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I'm not sure how this is the anesthesiologist's fault.

Should the doctor who ordered midazolam be held liable for the nurse giving vecuronium? No, right?

So why should the doctor who ordered propofol be held liable for the nurse not giving it?

Unless it's somehow the duty of the anesthesiologist to literally check everything? Maybe I could see it if it was a new resident anesthesiologist or anesthesia nursing student, but literally your degree should attest to the fact that you know how to properly place an IV and make sure it's working. And if your degree DOESN'T attest to that fact, then what good is it?
 
anes_swapper said:
I'm not sure how this is the anesthesiologist's fault.
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Legally there is a difference between responsibility and fault. It is likely that the supervising physician will be found partially responsible. But it is 100% the Anesthetist's fault.
 
I'm sure the crna didn't investigate why the patients BP and HR went through the roof when the propofol wore off.
 
Dr. Rude said:
Legally there is a difference between responsibility and fault. It is likely that the supervising physician will be found partially responsible. But it is 100% the Anesthetist's fault.
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But how can they be even partially responsible? Like I get that you're probably right in terms of legal precedent or whatever. But it is completely nonsensical imo. The only person who is responsible is the anesthesia nurse.
 
anes_swapper said:
But how can they be even partially responsible? Like I get that you're probably right in terms of legal precedent or whatever. But it is completely nonsensical imo. The only person who is responsible is the anesthesia nurse.
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Assuming the physician signed the terfa attestation then they’re very liable for this. Moreover with that Vanderbilt nurse legal approach, I can see several ways the physician and crna (/medic) can be criminally prosecuted.
 
anes_swapper said:
But how can they be even partially responsible? Like I get that you're probably right in terms of legal precedent or whatever. But it is completely nonsensical imo. The only person who is responsible is the anesthesia nurse.
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Thats the bed you make when you decide to supervise CRNAs; you get more money than MD only, but you also get to take responsibility for their screw-ups.

nimbus said:
Terrible.

And I wonder why anybody would disconnect a continuous infusion to push antiemetics. We usually hook up infusions to the port closest to the patient and have other free ports to push meds.
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Boggles the mind, but when in doubt, probably because it was the laziest approach. You couldve even pushed the antiemetic through the line running the propofol.... yikes.
 
GandalfTheWhite said:
Thats the bed you make when you decide to supervise CRNAs; you get more money than MD only, but you also get to take responsibility for their screw-ups.



Boggles the mind, but when in doubt, probably because it was the laziest approach.
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To me it seems like the dumbest, most task intensive, and most inefficient approach. The only reason I can think of is that maybe they are a newbie who read somewhere that propofol and the antiemetic are incompatible and didn’t want both drugs in the line at the same time??
 
TIVA is a risk factor for awareness and disconnected or infiltrated IV is a major reason why. Personally I give a little extra benzo and use a BIS when doing a TIVA when I would not otherwise when using volatile that is measured with every breath.
 
Mman said:
TIVA is a risk factor for awareness and disconnected or infiltrated IV is a major reason why. Personally I give a little extra benzo and use a BIS when doing a TIVA when I would not otherwise when using volatile that is measured with every breath.
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Same. I’m a BIS skeptic and use benzos sparingly but I use both for every TIVA. It’s what we have.
 
If I'm ever doing TIVA, I have a high high alert/red flag warning if I ever dose paralytic. It's really not a good idea in general. It's really not too hard to intubate without paralytic, or give sux. In general I think TIVA for PONV is not worth it if you have to dose paralytic in the case. If you gotta do it, AT LEAST just run a little sevo, like 0.5 MAC.

In general, TIVA is not worth it.
 
nimbus said:
Terrible.

And I wonder why anybody would disconnect a continuous infusion to push antiemetics. We usually hook up infusions to the port closest to the patient and have other free ports to push meds.
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Dude, it's just a CRNA kind of anesthesia. Anything is possible.
 
Mman said:
do you put a central line in for every spine case with tucked arms that is monitoring motors?

