Perioperative Sweating cases!

[DrAmir0078]

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Good Day Fellows,

I am bring something, hopefully interesting, It was a drama that we faced in the Laparoscopy theater a month ago!
One day, I was left alone to give anesthesia to one patient (young age), who ASA I, scheduled for lap cholecystectomy.

Premed: Fentanyl 50mcg
Induction: Ketamine 40 mg / Propofol 100 mg / Atracurium 30 mg
Maintenance : Isoflurane 1.4 Mac
During the Operation, the surgeon requested to load the patient with Paracetamol IV infusion (Acetaminophen) 1000 mg with Acupan (non opioid pain med) IM injection (As he used to do with all his patients).

Then 15 minutes after intubation, patient experienced Tachycardia, with sweating (The sweating better to be described as profuse sweating, you can imagine his sweats fell down from the OR table - an ocean of sweats), and his Blood pressure starts to raise.

We experienced in the past that Acupan can cause profuse sweating as a side effect (I witnessed it), and I thought it is from the Acupan this time, but patient was he awake? (using our parameters of vital signs, beside the patient's movement, swallowing, , etc - no BIS and I don't know what that is), probably he wasn't, because normally our Senior surgeon will tell (they look at the stomach or the organs by camera and tell us all the time- this time they didn't tell us, but the picture of awareness!)

From the vital signs, I suspected he is awake as I said, I gave him extra 10 mg of Atracurium, another dose of Fentanyl 25mcg and I called my Senior prior who instructed me "check his Blood glucose, increase the depth of Anesthesia, give muscle relaxants, , , etc" to do the last steps, and his Blood glucose was 230mg/dl!

The patient kept sweating, IV fluids were there, I had to give him 3 pints of NS !

Operation done !

Isoflurane is Off

The patient is not breathing by his own after 10 minutes, so I kept the Ventilator works, the next 30 minutes, the patient starts to breath, but not responding to jaw thrust, or painful stimuli, no movement at all, and I kept him on Spontaneous breathing and watching him!

I called my Senior 15 minutes later, he advised me to give him Furosemide 20 mg IV and give another pint of GS.

His Blood glucose was checked again and was almost raised a bit from the last reading!

I was thinking of hypothyroidism, but as the Senior Surgeon said "He is healthy guy", Or Metabolic disorder !

I even checked the Paracetamol infusion and read the ingredients and it said it has 5000 mg of mannitol and it left me suspicious (believe me, later at night I sent a message to the company and they explained that, this amount of mannitol is to make paracetamol fluidy like and he told me, that I was the first guy to ask them such question)

After we gave the Laxis, patient starts to urinate (foley was in), it was or not a coincidence that the patient starts to swallow, in 10 minutes later flickering his fingers, gets annoyed from the tube, then after such scenario, the patient woke up, and it took us around hour and a half, the patient became fully awake and tube removed !

Next day,
We had another two patients ASA I, for scheduled Lap Cholecystectomy.
First one --- Recovery time around 45 minutes then tube is out
Second one --- hour and a half = = = = =

Then what I did, I wrote on a white paper (The Machine is Out - contact BioMed Engineer) and sticked it on the Machine as we all agreed, this is not a coincidence, malfunctioned machine probably !

We believed the issue is the Vaporizer, as we checked mostly everything, we changed the Isoflurane vaporizer with another OR Anesthesia Machine, and it wasn't actually itself!

BioMed came a week later to fix the machine and they re-calibrated the Vaporizer !

We thought, we are going to be fine!

No actually, some patients still having issues with delayed recovery, but not as severe as the first three ones !

Have you ever faced such trouble, especially Profuse Sweating?

At that disastrous night for me, after the one I explained it, I found this interesting article from BJA :

Awareness during anaesthesia | Continuing Education in Anaesthesia Critical Care & Pain | Oxford Academic

Quoting this

Equipment malfunction
Breathing system malfunctions and disconnections have been
associated with awareness. Vaporizers may malfunction in a number
of ways, each having the potential to deliver an inadequate
dose of anaesthetic. These include: an empty vaporizer, miscalibration,
impurities in the volatile agent (reducing its saturated
vapour pressure) and disconnection from the anaesthetic machine.
Blockage of an i.v. infusion pump or catheter, disconnection from
the cannula or extravascular location of the cannula may risk
awareness during TIVA.

 

[San Marzano]

Do you have a gas analyzer to measure the end tidal isoflurane?

 

[DrAmir0078]

Do you have a gas analyzer to measure the end tidal isoflurane?

Can you please elaborate?
I don't know what that is!

 

[San Marzano]

Can you please elaborate?
I don't know what that is!

It’s a machine that samples the gas from the circuit as it leaves the patient and measures the amount of end tidal isoflurane which is the only way I know of to measure what MAC you’re at. If you had a malfunctioning gas delivery system then this machine would be able to alert you that the patient is not receiving enough anesthetic. When you talked to the patient after he woke up did he have any recall?

