would do a PEG on an awake pt? Not me. The pt would cough so much, even if he was extremely weak, that the endoscopist would look at you and say "I can't do it this way, he's moving too much".

 

[TIVA]

Technically speaking, a PEG shouldn't be too much more involved than your routine upper GI scope. Just add a bit of local and an extra 15 minutes and that's pretty much it.

However, patients who are getting PEGs in the first place aren't exactly ASA I and II or even III for that matter. My vote is for what Johan recommends ... explain to the family what the anesthesia entails ... if they say yes, go ahead ... if they say no, then anesthetic consent has been refused ... and then the endoscopist can have his own staff give whatever they want for sedation (I think versed and demerol is their cocktail of choice in the absence of anesthesia).