I don't

but I do make sure I have 2 good PIVs and a BIS
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The key is motors requires no paralytic, so light anesthesia is detectable with patient movement.
 
dipriMAN said:
The key is motors requires no paralytic, so light anesthesia is detectable with patient movement.
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by the time the patient starts moving you don't have a great way to ensure amnesia since you are now just realizing your IV is infiltrated
 
Mman said:
by the time the patient starts moving you don't have a great way to ensure amnesia since you are now just realizing your IV is infiltrated
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If the patient moved and I was worried about IV infiltration is would just turn in nitrous and half MAC sevo ….. would be on in a minute
 
dipriMAN said:
If the patient moved and I was worried about IV infiltration is would just turn in nitrous and half MAC sevo ….. would be on in a minute
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as would I, but personally I like the reassurance of the BIS in straight TIVA cases. They are literally the only cases I use a BIS in as I find it not very helpful in cases with volatile gas.
 
Mman said:
as would I, but personally I like the reassurance of the BIS in straight TIVA cases. They are literally the only cases I use a BIS in as I find it not very helpful in cases with volatile gas.
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but isnt bis just a random proprietary number? It doesnt provide you any useful info. Just keep between 40-60?
Ideally some sort of EEG like with the sedline would be better
 
wholeheartedly said:
aside from prevention mentioned above, are there ways to monitor for this occuring? would the EEG work, would it be feasible?
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From my experience the bis shows you that the patient is light after they are light. So I'll already know from them moving around or coughing. So wtf was the point of the bis?
 
GandalfTheWhite said:
but isnt bis just a random proprietary number? It doesnt provide you any useful info. Just keep between 40-60?
Ideally some sort of EEG like with the sedline would be better
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the BIS also shows you EEG aside from just the number
 
GandalfTheWhite said:
but isnt bis just a random proprietary number? It doesnt provide you any useful info. Just keep between 40-60?
Ideally some sort of EEG like with the sedline would be better
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It's worse than merely random. It reliably drops when paralytics are administered...which is precisely the only time a thoughtful practitioner would want a so-called "depth of anesthesia" monitor.

So, there are only two cases where I refuse to use the BIS:

1) In a non-relaxed patient, because I know the patient can move when he or she gets light. And
2) In a relaxed patient, because though the BIS is generally a terrible "monitor," it is EVEN WORSE when the patient is paralyzed.
 
BIS just false alarms. Waste of money. Then goes off 10 seconds after patient gets light.
 
coffeebythelake said:
Well the BIS isn't meant to prevent patient movement.
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What exactly is it meant to do?

If you are worried about awareness..you only need a minimum 0.3-0.4 Mac..which is way less than what we use for a typical case.

So the BIS doesn't provide you with any additional useful information to change management.

If you are running 0.8 Mac..and BIS jumps to 80..you think that your patient is aware now? Changes nothing. If your patient is so sick that they can only tolerate .3 Mac..and the BIS jumps to 80..are you going to increase the anesthetic and watch the patient tank?

If your patient is so sick that they aren't able to tolerate more than 0.3mac then I assure you they won't be aware at that level.
 
UscGhost said:
What exactly is it meant to do?

If you are worried about awareness..you only need a minimum 0.3-0.4 Mac..which is way less than what we use for a typical case.

So the BIS doesn't provide you with any additional useful information to change management.

If you are running 0.8 Mac..and BIS jumps to 80..you think that your patient is aware now? Changes nothing. If your patient is so sick that they can only tolerate .3 Mac..and the BIS jumps to 80..are you going to increase the anesthetic and watch the patient tank?

If your patient is so sick that they aren't able to tolerate more than 0.3mac then I assure you they won't be aware at that level.
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I don't use BIS when I'm running gas anesthetic. In fact I rarely use BIS at all, the most common exception is for TIVA cases because no better method exists in this situation to gauge depth of anesthesia. But my point holds. If you are using BIS to prevent patient movement you are using it wrong.
 
coffeebythelake said:
I don't use BIS when I'm running gas anesthetic. In fact I rarely use BIS at all, the most common exception is for TIVA cases because no better method exists in this situation to gauge depth of anesthesia. But my point holds. If you are using BIS to prevent patient movement you are using it wrong.
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I just said it alarms after the patient gets light (ie, you already detected patient wasn't deep enough so the BIS didn't provide useful info). I didn't say that it prevents movement.

Tiva plus paralytic is a pretty rare scenario. The vast majority you can switch 0.3 Mac of gas plus tiva and obtain the anti emetic effects.

And if the patient was TIVA, plus paralyzed, I assume you would notice the elev BP and HR that would suggest patient needs more propofol. And when a bolus didn't work, assessing the IV is my next step in case infiltrated.

