Mock Oral Exam

[Noyac]

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THis was my call last night (I have 3 cases to discuss pick them as you like):

1) 5pm called from OB for pt with retained placenta. She has a working epidural, sev. pre-eclampsia 180's/100's, >2+ pitting edema, PCN allergy, no meds, no PSH, plts150's. OB wants to go to OR for removal of retained plaenta. On arrival BP 80/42, HR 110, pt uncomfortable (epidural off per OB for delivery and hypotension). I take care of this issue and then Ortho/spine says he has 3 cases to do; nec fasc (this was the easy case so lets not talk about it).

2) 24 yo female rollover MVA major facial lacs (degloving the majority of her face) and a C2 fx (dens is free floating😱). Very little history. Pt somewhat uncooperative. She remembers nothing because she was asleep as the passenger when the MVA occurred.

3) 16 yo male fell from tree 25-50 ft. L3 burst fx with cord compromise and RLE weakness. No PMH, No PSH, no fam hx, no meds, nkda's. BP 160/ 84 temp 98.2, labs WNL. NPO >12 hrs. Physical exam reveals self inflicted lacerations on forearm ("Hi"). WTF? denies drugs, occasional etoh.

Pick the case you want to do and we can discuss. We can talk about them all together. Or you can makes comments on all, I don't care.

 

[Planktonmd]

Great.
Looking forward to participate.
I suggest that each post should address one case only to make the discussion easier.

 

[aredoubleyou]

THis was my call last night (I have 3 cases to discuss pick them as you like):

1) 5pm called from OB for pt with retained placenta. She has a working epidural, sev. pre-eclampsia 180's/100's, >2+ pitting edema, PCN allergy, no meds, no PSH, plts150's. OB wants to go to OR for removal of retained plaenta. On arrival BP 80/42, HR 110, pt uncomfortable (epidural off per OB for delivery and hypotension). I take care of this issue and then Ortho/spine says he has 3 cases to do; nec fasc (this was the easy case so lets not talk about it).

2) 24 yo female rollover MVA major facial lacs (degloving the majority of her face) and a C2 fx (dens is free floating😱). Very little history. Pt somewhat uncooperative. She remembers nothing because she was asleep as the passenger when the MVA occurred.

3) 16 yo male fell from tree 25-50 ft. L3 burst fx with cord compromise and RLE weakness. No PMH, No PSH, no fam hx, no meds, nkda's. BP 160/ 84 temp 98.2, labs WNL. NPO >12 hrs. Physical exam reveals self inflicted lacerations on forearm ("Hi"). WTF? denies drugs, occasional etoh.

Pick the case you want to do and we can discuss. We can talk about them all together. Or you can makes comments on all, I don't care.

1. GETA, blood, and more blood.

2. Dont have much experience w/ precedex, but this seems like it would be ideal in this situation for the awake FOB. Droperidol + Fent might not be to bad in this situation too, actually. Free floating dens - wouldnt think about glydescope, either FOB or trach. A-line, couple good IVs. Fluid loss will be higher 2/2 degloving. Face should be prepped with something along the lines of vasaline gauze, esp if going prone. Ketamine+propofol+sufent if motors are being monitored. Work in some volatile and maybe get rid of the propofol if SSEP. Low threshold for her waking up tomorrow in the icu.

3. Extra stick of propofol for induction...no drugs, yea right. More or less the same as above, can skip the a-line, same worries of unidentified injuries (pneumo, bleeding, stunned myocardium, etc). Plan to extubate at end of case.

 

[Noyac]

1. GETA, blood, and more blood.

2. Dont have much experience w/ precedex, but this seems like it would be ideal in this situation for the awake FOB. Droperidol + Fent might not be to bad in this situation too, actually. Free floating dens - wouldnt think about glydescope, either FOB or trach. A-line, couple good IVs. Fluid loss will be higher 2/2 degloving. Face should be prepped with something along the lines of vasaline gauze, esp if going prone. Ketamine+propofol+sufent if motors are being monitored. Work in some volatile and maybe get rid of the propofol if SSEP. Low threshold for her waking up tomorrow in the icu.

3. Extra stick of propofol for induction...no drugs, yea right. More or less the same as above, can skip the a-line, same worries of unidentified injuries (pneumo, bleeding, stunned myocardium, etc). Plan to extubate at end of case.