 

[DrAmir0078]

It’s a machine that samples the gas from the circuit as it leaves the patient and measures the amount of end tidal isoflurane which is the only way I know of to measure what MAC you’re at. If you had a malfunctioning gas delivery system then this machine would be able to alert you that the patient is not receiving enough anesthetic. When you talked to the patient after he woke up did he have any recall?

Thanks Dr. San for your explanation, so it is not Capnography ? (both we do not have) !
I didn't ask this question nor the patient said anything ( nor all of the rest - while some patients might say we heard you guys talking), I probably have to educate myself about asking the patients if they recall !
But Do I have to ask, in term of "Best of practice"?

 

[deleted697535]

What was the patients temperature? What was the warmer set to?

Pneumoperitoneum in healthy head up patients for lap chole causes sympathetic stimulation. That likely causes the htn/tachycardia. Maybe the sweating too.

This is a diagnosis of exclusion. But it's very common
Once you are happy with depth of anesthesia, consider esmolol to control this not more opioids. Lap chole is not very sore.

He stayed asleep to likely due to opioids and too much volatile.

Why would you give so much fluid? And then crystalloid along with diuretic at the same time?

 

[deleted697535]

If someone is not floridly hypo/hyper thyroid preop it is unlikely they will develop this under ga for 45 mins for a lap chole

If you are relying on a surgeon to tell you a patient is awake, then the horse has bolted!! Sorry

Also a surgeon 100% cannot tell you if a patient is 'awake'. They can only tell you that the abdo muscles are contracting which has nothing got to do with awareness.
Also you should always know more about the state of muscle relaxation than the surgeon. Do you use TOF? It is a minimum standard of monitoring when using nmb's

 

[DrAmir0078]

What was the patients temperature? What was the warmer set to?

Pneumoperitoneum in healthy head up patients for lap chole causes sympathetic stimulation. That likely causes the htn/tachycardia. Maybe the sweating too.

This is a diagnosis of exclusion. But it's very common
Once you are happy with depth of anesthesia, consider esmolol to control this not more opioids. Lap chole is not very sore.

He stayed asleep to likely due to opioids and too much volatile.

Why would you give so much fluid? And then crystalloid along with diuretic at the same time?

Wow
Interesting question Dr. Newtwo

Unfortunately we do measure the temperature once at the ward, not in the OR, only subjective (I mean by touching his forehead), but do you address that I have to buy my own thermometer?

A warmer? Do we need a warmer? Why?

So sympathetic stimulation causes tachycardia and Hypertension, true!
Sometimes we experienced hypotension, so we request to lower the CO2 tension inflation to 10 or 8 instead of 12 !

Esmolol is not available unfortunately, but if it is, what is the dose?
We have metoprolol only!

Yes, probably the case, too much opioid, but do you think 75 mcg of Fentanyl is the cause?

The sweating was so severe, I was afraid he is going to slide down off the table!

Why we give fluid + laxis (it is weird, but I believe it is like a substitute for the output, which has no scientific clue)

 

[DrAmir0078]

If someone is not floridly hypo/hyper thyroid preop it is unlikely they will develop this under ga for 45 mins for a lap chole

If you are relying on a surgeon to tell you a patient is awake, then the horse has bolted!! Sorry

Also a surgeon 100% cannot tell you if a patient is 'awake'. They can only tell you that the abdo muscles are contracting which has nothing got to do with awareness.
Also you should always know more about the state of muscle relaxation than the surgeon. Do you use TOF? It is a minimum standard of monitoring when using nmb's

Good to know about that regarding hypo/hyper thyroid..


That is true, we don't depend on the surgeon all the time, but sometimes they shout "the patient is awake"

TOF, I just looked it up, it is a device to monitor neuromuscular stimulation... Of course we don't have it!
Do I have to buy it too?
We rely on the corneal reflex!

Bear with me!

It is going to changed, my residency at the doorstep and I am learning!

I am so thankful!

 

[btbam]

Good to know about that regarding hypo/hyper thyroid..


That is true, we don't depend on the surgeon all the time, but sometimes they shout "the patient is awake"

TOF, I just looked it up, it is a device to monitor neuromuscular stimulation... Of course we don't have it!
Do I have to buy it too?
We rely on the corneal reflex!

Bear with me!

It is going to changed, my residency at the doorstep and I am learning!

I am so thankful!

Sometimes I really don’t appreciate working in a first world country.

 

[DrAmir0078]

Sometimes I really don’t appreciate working in a first world country.

Wow,
But Dr. btbam, we learn what you present to the world, your textbooks, techniques, machines
It is a grace, that we - in the third world rely on the science and technology of the west, and we have innovative ideas to modify things for us, and we have great Professors who learned in the west and teaching us !
Yet, we don't have everything, but still we can provide patients care!
It is what it is Dr. btbam!

