prolonged intubation for this?

[Sammich81]

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This situation came up between one of the general surgeons and the anesthesiologist. A morbidly obese patient had a hernia repair. He ripped the stitches on his last 3 repairs because he coughed so much post extubation. So the surgeon wanted the patient to stay intubated for a few days solely to prevent coughing. The anesthesiologist didn't think it was sufficient justification. Words were exchanged.

What would you guys do?

 

[Tenesma]

the surgeon is crazy

1) the surgeon needs to suture better or refer this patient to a more skilled surgeon

2) the patient could be extubated deep which would be a nightmare in a morbidly obese patient

3) the patient could be prepped for a no-cough extubation, and here is how you do it: 1) 4% lido 2 cc down the airway 2) 4% lido 2cc injected right above the cuff and slowly slowly slowly loosen the cuff 3) all the while running high dose remifentanil/propofol (no volatile) w/ some ketamine .... turn off the propofol/ketamine, glide on remifentanil - give 100mg lidocaine IV, and pull the tube as soon as the patient is taking 2-4 breaths per minute

4) or the easy way - figure out how you can do the repair w/ regional and local w/ sedation (no intubation)

but i would not keep a morbidly obese pt intubated for 3 days!!! and what will stop the patient from bucking on the tube in the ICU??? what will happen if the patient bears down for a bowl movement after extubation... maybe this hernia isn't surgically amenable to correction?

 

[militarymd]

surgeon needs to learn how to suture.

 

[UTSouthwestern]

surgeon needs to learn how to suture.

Tell us how you really feel.

 

[Sammich81]

Thanks for the replies.

I heard this story through a couple; the wife is an ED resident who was almost an anesthesiologist and her husband is a gen surg resident. He basically said, "It's anesthesia's job to make the case go the way the surgeon says it should." It smelled like bull s hit to me and y'all pretty much confirmed that.

God forbid I ever have to be his anesthesiologist...

 

[rn29306]

Only one situation comes to mind where, strictly from a surgical procedure alone, patients were kept in the unit on a ventilator post-op. While wiping crack in Atlanta, there was this one surgeon who would do a wham-bam thank-you-maam' UP3, tongue base reduction, essentially move the lower jaw forward, and a T&A on these guys with SEVERE sleep apnea (most of his pts had over 800 episodes on sleep studies). We kept them snowed on Propofol gtts / narcotic PCA for 3 days along with high dose steroids. Trach kits @ bedside. These patients thankfully returned to the OR for extubation by anesthesia with ENT dude along for the ride.

I'm sure that anesthesia had a say-so in this also, but all of his patients that I know received this treatment.

Everyone knew the severity of these guys and to my knowledge, no patient mishap occured in the unit.

 

[jetproppilot]

Only one situation comes to mind where, strictly from a surgical procedure alone, patients were kept in the unit on a ventilator post-op. While wiping crack in Atlanta, there was this one surgeon who would do a wham-bam thank-you-maam' UP3, tongue base reduction, essentially move the lower jaw forward, and a T&A on these guys with SEVERE sleep apnea (most of his pts had over 800 episodes on sleep studies). We kept them snowed on Propofol gtts / narcotic PCA for 3 days along with high dose steroids. Trach kits @ bedside. These patients thankfully returned to the OR for extubation by anesthesia with ENT dude along for the ride.

I'm sure that anesthesia had a say-so in this also, but all of his patients that I know received this treatment.

Everyone knew the severity of these guys and to my knowledge, no patient mishap occured in the unit.

sorry for the bluntness,

I've done a million UP3s.

And that post operative management is overkill beyond belief,

and a waste of medical resources/dollars.

Wanna keep the (extubated) UP3 patient in the ICU overnight for observation?

Great. You may have literature to back you up on that.

But keep them intubated/sedated for three days post op,

and bring them back to the OR for extubation??

Gimme a f ****** break.

Put down the crack pipe.

 

[rn29306]

sorry for the bluntness,

I've done a million UP3s.

And that post operative management is overkill beyond belief,

and a waste of medical resources/dollars.

Wanna keep the (extubated) UP3 patient in the ICU overnight for observation?

Great. You may have literature to back you up on that.

But keep them intubated/sedated for three days post op,

and bring them back to the OR for extubation??

Gimme a f ****** break.

Put down the crack pipe.

Don't shoot the messenger. That's how he did it.

And yes, there's alot of crack smoking in the ATL. 😀

 

[VentdependenT]

sorry for the bluntness,

I've done a million UP3s.

And that post operative management is overkill beyond belief,

and a waste of medical resources/dollars.

Wanna keep the (extubated) UP3 patient in the ICU overnight for observation?

Great. You may have literature to back you up on that.

But keep them intubated/sedated for three days post op,

and bring them back to the OR for extubation??

Gimme a f ****** break.