I should clarify something. It is 10pm, we are not planning on fixing the C2 fx tonight. All we are doing with face is repair of the lac's and she is in an aspen collar.

Would you use precedex on this case when you don't have much experience with it?

How would you induce #3?

 

[doctor712]

1. GETA, blood, and more blood.

2. Dont have much experience w/ precedex, but this seems like it would be ideal in this situation for the awake FOB. Droperidol + Fent might not be to bad in this situation too, actually. Free floating dens - wouldnt think about glydescope, either FOB or trach. A-line, couple good IVs. Fluid loss will be higher 2/2 degloving. Face should be prepped with something along the lines of vasaline gauze, esp if going prone. Ketamine+propofol+sufent if motors are being monitored. Work in some volatile and maybe get rid of the propofol if SSEP. Low threshold for her waking up tomorrow in the icu.

3. Extra stick of propofol for induction...no drugs, yea right. More or less the same as above, can skip the a-line, same worries of unidentified injuries (pneumo, bleeding, stunned myocardium, etc). Plan to extubate at end of case.

Quick questions (from a pre-med please don't skewer me, it's 1020pm and STILL 92 degrees out, long day 😀 )...

#3) Is the extra stick of propofol because kid cuts himself and occasionally uses etoh (16 y/o) so we're expecting he's dabbled in drugs and might need a little more pain med/hypnotic for induction?

#3) In the same 16 y/o...I remember a discussion from observing in OR about two years ago about certain paralytics (ND vs Depolarizing) after nerve trauma. And predisposing for...Hyperkalemia I think?? Is this one of those cases to choose paralytic according to trauma and cord damage? The discussion was along the lines of not using certain paralytics following trauma (could have been burn, or spinal cord trauma, wish I could recall)...until ~12 months following, then it becomes 'safe' again. The ENTIRE explanation was given to me, but I wish I could remember now. 😕 I guess that's code for I hope in this case discussion someone would give me a heads up where I could read about this topic again! 🙂

For those of you who know me, I really love reading these cases. And chime in rarely, which sort of makes sense since I don't know nuttin' bout this stuff!

D712

 

[Idiopathic]

1) 5pm called from OB for pt with retained placenta. She has a working epidural, sev. pre-eclampsia 180's/100's, >2+ pitting edema, PCN allergy, no meds, no PSH, plts150's. OB wants to go to OR for removal of retained plaenta. On arrival BP 80/42, HR 110, pt uncomfortable (epidural off per OB for delivery and hypotension). I take care of this issue and then Ortho/spine says he has 3 cases to do; nec fasc (this was the easy case so lets not talk about it).

so my first thought is that this some sort of embolism/DIC picture at this point...obv big vag bleeding is also possible but hasnt been mentioned. With those vitals I go to sleep, art line, good access (cordis?). transfuse rbc/ffp/plt/cryo as needed, wouldnt be shy based on what they find.

 

[Idiopathic]

2) 24 yo female rollover MVA major facial lacs (degloving the majority of her face) and a C2 fx (dens is free floating😱). Very little history. Pt somewhat uncooperative. She remembers nothing because she was asleep as the passenger when the MVA occurred.

ketamine 1-2 mg/kg and "take a look" with a video laryngoscope and inline stabilization, paralyze when i see the cords and intubate. if i cant get a view then based on scenario decide whether to wake up vs asleep FOI. leave intubated after surgery for the eventual C2 repair/decision to halo.

 

[Idiopathic]

3) 16 yo male fell from tree 25-50 ft. L3 burst fx with cord compromise and RLE weakness. No PMH, No PSH, no fam hx, no meds, nkda's. BP 160/ 84 temp 98.2, labs WNL. NPO >12 hrs. Physical exam reveals self inflicted lacerations on forearm ("Hi"). WTF? denies drugs, occasional etoh.

urgent case, deserves to go to the OR. id be most concerned with ecstasy/MDMA or cocaine, as those seem to be the most significant to interact with my anesthetics. i think id be okay with a propofol RSI although I would probably use rocuronium instead of sux as i think there may be increased risk of rhabdo which may relate to sux...cant remember offhand.

 

[aredoubleyou]

I should clarify something. It is 10pm, we are not planning on fixing the C2 fx tonight. All we are doing with face is repair of the lac's and she is in an aspen collar.

Would you use precedex on this case when you don't have much experience with it?

How would you induce #3?