 

[JOHNBROCHILL]

Serotonin syndrome? Fentanyl can precipitate. Any home medications?

 

[DrAmir0078]

Serotonin syndrome? Fentanyl can precipitate. Any home medications?

While he was asleep after the operation was done, I examined his reflexes like patella reflex / ankle , they were negative, nor planter reflex!

He was 85Kg (Fentanyl dose is within his kg, only 50mcg as permed pre induction and 25mcg during his awareness)

 

[deleted162650]

My first concern would be MH.

 

[DrAmir0078]

My first concern would be MH.

I know I failed to bring a thermometer, and I believe we need body core temperature!
He was pretty soaky with sweating!

While my first concern was that Acupan or the Acetaminophen containing weird mannitol to the cause!

 

[Ronin786]

Sounds incredibly suspicious for MH. Any change in urine color? Serotonin syndrome also is a possibility, we don't have nefopam in the US but it appears to have some serotonin effects.

Just as an aside, if you suspect somebody is awake then administering more opioid and muscle relaxant is the wrong thing to do. Neither one will provide amnesia and all you do is prolong their awareness under anesthesia. You need to increase your volatile anesthetic and administer a fast-onset hypnotic (ketamine/propofol/etomidate etc...) while the volatile anesthetic kicks in.

It's fascinating to think that you don't have capnography. What monitoring devices do you routinely use under general anesthesia?

 

[DrAmir0078]

Sounds incredibly suspicious for MH. Any change in urine color? Serotonin syndrome also is a possibility, we don't have nefopam in the US but it appears to have some serotonin effects.

Just as an aside, if you suspect somebody is awake then administering more opioid and muscle relaxant is the wrong thing to do. Neither one will provide amnesia and all you do is prolong their awareness under anesthesia. You need to increase your volatile anesthetic and administer a fast-onset hypnotic (ketamine/propofol/etomidate etc...) while the volatile anesthetic kicks in.

It's fascinating to think that you don't have capnography. What monitoring devices do you routinely use under general anesthesia?

Thanks Dr. Ronin786

No change in urine color!

Good point to take off my hat, so how about if the patient is moving?
For 15 months SHO, I was taught this :
If the patient starts moving his muscles, cricothyriod moving (swallowing like), twitching around his face, the first thing to do is to give muscle relaxant and increase the depth of Volatile gas, they justify that the patient is annoyed by the tube in his trachea. I had asked many times !

We give Propofol, Ketamine sometimes, but here they fear the delayed recovery!
Weird, isn't it?

No capnography!

EKG is rarely used !

We have Pulse, SPO2, BP, beside the screen of the machine that gives us about inspiration and expiration, Tv, RR, cmH2O, I:E,,, etc

 

[pgg]

Serotonin syndrome? Fentanyl can precipitate. Any home medications?

Acupan is nefopam which can precipitate serotonin syndrome.

 

[DrAmir0078]

Acupan is nefopam which can precipitate serotonin syndrome.

I had experienced Sweating, Tachycardia with Nefopam before this case, but woke up good, unlike this guy who woke up an hour and a half after operation done!


Thank You

 

[pgg]

It's fascinating to think that you don't have capnography. What monitoring devices do you routinely use under general anesthesia?

Capnography and gas analyzers seem to be pretty uncommon in developing nations.

Unfortunately we do measure the temperature once at the ward, not in the OR, only subjective (I mean by touching his forehead), but do you address that I have to buy my own thermometer?

A warmer? Do we need a warmer? Why?

Ideally you'd have the capability to monitor temperature in the OR. Even in warm climates and warm operating rooms, hypothermia is a risk to surgical patients. They're usually disrobed and exposed, subject to evaporative cooling from skin prep solutions, anesthesia causes peripheral vasodilation and rapid core cooling, add some room temperature IV fluids, etc, and patients can get significantly hypothermic. Even mild hypothermia has many bad effects on patients, e.g. delayed drug metabolism, delayed emergence, coagulopathy, higher wound infection rates, higher periop mortality, etc.

These are the ASA standards for monitoring:

Standards for Basic Anesthetic Monitoring - American Society of Anesthesiologists (ASA)

Even if you don't have access to all of these devices, it would be useful to be familiar with this standard and to read about some of the reasons for them.

 

[btbam]

Wow,
But Dr. btbam, we learn what you present to the world, your textbooks, techniques, machines
It is a grace, that we - in the third world rely on the science and technology of the west, and we have innovative ideas to modify things for us, and we have great Professors who learned in the west and teaching us !
Yet, we don't have everything, but still we can provide patients care!
It is what it is Dr. btbam!

Please don't interpret my answer as looking down on you. It's just shocking in 2018 to imagine doing anesthesia without capnography, a twitch monitor, or a gas analyzer.