BIS wouldn't provide much additional info in that setting
 
I mean atleast with the Sedline you have multiple EEG leads to evaluate compared to the BIS. Much better timed wakeups with that compared to blind TIVA or BIS
 
In residency I had a BIS stuck to the floor and it was reading 40. I rarely use it in private practice.
It’s not an ASA standard monitor, and if you administer ketamine it gets wonky.
I suppose I’d use it for a TIVA just to have some kind of monitor and documentation.
 
vector2 said:
To my knowledge MAC aware is 0.7
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"Antegrade amnesia at 0.25 Mac".

Minimum Alveolar Concentration - StatPearls - NCBI Bookshelf.

Most articles reference 1/3 Mac .maybe 0.3-0.4 that I could find. Boards said 0.3.

And that doesn't take into account the contribution of opioids, age, benzos, lido,etc. So even running 0.3 Mac of gas would generally always be a real world Mac much higher.

I was merely establishing the absolute floor..not recommending anyone do a case at 0.3 haha
 
UscGhost said:
"Antegrade amnesia at 0.25 Mac".

Minimum Alveolar Concentration - StatPearls - NCBI Bookshelf.

Most articles reference 1/3 Mac .maybe 0.3-0.4 that I could find. Boards said 0.3.

And that doesn't take into account the contribution of opioids, age, benzos, lido,etc. So even running 0.3 Mac of gas would generally always be a real world Mac much higher.

I was merely establishing the absolute floor..not recommending anyone do a case at 0.3 haha
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Separate from the additive MAC phenomenon, we probably need to be more specific about what were referring to with the terminology "MAC aware" or "MAC awake." Because those are distinct from the concept of "MAC amnesia" which is what you're describing.

Establishing antegrade amenesia shouldn't be minimum floor we're setting, because that implies the pt underwent an extremely unpleasant experience.....but simply didn't remember it. The salient point to me philosophically in that scenario is that their being awake for the unpleasant experience was the bad part- regardless of whether they remember it or not.

Ergo, "MAC aware" for me means the pt is actually unconsciousness and is not experiencing the event, which obviously precludes the possibility of even needing to have anterograde amnesia.

Screenshot_20220408-104549_Chrome Beta.jpg

www.apsf.org

Importance of End-Tidal Agent Monitoring as a Standard of Care

In some countries anesthetic agent monitoring is a written Standard of Care while in others it is not even mentioned.1 Most anesthesia care providers use
www.apsf.org www.apsf.org

Screenshot_20220408-103919_Chrome Beta.jpg

 
vector2 said:
To my knowledge MAC aware is 0.7
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MAC aware is around 0.3 to 0.4 MAC,
But remember it is based on population studies, and that means 50% of the population... just like 1 MAC of gas means 50% of the population will not respond with movement to surgical stimulus. We do 0.7 MAC so we can ensure 99.9% of patients are unaware
 
coffeebythelake said:
MAC aware is around 0.3 to 0.4 MAC,
But remember it is based on population studies, and that means 50% of the population... just like 1 MAC of gas means 50% of the population will not respond with movement to surgical stimulus. We do 0.7 MAC so we can ensure 99.9% of patients are unaware
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Yup yup.

Things got a little side tracked from the original thought. My main general argument was that BIS was largely a useless monitor as it hasn't been shown to reduce awareness. We target a MAC level far beyond what would lead to awareness, and if you were really trying to reduce your anesthesia so low that you were relying on BIS to monitor for awareness (pretty rare scenario) ..then other signs of awareness would present themselves earlier and more reliably anyways (elev BP, HR, movement,etc)

So it ends up being an unproven monitor to be used in rare scenarios where other monitors are more reliable. If it was free...sure. But the devices can be expensive.
 
Bis is by no means a perfect monitor but it has its uses. I also use it during TIVA cases.

I'm also going to guess that the people who dismiss the Bis as universally useless don't supervise CRNAs or residents. It's one more layer to prevent or mitigate one kind of catastrophic error, when you can't be there 100% of the time.
 