Put down the crack pipe.

Whazza UP3?

 

[rn29306]

UP3: uvulopalatopharyngoplasy. Definition at http://www.emedicine.com/ped/topic2114.htm. Look a couple pages down, the 3rd listing under "Surgical Care".


These guys were usually 310 - 400 lbs and got a UP3, tongue base reduction, their lower mandibles displaced more anterior, and usually a T&A.

Significant swelling as you can imagine.

Not a simple outpatient UP3.

 

[militarymd]

Only one situation comes to mind where, strictly from a surgical procedure alone, patients were kept in the unit on a ventilator post-op. While wiping crack in Atlanta, there was this one surgeon who would do a wham-bam thank-you-maam' UP3, tongue base reduction, essentially move the lower jaw forward, and a T&A on these guys with SEVERE sleep apnea (most of his pts had over 800 episodes on sleep studies). We kept them snowed on Propofol gtts / narcotic PCA for 3 days along with high dose steroids. Trach kits @ bedside. These patients thankfully returned to the OR for extubation by anesthesia with ENT dude along for the ride.

I'm sure that anesthesia had a say-so in this also, but all of his patients that I know received this treatment.

Everyone knew the severity of these guys and to my knowledge, no patient mishap occured in the unit.

apnea hypopnea indices of 800????????

800 episodes an hour?????? I don't think that is possible....a number of 60 essesntially means that the patient cannot sleep and breath at the same time.....

uhhh Jet, if what is posted is correct....an a/h index of 800....I would be keeping them intubated indefinitely.....IE trach from the get go..

 

[TheSleepMaster]

Whazza UP3?

Yeah I thought it was a new rap group from da ATL or something.

 

[rn29306]

apnea hypopnea indices of 800????????

800 episodes an hour?????? I don't think that is possible....a number of 60 essesntially means that the patient cannot sleep and breath at the same time.....

uhhh Jet, if what is posted is correct....an a/h index of 800....I would be keeping them intubated indefinitely.....IE trach from the get go..

I should have clarified. Some of these guys were having 800 apnea episodes per study. I don't know how long the study was conducted in terms of hours, but that is what his H&P reports said on the charts.

 

[jetproppilot]

UP3: uvulopalatopharyngoplasy. Definition at http://www.emedicine.com/ped/topic2114.htm. Look a couple pages down, the 3rd listing under "Surgical Care".


These guys were usually 310 - 400 lbs and got a UP3, tongue base reduction, their lower mandibles displaced more anterior, and usually a T&A.

Significant swelling as you can imagine.

Not a simple outpatient UP3.

gotcha.

my bad.

crack pipe joke retracted.

 

[Annette]

I should have clarified. Some of these guys were having 800 apnea episodes per study. I don't know how long the study was conducted in terms of hours, but that is what his H&P reports said on the charts.

Sleep studies are usually around 6 hours. At 800/study, that would be a little over 2 episodes a minute.

 

[rn29306]

Sleep studies are usually around 6 hours. At 800/study, that would be a little over 2 episodes a minute.

These guys were essentially rendered non-functional in their daily lives due to OSA. All this information came from the family at the BS.

I always tried to see different things (organ procurement, etc), but I never could manage to slip away and watch anesthesia extubate these guys. That would have been interesting.

 

[SoCuteMD]

Stupid, rookie, non anesthesiologist question. For my 2 hernia repairs I do not recall being intubated. They gave me some happy pills and a local anesthetic and I apparently was QUITE amusing in the OR.

Can this only be done depending on where the hernia is? Mine was spigelian, and I would assume that the same procedure could be used for inguinal and femoral - but what about hiatal hernias?

 

[jwk]

Stupid, rookie, non anesthesiologist question. For my 2 hernia repairs I do not recall being intubated. They gave me some happy pills and a local anesthetic and I apparently was QUITE amusing in the OR.

Can this only be done depending on where the hernia is? Mine was spigelian, and I would assume that the same procedure could be used for inguinal and femoral - but what about hiatal hernias?

Inguinal and femoral hernias can be done with local and blocks. I suppose small umbilical and incisional hernias might be attempted with local, but I've never seen one done that way. They can be done with a spinal or epidural. Hiatal hernias are either repaired laparoscopically or through an abdominal (and occasionally thorocoabdominal) incision. A general anesthetic is required for those.

 

[jetproppilot]

Inguinal and femoral hernias can be done with local and blocks. I suppose small umbilical and incisional hernias might be attempted with local, but I've never seen one done that way. They can be done with a spinal or epidural. Hiatal hernias are either repaired laparoscopically or through an abdominal (and occasionally thorocoabdominal) incision. A general anesthetic is required for those.

My previous gig all hernias regardless of type/location got a GA or a spinal.

Cuppla the surgeons at present gig do IHRs routinely with MAC only (plus local)