 

[DrAmir0078]

Please don't interpret my answer as looking down on you. It's just shocking in 2018 to imagine doing anesthesia without capnography, a twitch monitor, or a gas analyzer.

I am not!

Here, is like the old days, we are doing anesthesia without these fancy monitors!

If you came here one day, you will still able to give anesthesia with what available, you will be innovative, proactive too; that's why I came here at SDN to live virtually what you do instead of only reading the textbooks or watching YouTube videos; I want to make a difference, bridging my thoughts, filling out the gaps and to make myself better than today for tomorrow!

 

[DrAmir0078]

Capnography and gas analyzers seem to be pretty uncommon in developing nations.



Ideally you'd have the capability to monitor temperature in the OR. Even in warm climates and warm operating rooms, hypothermia is a risk to surgical patients. They're usually disrobed and exposed, subject to evaporative cooling from skin prep solutions, anesthesia causes peripheral vasodilation and rapid core cooling, add some room temperature IV fluids, etc, and patients can get significantly hypothermic. Even mild hypothermia has many bad effects on patients, e.g. delayed drug metabolism, delayed emergence, coagulopathy, higher wound infection rates, higher periop mortality, etc.

These are the ASA standards for monitoring:

Standards for Basic Anesthetic Monitoring - American Society of Anesthesiologists (ASA)

Even if you don't have access to all of these devices, it would be useful to be familiar with this standard and to read about some of the reasons for them.

Thanks a million Dr. Pgg
You are always helpful!
I probably will make a checklist !

I will get a thermometer at least, and 2 weeks ago, I got my engraved stethoscope and pulse oximeter celebrating my upcoming residency!
There are plenty of devices in the medical supply shops, will check for TOF.
It is really nice to do a solid research too!
In our third year PGY3 or CA2 we have to work on a graduation research project.
I was thinking to work every year with a project (I am keeping myself busy and hoping this spark will stay).

 

[dchz]

Acupan is nefopam which can precipitate serotonin syndrome.

Top of my DDx as well. MH is on there too but lower.

 

[drmwvr]

Dear Lord how I wish we had Forane again...all my old vaporizers are probably in Africa and the Middle East.

 

[DrAmir0078]

Dear Lord how I wish we had Forane again...all my old vaporizers are probably in Africa and the Middle East.

Are you telling me, you don't use Isoflurane in the US ?
What do you use?
Yeah, probably we are re-using them as refurbished or certified

 

[shepardsun]

@DrAmir0078 I respect greatly your drive to deliver excellent patient care with the resources and technologies you have, and believe that in many ways you will be a stronger clinician for it. There are many areas that I feel I am weak in and need to improve, and sometimes I feel the different technologies we have access to can act as a crutch in steering us away from the fundamentals.

I know you have already mentioned many of the technologies you do and do not have access to, but it would be very interesting to get a "tour" of one of your typical operating rooms. Do you have the ability to monitor continuous arterial blood pressure? Do you have video laryngoscopes? What intravenous induction agents do you have?

So fascinating and inspiring to see how even in such different environments we all have the same dedication to the best care of the patient possible.

 

[drmwvr]

Are you telling me, you don't use Isoflurane in the US ?
What do you use?
Yeah, probably we are re-using them as refurbished or certified

I'm sure lot's of places do, but we're too sophisticated 😉...des and sevo only now.....unusual for serotonin syndrom to present with diaphoresis, tho not unheard of...light anesthesia, my vote...back in the day of no end tidal, shared mass spectroscopy...vaporizers would run dry...not uncommon, unfortunately, but luckily recall was...

 

[deleted697535]

I'm sure lot's of places do, but we're too sophisticated 😉...des and sevo only now.....unusual for serotonin syndrom to present with diaphoresis, tho not unheard of...light anesthesia, my vote...back in the day of no end tidal, shared mass spectroscopy...vaporizers would run dry...not uncommon, unfortunately, but luckily recall was...

If you read nap5 from UK, awareness is more common than we think

 

[daneeka]

It's fascinating to read your experiences DrAmir.

I don't have Acupan/nefopam available where I work (to my knowledge), but I definitely see copious sweating with a bolus of tramadol (say 200mg), which I figure is its serotonergic activity. Could this be the reason?

Could I ask what fresh gas flows you run? With end-tidal gas analysis I believe it is possible to save money in the long run by running very low gas flows (and therefore wasting less volatile agent) but still being confident of the concentration of volatile that the patient receives. This might only be cost effective with something more expensive like desflurane, however!

With regard to the long wakeup, I wonder whether it is simply running isoflurane at 1.4MAC, which will take quite a while to wash out. Possibly more opioid (say 300-400microg fentanyl or 10mg morphine) and less volatile (maybe 0.9MAC)?

