Post laryngospasm hospital stay

[residency2010]

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Hello, we ve had couple of cases lately where patient had laryngospasm that were managed appropriately in the OR but still ended up for overnight observation and one needed oxygen support for more than 2 days. They all got the usual X ray, abg, incentive spirometer and Bipap if needed. Is there anything else that can be done? When can you discharge them the same day?

 

[GassYous]

Why do you need any of that workup
Laryngospasm happened because you pulled the tube in stage 2. If they're satting ok on room air and they're awake what's the issue?

 

[DrOwnage]

Patients laryngospasm all the time. It’s pretty rare that they become very symptomatic afterwards if managed appropriately at the time. Would D/C based on patients change from baseline. Pretty much just comes down to the numbers and patient comfort. I’ve had a patient laryngospasm with an LMA in at a MAC of 1.2 with narcotic on board, or at least bronchospasm that led to laryngospasm. Healthy adult who needed to stay a night to re-recruit. If they have real NPPE they’re likely going to the ICU. More than 2 days without true NPPE is a little out of the ordinary but could see it with someone who’s not the healthiest at baseline.

 

[deleted87051]

Sounds like NPPE. If laryngospasm is recognized immediately and managed quickly (sux), it will not lead to NPPE. If laryngospasm results in NPPE, it was allowed to go on too long and was most likely not managed optimally (personal experience, yes I f’d up). At that point, you must provide supplemental oxygen and monitor the patient until they can maintain acceptable oxygen saturation on room air. They get better but it takes time. So yes they bought a hospital stay.

 

[Planktonmd]

Educate your staff on how to time extubation correctly.

 

[residency2010]

Most likely it’s NPPE. Do we need to do serial abg/ x ray to show that the pt is getting better or as long as the saturation is ok on RA? Is there any specific therapeutics I am missing for this scenario or just let the lungs take its time?

 

[coffeebythelake]

Most likely it’s NPPE. Do we need to do serial abg/ x ray to show that the pt is getting better or as long as the saturation is ok on RA? Is there any specific therapeutics I am missing for this scenario or just let the lungs take its time?

Just needs Time. Supplemental O2. Perhaps NIPPV. No abg. Cxr not going to show u anything u don't already know.

 

[GassYous]

Most likely it’s NPPE. Do we need to do serial abg/ x ray to show that the pt is getting better or as long as the saturation is ok on RA? Is there any specific therapeutics I am missing for this scenario or just let the lungs take its time?

How would it change your management

 

[UscGhost]

Small aspiration causing laryngospasm/bronchospasm perhaps?

 

[coffeebythelake]

Small aspiration causing laryngospasm/bronchospasm perhaps?

Still won't change management

 

[gunnershow]

I'm glad that people ITT aren't suggesting diuretics as a treatment like my attendings in residency.

 

[UscGhost]

Still won't change management

Correct.

I was just thinking more about what might have led to two patients needing to stay in the hospital postop from just laryngospasm

I haven't really seen many cases of NPPE , but I am guessing that aspiration+laryngospasm might be more likely than NPPE from laryngospasm alone. Not sure

 

[deleted87051]

Just needs Time. Supplemental O2. Perhaps NIPPV. No abg. Cxr not going to show u anything u don't already know.

The frothy pink sputum they cough up and the low sats tell you what’s going on.

 

[DocMcCoy]

The frothy pink sputum they cough up and the low sats tell you what’s going on.

Had two. Interestingly, no pink sputum in either case.

 

[jwk]

Sounds like NPPE. If laryngospasm is recognized immediately and managed quickly (sux), it will not lead to NPPE. If laryngospasm results in NPPE, it was allowed to go on too long and was most likely not managed optimally (personal experience, yes I f’d up). At that point, you must provide supplemental oxygen and monitor the patient until they can maintain acceptable oxygen saturation on room air. They get better but it takes time. So yes they bought a hospital stay.

Too many people think sux is a bad drug and never want to use it. It's a near-perfect drug in appropriate situations, like laryngospasm. I've got an extremely short fuse for using sux in laryngospasm. Back in the dark ages, we used DTC, sux, and pancuronium - that was all - so pretty much any case that needed relaxation and/or an ETT got sux. Someone spasmed and we couldn't break it with positive pressure, we'd give 10mg of sux and it would magically get better in about 20sec. We'd never let it progress far enough to get NPPE.

 

[repititionition]

I'm glad that people ITT aren't suggesting diuretics as a treatment like my attendings in residency.

the reason to use isn’t that lasix is a diuretic, it’s that it’s a direct pulmonary vasodilator.

 

[Angus Avagadro]

Only ever had 1 case of NPPE. A young man for shoulder repair. Got into a Fiesty back and forth with a pulmonologist who believed it was caused by trying to exhale against a closed glottis.🙃 Regardless, the patient did well and went home later that day. I could imagine some obese or OSA patients requiring an overnight stay.

 

[coffeebythelake]

the reason to use isn’t that lasix is a diuretic, it’s that it’s a direct pulmonary vasodilator.

Biggest questions. 1. Does it improve pulmonary edema a lot quicker? In a clinically relevant way? 2. Is it safe in this particular scenario? I believe giving lasix for NPPE has gone out of vogue as more anesthesiologists recognize the potential harm in doing so.

 

[Beeftenderloin]

Got into a Fiesty back and forth with a pulmonologist who believed it was caused by trying to exhale against a closed glottis.🙃

Not to derail the thread, but I got in an argument over the weekend with an OB that called an MTP on a post op, non-bleeding, hemodynamically stable patient because “everything’s low” (except it was more like “EVERYTHING’S LOW”). Hgb 6.8, plts 140, fibrinogen 130, INR 0.8, PTT 22. 🙃

 

[GassYous]

Biggest questions. 1. Does it improve pulmonary edema a lot quicker? In a clinically relevant way? 2. Is it safe in this particular scenario? I believe giving lasix for NPPE has gone out of vogue as more anesthesiologists recognize the potential harm in doing so.

Supplemental oxygen if necessary +/- ppv and obs is really all you need imo

 

[repititionition]

Biggest questions. 1. Does it improve pulmonary edema a lot quicker? In a clinically relevant way? 2. Is it safe in this particular scenario? I believe giving lasix for NPPE has gone out of vogue as more anesthesiologists recognize the potential harm in doing so.

Not arguing for it, just giving the pharmaco/physiological explanation.

I think it is dumb in the vast majority of patients expect those in whom you have a reasonable index of suspicion that their right heart will have tolerated the episode poorly.