Postoperative paresis?

[Intensivist]

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Today l entered an OR in middle of laparoscopic cholecystectomy. Patient was induced with midazolam, thiopental, vecuronium and fentanyl. Sevo was volatile agens. Nothing happened during the procedure. But after operation patient was having difficulty emerging. Took him about 15 to partialy awake, was somnolent somwhat. But breathing insufficiently. Was extubated because he was somewhat fighting the tube. After extubation, was maintaining airway?, tried to breathe, making an effort, but no air was passing. Stayed normoxygenated through out whole ordeal. But after minute or two of insufficient breathing without tube was easily intubated using no medication and sent to ICU to emerge. What could have been the problem? Had several previous surgeries without any problems. Had cerebral palsy as a child, apparently not that severe form.

 

[jwk]

First thought is inadequate reversal of the vec (or did they even reverse?). Just about everything you're describing fits perfectly with a patient that is still has NMB on board.

I'm curious about your timeline, as well as who was doing the case. IF this is the problem, this is not that uncommon an occurence, but is usually fairly easily handled. Reintubating a a minute or two after extubation would be over-reaction unless they had a totally obstructed airway.

 

[Planktonmd]

This is a well known problem called: Crappy anesthesia.

 

[Noyac]

This is a well known problem called: Crappy anesthesia.

Bingo.

And then that crappy anesthesia provider sent him to the ICU to finish the job, WTF?

 

[sevoflurane]

This case = Wasted resources + Expensive bill.

 

[2ndyear]

And we all know what happens in the ICU. Sedated. Intubated longer than they should be. We've all had a case like this. If it's night time then maybe to the unit if I have another long case to do. If I'm around and available then PACU it is and clean up your own messes, get the tube out.

 

[ProRealDoc]

This is a well known problem called: Crappy anesthesia.

 

[Coastie]

Today l entered an OR in middle of laparoscopic cholecystectomy. Patient was induced with midazolam, thiopental, vecuronium and fentanyl. Sevo was volatile agens. Nothing happened during the procedure. But after operation patient was having difficulty emerging. Took him about 15 to partialy awake, was somnolent somwhat. But breathing insufficiently. Was extubated because he was somewhat fighting the tube. After extubation, was maintaining airway?, tried to breathe, making an effort, but no air was passing. Stayed normoxygenated through out whole ordeal. But after minute or two of insufficient breathing without tube was easily intubated using no medication and sent to ICU to emerge. What could have been the problem? Had several previous surgeries without any problems. Had cerebral palsy as a child, apparently not that severe form.

Had a case like this with a CRNA I was supervising (as a CA-2) a few weeks ago.

Gotta love it when they don't fully reverse, yet tell you that they did..only to check the chart later.....

But, you know, militant murse = MD(a), right?

 

[Idiopathic]

would have at least watched this guy in PACU for an hour, quick call on the unit transfer

 

[IlDestriero]

Had a case like this with a CRNA I was supervising (as a CA-2) a few weeks ago.

Gotta love it when they don't fully reverse, yet tell you that they did..only to check the chart later.....

But, you know, militant murse = MD(a), right?

Did your attending bring this up with the CRNA after the error, or lie?, was discovered? Did you tell them about the error? It was either bad math (forgivable), or bad practice (correctable), or a lie (terminal) either way, they should be standing tall before the man. If your attending didn't at least mention it to the CRNA and get an explanation they're pathetic. Pointing out someone's errors and learning from them is part of the process. It solves problems. Otherwise, someone is going to get hurt, or worse.
If a CRNA blatantly lied to me, it would cost them their job. That's inexcusable and unforgivable, and they would HAVE to go, that day. They could never be trusted to provide anesthesia again.

 

[Sergio99]

...If a CRNA blatantly lied to me, it would cost them their job...

Hello,

I have a hard time imagining someone intentionally lying for something like this. Yes, they do intentionally lie for narcotics, if they are stashing them for personal use, but for reversal of muscle relaxants? I doubt. My impression is that most probably he or she thought he gave it and didn't realize that the syringe was still there. With all the syringes some people have on their trays it is easy to get distracted.

Actually, these types of incidents were much more common before the days when the use of nerve stimulators become routine; but even now, sometimes I see people that give much smaller doses of reversal than what is needed, and then don't check train-of-four and tetanus.

Greetings

 

[IlDestriero]

Hello,

I have a hard time imagining someone intentionally lying for something like this. Yes, they do intentionally lie for narcotics, if they are stashing them for personal use, but for reversal of muscle relaxants? I doubt. My impression is that most probably he or she thought he gave it and didn't realize that the syringe was still there. With all the syringes some people have on their trays it is easy to get distracted.