I dont know her npo status, but at night with traumas unless Ive got clear evidence that she is 6-8 hrs npo BEFORE the trauma, I'm treating her like a full stomach. There is little to gain from trying to be a hero and either placing an lma, natice airway ketamine, or intubating her in any other way than awake FOB. A floating dens on an otherwise healthy girl with a long life ahead of her is nothing to take lightly. Numb her up. No, youre right, I wouldnt experiment w precedex, it would be fent, droperidol, and maybe some vsd...(usually dont use droperidol, but you inferred she wouldnt be terribly cooperative...).

For number 3, generous fentanyl, lidocaine, propofol, sux, tube...RSI. If 8 hrs npo before the fall.....still rsi due to the cuts on his arms. Nothing good comes from weirdos at night. And no, that is not my oral board answer.

 

[aredoubleyou]

ketamine 1-2 mg/kg and "take a look" with a video laryngoscope and inline stabilization, paralyze when i see the cords and intubate. if i cant get a view then based on scenario decide whether to wake up vs asleep FOI. leave intubated after surgery for the eventual C2 repair/decision to halo.

I'd be down with that for a type III dens, but floating....no sir, she is wigling her toes and fingers for me with an ETT in place. Maybe im an a-hole, but this girl should be in a halo, she's a ticking time bomb.

 

[aredoubleyou]

Quick questions (from a pre-med please don't skewer me, it's 1020pm and STILL 92 degrees out, long day 😀 )...

#3) Is the extra stick of propofol because kid cuts himself and occasionally uses etoh (16 y/o) so we're expecting he's dabbled in drugs and might need a little more pain med/hypnotic for induction?

#3) In the same 16 y/o...I remember a discussion from observing in OR about two years ago about certain paralytics (ND vs Depolarizing) after nerve trauma. And predisposing for...Hyperkalemia I think?? Is this one of those cases to choose paralytic according to trauma and cord damage? The discussion was along the lines of not using certain paralytics following trauma (could have been burn, or spinal cord trauma, wish I could recall)...until ~12 months following, then it becomes 'safe' again. The ENTIRE explanation was given to me, but I wish I could remember now. 😕 I guess that's code for I hope in this case discussion someone would give me a heads up where I could read about this topic again! 🙂 For those of you who know me, I really love reading these cases. And chime in rarely, which sort of makes sense since I don't know nuttin' bout this stuff!

D712

In all honesty, I wouldn't actually draw up an extra stick, but often drug abusing weirdos take a lot more juice to go down...on average. The relaxant your referring to is succinylcholine. After a major denervation injury, your muscles up regulate additional nicotinic receptors, outside the neuromuscular junction (extrajunctional). Sux will depolarize all of these receptors, causing a net outflow of K. B/c theres so many additional extrajunctional receptors, the amount of K is much greater than normal. Too much K....bad.

Ok, now go be a good college student and go to the pub, get drunk and have sex with a fat girl (then deny it the next day).

 

[aredoubleyou]

urgent case, deserves to go to the OR. id be most concerned with ecstasy/MDMA or cocaine, as those seem to be the most significant to interact with my anesthetics. i think id be okay with a propofol RSI although I would probably use rocuronium instead of sux as i think there may be increased risk of rhabdo which may relate to sux...cant remember offhand.

sux all the way, man. Rhabdo -Shmabdo....yea, I just said that. If he was going to go next week, yea I'd agree with you. But tonight...make him fasciculate 😀

 

[doctor712]

In all honesty, I wouldn't actually draw up an extra stick, but often drug abusing weirdos take a lot more juice to go down...on average. The relaxant your referring to is succinylcholine. After a major denervation injury, your muscles up regulate additional nicotinic receptors, outside the neuromuscular junction (extrajunctional). Sux will depolarize all of these receptors, causing a net outflow of K. B/c theres so many additional extrajunctional receptors, the amount of K is much greater than normal. Too much K....bad.

Ok, now go be a good college student and go to the pub, get drunk and have sex with a fat girl (then deny it the next day).

So it was HyperK and Sux with nerve injury, I remembereda tidbit from two years ago!!! I'll read up on that more though, I thought it was an interesting topic.