 

[drmwvr]

If you read nap5 from UK, awareness is more common than we think

I do believe that. But recall and awareness are 2 different things. You're referring to recall, I know...

 

[anbuitachi]

so you dont have a body warmer correct?

i sometimes see profuse sweating under GA. though all my patients with GA gets a warmer and temperature monitored.

what was lap chole for? was patient septic etc? why is a Young ASA1 patient getting a lap chole.
again since your patient is ASA1, i do not think it's serotonin syndrome. serotonin syndrome is extremely rare unless you are taking drugs like MAOI or similar drugs. he is ASA1 so clearly does not have depression/anxiety or those disorders. also he got very little fentanyl.

MH is possible still its very rare

i would say most likely cause is just being warm , possibly a warm OR? Awareness is unlikely unless your machine is completely broken and was delivering barely any isoflurane. You said you put it on 1.4 MAC. Even if it only delivered 0.7 MAC, with all the other drugs you gave like ketamine/fentanyl, awareness is unlikely.

Another possibility is drug reaction or histamine release from atracurium.

3 pints of fluid is only 1.5L, which for a 85kg person is not crazy. i would not have given lasix. In your situation with limited monitors, and especially for short surgeries like lap chole, i would limit the # of different medications you give, to limit side effects. unless you guys dont have much fentanyl or its very expensive over there, i would have done simple Propofol, fentanyl, paralysis with volatile maintenance (for your case 85kg, probably 200mcg propofol, 250 fentanyl, paralyze. No need for tylenol, ketamine, etc. it also makes figuring things out a lot easier if you have delayed emergence. over here, 1 bottle of IV tylenol can probably buy miligrams of fentanyl!

 

[DrAmir0078]

@DrAmir0078 I respect greatly your drive to deliver excellent patient care with the resources and technologies you have, and believe that in many ways you will be a stronger clinician for it. There are many areas that I feel I am weak in and need to improve, and sometimes I feel the different technologies we have access to can act as a crutch in steering us away from the fundamentals.

I know you have already mentioned many of the technologies you do and do not have access to, but it would be very interesting to get a "tour" of one of your typical operating rooms. Do you have the ability to monitor continuous arterial blood pressure? Do you have video laryngoscopes? What intravenous induction agents do you have?

So fascinating and inspiring to see how even in such different environments we all have the same dedication to the best care of the patient possible.

Dr. Shepardsun,
Thanks a lot, I am trying my best, technologies are required and it helps to pave the road to drive easier, but it is still a road but the time and efforts you put will be much bigger!

I will try to make a video of one of our OR room, in respect to HIPPA and show you our Anesthesia machine, and what do we have; in regard of Arterial Blood pressure monitoring, we do not have in this hospital, we hope that in Baghdad best teaching hospital, they have continuous ABP, at least in our Cardiac teaching centers; and regarding video laryngoscopes some teaching hospitals have as I heard, the one I am going to, probably the have one. Honestly, last week, I purchased a USB cable camera 5mm diameter with 2 meters length and it can easily connected to your mobile phone and by taping it to the blade you can have simple Video laryngoscope (I was thinking of it, and google it, and it appeared it is possible as it has been used by Anesthesiologists from India, very cool to try); regarding Intravenous agents we have now in this hospital (few days and I am out to my residency program and then I will update these things):

1- Ketamine 50mg/ml 10 ml amp
2- Propofol 200 mg amp

No thiopental or etomidate (We had only one big vial of thiopental and we used it, but etomidate what that is, only in textbooks), Midazolam (Versed) it depends, one day available, ten days is not!

Paralytics:
1- Uncle Sux is here 🙂 Succinylcholine
2- Rocuronium
3- Atracurium
2&3 are in Battle of existence !
4- Pancuronium (sometimes)

Reversal Agents :
Neostigmine 2.5 mg / Atropine 0.6 amp (the other day, we run out Atropine, even it happens to run out any of the these agents listed and we stop the Operations until resupply them from nearby hospitals)

Interestingly, we had Sugammadex for 2 months at the beginning of my SHO, it was awesome, then gone with the wind !

For Spinal we have Bupivacaine, Lidocaine for locals !

Yes, we all are providing excellent patients care, we are trying our best !

Many thanks Dr.@shepardsun

 

[DrAmir0078]

It's fascinating to read your experiences DrAmir.

I don't have Acupan/nefopam available where I work (to my knowledge), but I definitely see copious sweating with a bolus of tramadol (say 200mg), which I figure is its serotonergic activity. Could this be the reason?

Could I ask what fresh gas flows you run? With end-tidal gas analysis I believe it is possible to save money in the long run by running very low gas flows (and therefore wasting less volatile agent) but still being confident of the concentration of volatile that the patient receives. This might only be cost effective with something more expensive like desflurane, however!