Actually, these types of incidents were much more common before the days when the use of nerve stimulators become routine; but even now, sometimes I see people that give much smaller doses of reversal than what is needed, and then don't check train-of-four and tetanus.

Greetings

I'm not saying that they lied, just that if they did, and you caught them, they would have to go. Lying is the fast track out of medicine.
Also, if they lie about something like this, can you trust them again for anything? No.
Most likely they think a 1/2 reversal is adequate, and than don't check TOF. That can be corrected. Telling you that they reversed the patient when they did not is a completely different situation.

 

[Sergio99]

I'm not saying that they lied, just that if they did, and you caught them, they would have to go. Lying is the fast track out of medicine.
Also, if they lie about something like this, can you trust them again for anything? No.
Most likely they think a 1/2 reversal is adequate, and than don't check TOF. That can be corrected. Telling you that they reversed the patient when they did not is a completely different situation.

Hello,

Of course, I agree with that. I didn't mean to argue against the principle. I was just speculating about probabilities.

Greetings

 

[Intensivist]

sorry for delay with posting, anyways, attending was there when patient was emerging, she was ordering the drugs, patient was reversed, atleast one dose of neostigmine was given. Patient was somewhat fighting the tube, didn't move anything below neck, and was taking small tidal volumes, about 100 mLs therefore doc decided to reintubate and send him to ICU b/c PACU wasn't available, and in the ICU attendings and residends are anaesthetists. I'm not sure, but think he emerged after so 30 mintues up to an hour and was sent to ward. I believe that all NMBD he got for this 45-50 mintues long surgery was 8 mg of vec. Fentanyl maybe up to 200 mics, eventhough l think that 150 was the dose; 100 at start in two fractions and one later on.
Sorry for speculations, l wasn't there throughout the induction and rest of the surgery, but by knowing the attending, l am presuming that being ther case.

 

[Noyac]

sorry for delay with posting, anyways, attending was there when patient was emerging, she was ordering the drugs, patient was reversed, atleast one dose of neostigmine was given. Patient was somewhat fighting the tube, didn't move anything below neck, and was taking small tidal volumes, about 100 mLs therefore doc decided to reintubate and send him to ICU b/c PACU wasn't available, and in the ICU attendings and residends are anaesthetists. I'm not sure, but think he emerged after so 30 mintues up to an hour and was sent to ward. I believe that all NMBD he got for this 45-50 mintues long surgery was 8 mg of vec. Fentanyl maybe up to 200 mics, eventhough l think that 150 was the dose; 100 at start in two fractions and one later on.
Sorry for speculations, l wasn't there throughout the induction and rest of the surgery, but by knowing the attending, l am presuming that being ther case.

There's your problem.

What country is this in?

 

[IlDestriero]

There's your problem.

What country is this in?

 

[Idiopathic]

good lesson here: sometimes "fighting the tube" equals "fighting to breathe" and the patient may need more support rather than fewer endotracheal tubes

 

[Intensivist]

You guys think 8 mg of vec was too much for a 80sih kgs male for 1 hrs procedure? I guess 4 to 6 would do the trick but this attending was being more liberal l guess. Another thing is that he wasn't the one to reverse anaesthesia, but he called in another attending, he had another thing doing at the moment.
What about extubating and reintubating issue? He wasn't taking sufficient volumes, that was obvious and wasn't alert and maintaining his a/w properly. So how would you procede with this one? Extra dose of neostigmine? Some naloxon? Wait few more minutes and take it from there?
Another reminder, PACU wasn't available at the moment, so he was sent to ICU there another anaesthetist took him.

 

[sevoflurane]

You guys think 8 mg of vec was too much for a 80sih kgs male for 1 hrs procedure? I guess 4 to 6 would do the trick but this attending was being more liberal l guess. Another thing is that he wasn't the one to reverse anaesthesia, but he called in another attending, he had another thing doing at the moment.
What about extubating and reintubating issue? He wasn't taking sufficient volumes, that was obvious and wasn't alert and maintaining his a/w properly. So how would you procede with this one? Extra dose of neostigmine? Some naloxon? Wait few more minutes and take it from there?
Another reminder, PACU wasn't available at the moment, so he was sent to ICU there another anaesthetist took him.

Make sure he gets a full reversal dose. Put him on the vent in the pacu. Wait for him to gain strength. Extubate. 8 mg of vec for a 1hr procedure will burn you from time to time. No doubt. Anything 1 hr. or less, I'm using ROC.
80kg of IBW vs. 80kg in a short person with BMI>35 will have different durations IMO.

 

[Intensivist]

l think that was the plan with him in the end. His 80 kg are IBW. Tnx for advices guys!