College student? You realize I'm 37... 😱

Thanks for the reply! D712

 

[narcusprince]

As to using succinycholine in the third case. My understanding is that it takes time to upregulate psuedoreceptors that can cause hyperkalemia roughly 24-48 hrs. I think it would be safe to use succinycholine if the fracture occured in the last 12 hrs. Also, it would depend on what type of drug the patient ingested cocaine stimulant, MDMA stimulant, vs depressive agents Alcohol, THC. Nonetheless you cannot go wrong with having an extra stick of propofol. I would be concerned with an exagurated response to intubation so have some labetalol and or esmolol ready to go and nitroglycerin. Understanding that he does not have a sick heart, but even in a normal heart people still vasospasm their coronarys with cocaine.

 

[Planktonmd]

For case #2 (Facial trauma)
Provided that there does not appear to be airway injury and that the airway does not appear difficult can we just induce GA and intubate with inline immobilization?
Is an induction of GA using Etomidate + Sux acceptable?
Any intra-op concerns about the cervical spine?

 

[sevoflurane]

If there is evidence of significant facial injury either by physical exam or radiology, the board will not fault you for saying surgical airway under local. Broken mandible, maxilla, cribiform plate, soft tissue injuries, etc are concerning. Degloving injury to the face is concerning in itself. Facial edema is around the corner if not there already. Swollen tongue and lips may pose a problem.

If the person is lucid, cooperative with no acute issues with re. to vital signs, you can do an AFOI with sedation + topicalization + blocks + glyco + inline stabilization. You don't want this person bucking. I would take my time if there is no immediate need for an AW. You have not burned any bridges if you have not removed your ability to ventilate/SV.

IF in dire need, and the sats are in the toilet you can

1. Assist ventilation while a surgical AW is placed
2. If there is not enough time, then RSI with inline stab.

Halo can go on in the trauma bay under local after ABC's.

Sux is safe to give so long as labs are ok. Give a defasciculating dose of NDNMB to try and decrease movement. I would not use it after 1-2 days.
Etomidate may give you unwanted myoclonous and HTN with a C-spine injury (and possible intracranial injury). Better choice would be propofol or pent.

Intraop concerns are: Edema, Bleeding, Mechanical trauma, VAE, maintanence of SCBF, increases or decreases in ICP. Compression of Spinal Cord at C2 may knock out T1-4 as well as phrenic. EPI or DA should be available to correct for bradycardia and hypotension. Paicing may be required. Postop ventilation may be necessary.

 

[bostonblaz]

#1 If I had an epidural that worked I may take her back and give her 5 cc of cpc and have her sitting and see if I can get her numb enough to do it cause a baby just came outta there and most likey the ob can get elbow deep in there with minimal discomfort. Also if she has had an epidural running for hours as well as an IV there is a small chance that 5 of cpc will do anything hemodynacially. This also affords me time to get ready (pound in some colloid like albumin or hespan)for the **** show that I am sure will follow as the ob continues to try and 007 yet another women. If all goes well then she gets a little duramorph in the epidural and we call it a day.
#2 I would use dex, in her age range i would start with a bolus dos of 0.5 mcg per kilo and then start her on a 1 mcg/kg/hr drip as I numb her up with the atomiser and the 5% lido gel on the oral airway. I would also do a trans tracheal block cause I really dont want her to cough. once I am all set and she tolerates the oral airway with out a gag, i would bolus the other .5 mg/kg and then some verced if needed. slip in the tube and have her wiggle everything with the scrub nurse and neurosurgeon see it then sit back and call it a day
#3 I would use prop, roc and call it a day

 

[gaspasser2004]

1) 5pm called from OB for pt with retained placenta. She has a working epidural, sev. pre-eclampsia 180's/100's, >2+ pitting edema, PCN allergy, no meds, no PSH, plts150's. OB wants to go to OR for removal of retained plaenta. On arrival BP 80/42, HR 110, pt uncomfortable (epidural off per OB for delivery and hypotension). I take care of this issue and then Ortho/spine says he has 3 cases to do; nec fasc (this was the easy case so lets not talk about it).

Pt too unstable for epidural dosing and needs airway secured. RSI with etomidate/succinylcholine. Fluid/blood as indicated.

2) 24 yo female rollover MVA major facial lacs (degloving the majority of her face) and a C2 fx (dens is free floating😱). Very little history. Pt somewhat uncooperative. She remembers nothing because she was asleep as the passenger when the MVA occurred.