With regard to the long wakeup, I wonder whether it is simply running isoflurane at 1.4MAC, which will take quite a while to wash out. Possibly more opioid (say 300-400microg fentanyl or 10mg morphine) and less volatile (maybe 0.9MAC)?

Thanks Dr. Daneeka,
It seems like everybody is pointing his finger on Serotonin Syndrome !

Fresh gas we run? It is only Oxygen by Cylinder / no Nitrous oxide anymore and for Anesthestic volatile gases we had and run out the Halothane then a statement came from the Ministry of Health (Department of Health) to ban using Halothane; so we kept using Isoflurane and later on, they provided us with Sevoflurane (it has been 2 weeks, we are out of Sevo!)

As you notice, I didn't give extra Fentanyl beyond the dose, it was only 75 micrograms (50mcg induction/25mcg maintenance) but as we know we can adjust MAC, don't you think it is too low to run 0.9 MAC isoflurane? lots of books say different ideal MAC, who to believe?

Thanks again !

 

[DrAmir0078]

so you dont have a body warmer correct?

i sometimes see profuse sweating under GA. though all my patients with GA gets a warmer and temperature monitored.

what was lap chole for? was patient septic etc? why is a Young ASA1 patient getting a lap chole.
again since your patient is ASA1, i do not think it's serotonin syndrome. serotonin syndrome is extremely rare unless you are taking drugs like MAOI or similar drugs. he is ASA1 so clearly does not have depression/anxiety or those disorders. also he got very little fentanyl.

MH is possible still its very rare

i would say most likely cause is just being warm , possibly a warm OR? Awareness is unlikely unless your machine is completely broken and was delivering barely any isoflurane. You said you put it on 1.4 MAC. Even if it only delivered 0.7 MAC, with all the other drugs you gave like ketamine/fentanyl, awareness is unlikely.

Another possibility is drug reaction or histamine release from atracurium.

3 pints of fluid is only 1.5L, which for a 85kg person is not crazy. i would not have given lasix. In your situation with limited monitors, and especially for short surgeries like lap chole, i would limit the # of different medications you give, to limit side effects. unless you guys dont have much fentanyl or its very expensive over there, i would have done simple Propofol, fentanyl, paralysis with volatile maintenance (for your case 85kg, probably 200mcg propofol, 250 fentanyl, paralyze. No need for tylenol, ketamine, etc. it also makes figuring things out a lot easier if you have delayed emergence. over here, 1 bottle of IV tylenol can probably buy miligrams of fentanyl!

Hello Dr. Anbuitachi,
Yes, we do not have body warmer (sometimes we use the OR lights faced on the patient to give him heat or extra gown and turning off the Air Conditioner)

I meant by ASA I, the patient is healthy and no previous suspicious medicosurgical history, we have lots of cases of Gallstones in our country, I think we need to run an epidemiology research!

i would say most likely cause is just being warm , possibly a warm OR? Awareness is unlikely unless your machine is completely broken and was delivering barely any isoflurane. You said you put it on 1.4 MAC. Even if it only delivered 0.7 MAC, with all the other drugs you gave like ketamine/fentanyl, awareness is unlikely.

Well, that what I was thinking, it was not delivering enough Isoflurane, but surely you can smell it, that is why BioMed engineers came and recalibrate the vaporizers, but it is still not working proficiently!
Wow, so awareness was unlikely, so like other said Serotonin Syndrome due to Acupan!

3 pints of fluid is only 1.5L, which for a 85kg person is not crazy. i would not have given lasix. In your situation with limited monitors, and especially for short surgeries like lap chole, i would limit the # of different medications you give, to limit side effects. unless you guys dont have much fentanyl or its very expensive over there, i would have done simple Propofol, fentanyl, paralysis with volatile maintenance (for your case 85kg, probably 200mcg propofol, 250 fentanyl, paralyze. No need for tylenol, ketamine, etc. it also makes figuring things out a lot easier if you have delayed emergence. over here, 1 bottle of IV tylenol can probably buy miligrams of fentanyl!

I had to rehydrate him, to replace the fluid loss by sweating, and I believe (between us), giving lasix to help wash out what he got (I don't know if that is a true clue)!
Fentanyl, is available by Government supply,
Hold on a second Sir!
You said this (for your case 85kg, probably 200mcg propofol, 250 fentanyl, paralyze. No need for tylenol, ketamine, etc.), you are reminding of my Senior Anesthesiologist who address single agent anesthesia to minimize the side effects, he uses either Ketamine of Propofol!
Please, is that possible to use single agent?
If he was doing this case mentioned, he will check his blood pressure, and his history of hypertension, if he is HTN he would recommend giving him 200mg propofol + extra 50 and then paralysis with Isoflurane 1.5 MAC [this is his usual map] and he is not a fan of narcotics, but sometimes he feels to give extra Fentanyl like 100mcg !
But giving 250mcg of Fentanyl, won't do synergism effect with Propofol leading to hypotension! (Believe me, whenever I give Fentanyl, I go back and forth in the this OR worrying about bradycardia, and it happens a lot) so, if I gave him 250 mcg of Fentanyl !?