Unfortunately we never got to use target controlled TIVA pumps in the US. Doing TIVA in the US is pretty much like when I was a medical student and resident using a copper kettle and vernitrol vaporizer to deliver halothane. I remember slide rules, thermometers and barometers attached to each anesthesia machine to calculate concentrations. Or I could just take the easy out and run a 5 liter flow with 60 percent nitrous and just bubble 100 cc per minute of oxygen through either of those vaporizers. In our complex neuro cases we get to have neuromonitoring techs do EEG, SSEP and motor evoked potentials so we are in monitoring nirvana. And paying attention to data in those cases makes it easier to be in the ballpark in other cases just as experienced pilots land planes in airports without instrument landing systems.
 
Drwine said:
Unfortunately we never got to use target controlled TIVA pumps in the US.
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While cool, those pumps don't mitigate the awareness/recall risk of TIVAs. (Except perhaps for the models that incorporate direct automatic feedback from Bis.)


A big part of the TIVA risk is the difficulty in being 100% certain that the drug you think you're giving is actually getting into the patient's circulation.

Those fancy target controlled TIVA pumps won't help you if someone plugs the cefazolin bag into the line via piggyback tubing without a check valve, and the propofol from the pump starts filling the cefazolin bag instead of going into the patient.

Or if the circ RN bolts the giant ex-lap ring clamp thingy to the bed rail, pinching and severing the IV tubing, making a puddle of propofol under the drapes.

Or if the IV infiltrates.

Or if the IV luer lock connector is juuuuust loose enough to let a slow, low pressure infusion leak out, but tight enough to let enough of the high-pressure induction dose go in to get the patient off to sleep.

All of which have happened to me when running TIVAs ...


The technology solution to eliminate these risks is an end-tidal propofol monitor. I'd like to have those pumps available, they sound great for timing wakeups after prolonged infusions, but they don't solve my biggest concern with TIVAs.
 
pgg said:
While cool, those pumps don't mitigate the awareness/recall risk of TIVAs. (Except perhaps for the models that incorporate direct automatic feedback from Bis.)


A big part of the TIVA risk is the difficulty in being 100% certain that the drug you think you're giving is actually getting into the patient's circulation.

Those fancy target controlled TIVA pumps won't help you if someone plugs the cefazolin bag into the line via piggyback tubing without a check valve, and the propofol from the pump starts filling the cefazolin bag instead of going into the patient.

Or if the circ RN bolts the giant ex-lap ring clamp thingy to the bed rail, pinching and severing the IV tubing, making a puddle of propofol under the drapes.

Or if the IV infiltrates.

Or if the IV luer lock connector is juuuuust loose enough to let a slow, low pressure infusion leak out, but tight enough to let enough of the high-pressure induction dose go in to get the patient off to sleep.

All of which have happened to me when running TIVAs ...


The technology solution to eliminate these risks is an end-tidal propofol monitor. I'd like to have those pumps available, they sound great for timing wakeups after prolonged infusions, but they don't solve my biggest concern with TIVAs.
Click to expand...
The IV pigtail loose but still connected is a killer. Had it happen once, first day case, the preop nurse didn’t connect it tightly, now I’m paranoid and checked every connector in the IV set and pigtail.
 
Some bullet point thoughts:

  • Jesus Christ, her description sounds especially horrifying and genuine.
  • SedLine > BIS, and it's much easier than many think to learn to read basic EEG in an anesthesized patient without movement artifact. Many are intimidated by neurologists doing complex analysis looking for seizure foci or whatever, but depth of anesthesia is much easier, especially with something like Sedline that also shows the frequencies separated out by Fourier analysis and plotted over time with color coded intensity.
  • TCIs are outlawed, but apps that tell you when to change the pump manually for a desired effect site concentration of medications are not, and are pretty useful in my opinion. I use iTiva a lot, especially for dosing hydromorphone, ketamine, or propofol TIVAs.
  • One attending in residency shared a TIVA strategy with me I like opposite to ~90% of anesthesiologists do: instead of connecting the propofol to the closest port, which is often hidden in surgery, connect it to the closest one you can see and place a nonwhite towel under it so you always have visualization of the propofol running into the carrier fluid and mixing. Combine this with a reliable IV you placed and secured yourself and you have a reliable infusion. If you're concerned about it interfering with boluses and such for a longer case, just start with a second IV since you're planning a TIVA anyway so you have a bolus line and gtt line.
 
I was always partial to this textbook line…
John Mayers commenting on the disadvantages of the much flouted bispectral index – “I once applied bispectral index electrodes to a serving of cherry gelatin with fruit cocktail from our cafeteria and recorded a bispectral index value of 22
 
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