Any airway techinque in this patient should be done awake because we don't know for sure how much her airway has been compromised by the MVA given the extensive facial injuries. My preference would be to do an awake tracheostomy to get a definitive airway for the rest of her hospital course as she currently has an unstable neck and will likely be returning to the OR for additional procedures.

3) 16 yo male fell from tree 25-50 ft. L3 burst fx with cord compromise and RLE weakness. No PMH, No PSH, no fam hx, no meds, nkda's. BP 160/ 84 temp 98.2, labs WNL. NPO >12 hrs. Physical exam reveals self inflicted lacerations on forearm ("Hi"). WTF? denies drugs, occasional etoh.

RSI with sux. You don't have to worry about extrajunctional receptors until 24 hours after cord injury.

 

[Planktonmd]

If there is evidence of significant facial injury either by physical exam or radiology, the board will not fault you for saying surgical airway under local.

How do you do an awake tracheostomy on a patient with unstable C2 fracture?
Do you keep her fully awake?
Do you give some kind of sedation?
How do you stabilize the neck while providing good access for the surgeon?

 

[Planktonmd]

#2 I would also do a trans tracheal block cause I really dont want her to cough.

How do you do a trans tracheal block without the patient coughing?

 

[Idiopathic]

nobody said i was worried about extrajunctional receptors. ecstasy and cocaine (maybe also meth?) can cause delayed rhabdo and sux will worsen that so yes its rare but i think i could get away with roc. am not concerned about his cord injury in regards to defasiculation.

 

[sevoflurane]

How do you do an awake tracheostomy on a patient with unstable C2 fracture?
Do you keep her fully awake?
Do you give some kind of sedation?
How do you stabilize the neck while providing good access for the surgeon?

Depends on the situation. Sometimes you have to give sedation, however:

Percutaneous Tracheostomy.
Lots of Local with minimal to no sedation especially with neurological or cardiorespiratory compromise.
Lots of reassurance.
No head extension/shoulder roll.
Inline stabilization with slight rostral traction.

 

[Noyac]

Good responses all of them and many different approaches. I don't know if what we did that night was the right way and I do know that the oral examiners would probably have me return for another attempt with the choices we made but it all worked smoothly or as you will see somewhat smoothly.

1) This one can be tricky and a GA is definitely a reasonable approach. However, I find GA to be somewhat risky here as well. No matter what you give her, her BP is going to tank. The OR team was on there way in but this girl was bleeding behind the placenta as best we could tell due to her vitals and the lack of obvious hemorrage on the bed. I gave a little neo to see what the respond would be and it was favorable. I didn't want to wait for the OR team since she was bleeding (if things went terribly wrong they would be there by the time we got her to the OR and if not the OB nurses know how to work the OR) so I dosed the epidural sort of slowly enough to allow the OB get his arm up there and extract the placenta. We ran 2L IVF into her in a matter of 10 minutes and some additional neo. She did fine.

I think in this situation Bostonblaz gets it right (other approaches are not wrong, just not my approach). I believe delaying her for the OR would have made things worse and dosing an epidural is not as dramatic of a sympathetic block as a spinal and therefore, manageable. This may have been a greater resuscitation had she received a GA.

 

[Idiopathic]

How do you do an awake tracheostomy on a patient with unstable C2 fracture?
Do you keep her fully awake?
Do you give some kind of sedation?
How do you stabilize the neck while providing good access for the surgeon?

These are all my questions, and this is why i do not elect to do awake airway techniques on unstable necks especially those that are not necessarily cooperative, which is an absolute necessity for such a procedure. In my opinion, this is why the video laryngoscope was invented and id do as i said: ketamine->take a look->if cant see anything would pass bronchoscope unless obvious problems like traumatized or bloody airway or patient is 500 pounds etc. If that doesnt look good then i think you have to consider paralyzing, mask ventilating, followed by tracheostomy. Maybe pass an orogastric tube early but still up to patient tolerance.

is this that far off base?

 

[Idiopathic]

Noyac my concern would be how long the epidural was off and how long its going to take to get a surgical level of analgesia - she is going to need supplementation for that procedure. Now if it was JUST turned off i think thats a little different but you said off for delivery and hypotension (2 hours? 6 hours?) just wondering the time frame. But again, you saw the patient, and I was thinking DIC at first so...