Thanks a lot !

 

[vector2]

Never assume that because a pt is hypertensive that he will remain so after a normal to high dose of propofol for induction. This is especially dangerous where you're at because of limited availability of phenylephrine and ephedrine. Chronic HTN pts can have significant intravascular volume depletion due to medications and renin-angiotensin-aldosterone system derangement which can be unmasked with severe hypotension after induction.

 

[DrAmir0078]

Never assume that because a pt is hypertensive that he will remain so after a normal to high dose of propofol for induction. This is especially dangerous where you're at because of limited availability of phenylephrine and ephedrine. Chronic HTN pts can have significant intravascular volume depletion due to medications and renin-angiotensin-aldosterone system derangement which can be unmasked with severe hypotension after induction.

I truly need to work hard to get it in and understand what you have mentioned !
I just read this (overviewing) Mechanisms whereby Propofol Mediates Peripheral Vasolidation in Humans:Sympathoinhibition or Direct Vascular Relaxation? | Anesthesiology | ASA Publications
or this : Playing with fire: debate about propofol-induced hypotension | BJA: British Journal of Anaesthesia | Oxford Academic
Correct me if I am wrong
"By giving normal or high dose of Propofol in Chronically HTN patients is dangerous - my question, even if they are on controlled medicine and they didn't cut it prior to operation? - because these transient reduction in CO, preload, and contractility , SVR, FVR, , ,etc and still unclear its action, according to the studies; will affect the myocardium and lead to ischemia, especially in ASA III, IV.
So, when you given Propofol in practice, do you usually give after administering it - Propofol - a dose of phenylephrine or ephedrine to overcount the side effects of Propofol? Interesting to be honest!.
So, this unmasking, because their Intravascular volume depletion, and renin-angiotensin-aldosterone system derangement, adding extra normal to high dose of propofol will induce vasodilation effect beside the myocardium depressant effect and that will lead to extra stress on the myocardium and can lead to Ischemia!, so I have to be prepared when I give Propofol"

But, how about the rule of Fentanyl here? - this will add extra effect, isn't it!

 

[daneeka]

Fresh gas we run? It is only Oxygen by Cylinder / no Nitrous oxide anymore and for Anesthestic volatile gases we had and run out the Halothane then a statement came from the Ministry of Health (Department of Health) to ban using Halothane; so we kept using Isoflurane and later on, they provided us with Sevoflurane (it has been 2 weeks, we are out of Sevo!)

Oh I just mean how many L/min runs through the vaporiser (like how much you set the O2 + air rotameter to). If you can imagine, running 3L/min would mean that the number on the vaporiser dial is approximately what the patient receives (so vaporiser setting 2% = patient gets 1.9%). Whereas at 0.5L/min this is not the case (vaporiser setting 2% might mean patient gets ~0.7%). With gas analysis, it is possible to run 0.5L/min because we can check the true concentration going to the patient and don't have to trust the vaporiser dial. I imagine you must run higher flows because you have only the vaporiser setting to tell you how much the patient gets.

Don't you think it is too low to run 0.9 MAC isoflurane? lots of books say different ideal MAC, who to believe?

Not too low if balanced with MAC sparing agents like opioid. Using a bit of extra opioid will let you run a lower iso%, and then there's less iso to get rid of = quicker wakeup.

(Also to clarify: when I say 1.0 MAC of isoflurane = 1.1% of isoflurane; or 1.0 MAC of sevoflurane = 2.0% sevoflurane; or 1.0 MAC halothane = 0.75% halothane. If by 1.4 MAC isoflurane you mean the vaporiser is turned to 1.4%, it could be that the patient is getting 0.9 MAC anyway depending on your fresh gas flow!)

 

[DrAmir0078]

Oh I just mean how many L/min runs through the vaporiser (like how much you set the O2 + air rotameter to). If you can imagine, running 3L/min would mean that the number on the vaporiser dial is approximately what the patient receives (so vaporiser setting 2% = patient gets 1.9%). Whereas at 0.5L/min this is not the case (vaporiser setting 2% might mean patient gets ~0.7%). With gas analysis, it is possible to run 0.5L/min because we can check the true concentration going to the patient and don't have to trust the vaporiser dial. I imagine you must run higher flows because you have only the vaporiser setting to tell you how much the patient gets.


Not too low if balanced with MAC sparing agents like opioid. Using a bit of extra opioid will let you run a lower iso%, and then there's less iso to get rid of = quicker wakeup.