 

[Noyac]

2) This one is a little bit trickier. This girl was not going to cooperate (yes we have ways to make her cooperate) and the last thing we want is for her to extend her neck. I had a long discussion with the spine guy while we were doing the fec fasc case. He could not place a halo with her facial injuries (possibly afterwards) and he felt that she was reasonably stable if she remained in an Aspen collar. We reviewed the CT/MRI and the anatomy was intact but the fx went straight thru the base of the dens. She had zero deficits but was getting more and more anxious. Time was important her so my partner and I teamed up to get her off to sleep for a look. We used the glidescope and left her in the aspen collar.

I don't know of any guaranteed way to topicalize an airway 100% without coughing on the transtracheal block or at least some on the tube as it goes in. This girl was not going to smoke the peacepipe or tolerate us atomizing her airway without some movement. Sure I've done many awake intubations that didn't cough or buck but I've also seen them buck some when they have been extensively topicalized. I would not want this pt to buck at all.

Plan is for her to remain in Aspen collar and return to OR in a few days for dens screw. Surgeon was fine with extubation and sending her to the floor to await dens screw. How you gonna extubate her?

BTW, I have seen a lot of request for surgical airways on this forum, even some by myself. But how many times have you guys had to resort to this? I would think there would be a lot of people walking around this country with scars on their necks from surgical airways the way we throw them around on this forum. Not an option in this case IMHO.

 

[Noyac]

3) This case caught me off guard. Normal looking kid with the exception of self mutilation. Normal parents and no real history. Kid has never had surgery. I usually don't give sux especially to young males if they haven't had it before and there is no good indication. He may have had an indication since he was a trauma but the accident occurred about 24 hours ago and he hadn't had anything to eat or drink in at least 12 hrs. I did an RSI but with roc 50mg. We are monitoring for the spine case so thats all the relaxant he gets. I usually run total TIVA but with the propofol shortage I cut down the amount of prop and add some background DES. No ketamine for this guy since his history is suspect. THe case goes perfectly. The vitals are train tracks as you would expect from a 16 yo. 120/70, 64, 100% on FiO2 0.6, T 37.6 ETCO2 35, DES 2.0 Prop 100mcg/kg/min, TOF 4/4, BIS 40-55. Pt is prone and the strangest thing happens around 1:30 hrs into the case. He starts to shake. Its like a slight tremor over his entire body. I bolus with prop, give some fent, and then 10mg roc maintaining 4/4 twitches. I'll stop here😕

 

[Noyac]

Noyac my concern would be how long the epidural was off and how long its going to take to get a surgical level of analgesia - she is going to need supplementation for that procedure. Now if it was JUST turned off i think thats a little different but you said off for delivery and hypotension (2 hours? 6 hours?) just wondering the time frame. But again, you saw the patient, and I was thinking DIC at first so...

Good point. She still had some effect from the epidural so it hadn't been off for long. It usually just takes a few minutes to get an adequate level if yo are using the right stuff. I wasn't using the labor mix, that's for sure.

 

[Planktonmd]

Depends on the situation. Sometimes you have to give sedation, however:

Percutaneous Tracheostomy.
Lots of Local with minimal to no sedation especially with neurological or cardiorespiratory compromise.
Lots of reassurance.
No head extension/shoulder roll.
Inline stabilization with slight rostral traction.

🙂
Do we keep the collar on or take it off during this procedure?

 

[Planktonmd]

Tell the evoked potentials guy to stop stimulating the patient. 😀

3) This case caught me off guard. Normal looking kid with the exception of self mutilation. Normal parents and no real history. Kid has never had surgery. I usually don't give sux especially to young males if they haven't had it before and there is no good indication. He may have had an indication since he was a trauma but the accident occurred about 24 hours ago and he hadn't had anything to eat or drink in at least 12 hrs. I did an RSI but with roc 50mg. We are monitoring for the spine case so thats all the relaxant he gets. I usually run total TIVA but with the propofol shortage I cut down the amount of prop and add some background DES. No ketamine for this guy since his history is suspect. THe case goes perfectly. The vitals are train tracks as you would expect from a 16 yo. 120/70, 64, 100% on FiO2 0.6, T 37.6 ETCO2 35, DES 2.0 Prop 100mcg/kg/min, TOF 4/4, BIS 40-55. Pt is prone and the strangest thing happens around 1:30 hrs into the case. He starts to shake. Its like a slight tremor over his entire body. I bolus with prop, give some fent, and then 10mg roc maintaining 4/4 twitches. I'll stop here😕

 

[sevoflurane]

🙂
Do we keep the collar on or take it off during this procedure?

I would punt this question to the surgeon. 😛 ... although my guess is that most will take it off.

 

[Noyac]

Tell the evoked potentials guy to stop stimulating the patient. 😀

Wish that was it. Everyone in the room started looking at him and he said "What the ----". It settled down with the 10 mg of roc. But it happened 2 more times b/4 we were done.

 

[Planktonmd]

Wish that was it. Everyone in the room started looking at him and he said "What the ----". It settled down with the 10 mg of roc. But it happened 2 more times b/4 we were done.

So, 2 remaining possibilities:
1- Seizure activity: would be unlikely under propofol infusion and I would think that the SSEP guy would be able to see abnormal EEG on his equipment.
2- Shivering: patient is cold and lightly anesthetized.

 

[sevoflurane]

Light anesthesia in someone with increased MAC requirements? Infusion pumps properly working? Did his vitals go up during these episodes. Generalized tremor? Seizure maybe. Maybe just unexplainable weirdness or having a dream in which he is a wiggling worm.

 

[Noyac]

So, 2 remaining possibilities:
1- Seizure activity: would be unlikely under propofol infusion and I would think that the SSEP guy would be able to see abnormal EEG on his equipment.
2- Shivering: patient is cold and lightly anesthetized.

Sz activity possible but unlikely under propofol anesthetic like you said and the neuro monitoring guy noticed nothing.

Shivering unlikely b/c his temp was 37.6 at the time.

 

[Noyac]

Light anesthesia in someone with increased MAC requirements? Infusion pumps properly working? Did his vitals go up during these episodes. Generalized tremor? Seizure maybe. Maybe just unexplainable weirdness or having a dream in which he is a wiggling worm.

Vitals stable and unchanged at any point during this tremor. BIS read 40's the whole time as well.

 

[Narcotized]

I dont know her npo status, but at night with traumas unless Ive got clear evidence that she is 6-8 hrs npo BEFORE the trauma, I'm treating her like a full stomach.

Gastric secretions can be about 1 1/2 l/day. Unless the delay between accident and surgery is very minimal, I would treat everyone like a full stomach regardless of when they ate.

 

[TenaciousGirl]

3) This case caught me off guard. Normal looking kid with the exception of self mutilation. Normal parents and no real history. Kid has never had surgery. I usually don't give sux especially to young males if they haven't had it before and there is no good indication. He may have had an indication since he was a trauma but the accident occurred about 24 hours ago and he hadn't had anything to eat or drink in at least 12 hrs. I did an RSI but with roc 50mg. We are monitoring for the spine case so thats all the relaxant he gets. I usually run total TIVA but with the propofol shortage I cut down the amount of prop and add some background DES. No ketamine for this guy since his history is suspect. THe case goes perfectly. The vitals are train tracks as you would expect from a 16 yo. 120/70, 64, 100% on FiO2 0.6, T 37.6 ETCO2 35, DES 2.0 Prop 100mcg/kg/min, TOF 4/4, BIS 40-55. Pt is prone and the strangest thing happens around 1:30 hrs into the case. He starts to shake. Its like a slight tremor over his entire body. I bolus with prop, give some fent, and then 10mg roc maintaining 4/4 twitches. I'll stop here😕

Have you ever seen anything like this before?

can "anesthesia awareness" cause this? From what I've read it seems unlikely ... but, it also seems unlikely that a pt would have physical movement at all with those types of drugs in their system. ??

 

[Idiopathic]

an interesting question to ask would be if the twitching was global or were the lower extremities spared. certainly unlikely to be a cortical process (i.e. seizure) if the legs were moving, since i assume they are currently paralyzed

i also dont understand what kind of monitoring you are doing. we do motor evoked potentials without any volatile agent or paralytic and we do sensory evoked with 1/2 MAC and paralytic - seems like you combined the two techniques here. do your neuromonitoring guys not care about volatile anesthetic in MEPS cases?

 

[aredoubleyou]

Gastric secretions can be about 1 1/2 l/day. Unless the delay between accident and surgery is very minimal, I would treat everyone like a full stomach regardless of when they ate.

Good point, defenitely something to keep in mind, especially for oral boards👍

I do, however, consider that concern a bit steeped in dogma, and in practice, and dont make a hard/ fast rule to rsi those people. Same with run of the mill diabetics, or inactive gerd.