(Also to clarify: when I say 1.0 MAC of isoflurane = 1.1% of isoflurane; or 1.0 MAC of sevoflurane = 2.0% sevoflurane; or 1.0 MAC halothane = 0.75% halothane. If by 1.4 MAC isoflurane you mean the vaporiser is turned to 1.4%, it could be that the patient is getting 0.9 MAC anyway depending on your fresh gas flow!)

Interesting, I have read in the past of low fresh gas, but on reality, we set Adults on 7 L/min; Children 4-5 L/min; infants 2 L/min.
So my patient was on 1.4 Isoflurane + 7 Lt/min with I:E =1:2 with Set 10 /min on VC setting!
So how much he was getting?

So, can I run 3 Lt/min of fresh gas on the same patient?

 

[daneeka]

So, can I run 3 Lt/min of fresh gas on the same patient?

At 7L of flow, the patient would be getting 1.4% iso for sure! It would be possible to turn the flow lower, but without gas analysis it would require estimation of O2 consumption, and volatile uptake to do safely - and the main benefit would be reduced volatile agent consumption.

I think it'd be safer to stick to what is usually done in your institution. The last thing you want is to accidentally give someone a hypoxic mixture, or awareness.

 

[DrAmir0078]

At 7L of flow, the patient would be getting 1.4% iso for sure! It would be possible to turn the flow lower, but without gas analysis it would require estimation of O2 consumption, and volatile uptake to do safely - and the main benefit would be reduced volatile agent consumption.

I think it'd be safer to stick to what is usually done in your institution. The last thing you want is to accidentally give someone a hypoxic mixture, or awareness.

Thanks Dr. Daneeka

 

[nimbus]

Honestly, last week, I purchased a USB cable camera 5mm diameter with 2 meters length and it can easily connected to your mobile phone and by taping it to the blade you can have simple Video laryngoscope (I was thinking of it, and google it, and it appeared it is possible as it has been used by Anesthesiologists from India, very cool to try)

Let us know how this works out! Post some pics if you can.

 

[DrAmir0078]

Let us know how this works out! Post some pics if you can.

This is the camera,
Once I get a chance, I will make a video ... Let's see if it will work properly as I am hoping!

 

[deleted697535]

7 litres of flow? Oh we definitely do live in different worlds...
Basically everyone here gets 500ml per minute fgf. Some of my colleagues use 200ml/min for low flow anesthesia. I guess our machines are better calibrated

 

[btbam]

Interesting, I have read in the past of low fresh gas, but on reality, we set Adults on 7 L/min; Children 4-5 L/min; infants 2 L/min.
So my patient was on 1.4 Isoflurane + 7 Lt/min with I:E =1:2 with Set 10 /min on VC setting!
So how much he was getting?

So, can I run 3 Lt/min of fresh gas on the same patient?

Where did you come up with these FGF settings??

 

[anbuitachi]

How much is in your oxygen cylinder? 7L a min is a lot

 

[Mman]

Where did you come up with these FGF settings??

I'll just assume what his attending tells him to do.

But yes, even without end tidal gas monitoring you could probably easily get away with 3-4 L flow/min and have no compromise in patient care. I mean you could just use around 2L/min if you were experienced and knew to keep the vaporizer up higher for the first 15 minutes.

 

[B-Bone]

Dr. Shepardsun,
Thanks a lot, I am trying my best, technologies are required and it helps to pave the road to drive easier, but it is still a road but the time and efforts you put will be much bigger!

I will try to make a video of one of our OR room, in respect to HIPPA and show you our Anesthesia machine, and what do we have; in regard of Arterial Blood pressure monitoring, we do not have in this hospital, we hope that in Baghdad best teaching hospital, they have continuous ABP, at least in our Cardiac teaching centers; and regarding video laryngoscopes some teaching hospitals have as I heard, the one I am going to, probably the have one. Honestly, last week, I purchased a USB cable camera 5mm diameter with 2 meters length and it can easily connected to your mobile phone and by taping it to the blade you can have simple Video laryngoscope (I was thinking of it, and google it, and it appeared it is possible as it has been used by Anesthesiologists from India, very cool to try); regarding Intravenous agents we have now in this hospital (few days and I am out to my residency program and then I will update these things):

Wait, Iraq has HIPAA?

Like the Health Insurance Portability and Accountability Act of 1996? I know we were "greeted as liberators", but this seems suspect.

 

[anbuitachi]

Wait, Iraq has HIPAA?

Like the Health Insurance Portability and Accountability Act of 1996? I know we were "greeted as liberators", but this seems suspect.

i had the same reaction!

 

[DrAmir0078]

7 litres of flow? Oh we definitely do live in different worlds...
Basically everyone here gets 500ml per minute fgf. Some of my colleagues use 200ml/min for low flow anesthesia. I guess our machines are better calibrated

Goodmorning !
Probably there is something wrong, why do we use 7 Lt though? Definitely your Machines are better !