 

[Noyac]

Have you ever seen anything like this before?

can "anesthesia awareness" cause this? From what I've read it seems unlikely ... but, it also seems unlikely that a pt would have physical movement at all with those types of drugs in their system. ??

Never.

Could be awareness but I'd think awareness when not paralyzed would lead to more movement rather tremors but I've never seen awareness either.

 

[Noyac]

an interesting question to ask would be if the twitching was global or were the lower extremities spared. certainly unlikely to be a cortical process (i.e. seizure) if the legs were moving, since i assume they are currently paralyzed

i also dont understand what kind of monitoring you are doing. we do motor evoked potentials without any volatile agent or paralytic and we do sensory evoked with 1/2 MAC and paralytic - seems like you combined the two techniques here. do your neuromonitoring guys not care about volatile anesthetic in MEPS cases?

TRemor was global. The lower extremities were not paralyzed, he came to us with RLE weakness only. I don't follow you when you say unlikely to be cortical if legs were moving.

Our neuro monitoring guys are very good and very reasonable. As long as we don't make drastic changes they can monitor the pt with whatever technique we do within reason. I usually go sans volatile but most of my partners use some volatile agent. I gave non-depolarizer up front which was gone at the time of spinal manipulation.

 

[Idiopathic]

my thought was the if the legs were our (i.e. cord injury) then a cortical seizure would be unlikely to demonstrate pronounced lower extremity tremor but thats really just supposition on my part. interesting case.

 

[Noyac]

I would punt this question to the surgeon. 😛 ... although my guess is that most will take it off.

I would hope most would keep it on.

 

[proman]

an interesting question to ask would be if the twitching was global or were the lower extremities spared. certainly unlikely to be a cortical process (i.e. seizure) if the legs were moving, since i assume they are currently paralyzed

i also dont understand what kind of monitoring you are doing. we do motor evoked potentials without any volatile agent or paralytic and we do sensory evoked with 1/2 MAC and paralytic - seems like you combined the two techniques here. do your neuromonitoring guys not care about volatile anesthetic in MEPS cases?

1/2 MAC of volatile doesn't affect MEPS no matter what the neuromonitoring guys say. Either way, Noyac said he was using des at 2, which definitely wouldn't affect MEPS.

If the monitoring guys had their way we'd be doing remi-only anesthesia.

 

[sevoflurane]

I would hope most would keep it on.

Honestly, it's been a while since I've been part of an emergency surgical AW, but the ones I recall, I believe the C-collar came off most of the time. Floating dens may be a different story. When doing a surgical AW, I imagine moving around a C-collar is a bit combersome. I'm sure the right size c-collar is paramount. If it comes off, obviously inline stab. is going to be needed.
What is most peoples experience with this and is there a standard of care when doing one? Just asking cuz i don't know.

 

[sevoflurane]

1/2 MAC of volatile doesn't affect MEPS no matter what the neuromonitoring guys say. Either way, Noyac said he was using des at 2, which definitely wouldn't affect MEPS.

If the monitoring guys had their way we'd be doing remi-only anesthesia.

We were taught TIVA for MEPS. PP has taught me otherwise. Unless there is pre-existing neurological pathology, I tend to run .2-.3 MAC's. I usually add ketamine to all my neuromonitoring cases. They love it.
I'll run a TIVA from time to time so I can play "wake up when I want with my infusion". It's easier to have a little volatile on board and a bit more challanging when you don't use them for an 8 hour case.

 

[Noyac]

Honestly, it's been a while since I've been part of an emergency surgical AW, but the ones I recall, I believe the C-collar came off most of the time. Floating dens may be a different story. When doing a surgical AW, I imagine moving around a C-collar is a bit combersome. I'm sure the right size c-collar is paramount. If it comes off, obviously inline stab. is going to be needed.
What is most peoples experience with this and is there a standard of care when doing one? Just asking cuz i don't know.

Sorry, I didn't realize we were talking about a surgical airway procedure when removing the collar. Can't imagine keeping the collar on for this.

 

[sevoflurane]

No worries bro. You did have me second guessing myself however. 😀
Over yonder, I only do the trauma patients that can't get shipped out... which is a rare event.

 

[ssmallz]

What about drug withdrawl? for the shaking.....Did the ED get a tox?