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Routine ERCP

Discussion in 'Anesthesiology' started by Hawaiian Bruin, Aug 14, 2015.

  1. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    I'll jump on the case bandwagon.

    Your patient is a 41 year old woman with symptomatic bile duct stones, referred for outpatient ERCP.

    Past history significant for severe COPD, with admissions every few months for exacerbations/ CAPs. Currently at baseline per pulmonologist. Pulm status is as good as it gets. Baseline room air sat is 78%. Pt is noncompliant with home oxygen, but when she uses it sat is in the low 90s.

    She also has cor pulmonale. RV is massively dilated and has mildly depressed systolic function. There is moderate TR. PA systolic pressure is estimated as 75mmHg, systemic pressure at time of exam is 120/66.

    LV function is mildly depressed at 40-45%.

    Anything else you want to know?

    What's your plan?

    Residents first...
     
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  3. Noyac

    Noyac ASA Member
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    This is a good one.
     
  4. Lurch

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    Ketafol MAC. Maybe 2mg/cc on the ketamine. NIBP and good PIV. Access to vaso/epi.

    Frank discussion with patient and GI doc about real risks and goals of care.

    Is this in a free-standing GI procedural clinic or a hospital? This might be one for the OR.
     
  5. Hoya11

    Hoya11 Senior Member
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    Assuming no other curve balls, good exercise tolerance with o2 on, Id do it in the ERCP suite with an anesthesia machine.

    Discuss high probability of post op veniltation in ICU intubated.
    Fent. Etomidate. Sux. Tube. Roc. Prone.
    Be ready to do aline depending on how she behaves.
    Neo gtt vs neo pushes to keep SBP > 100. Epi ready. NTG ready.
    Most likely wean her in the PACU on a vent for the rest of the working day until extubation by days end or ICU admission for further weaning.
     
  6. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    This is a GI suite in a full-service hospital. Every conceivable tool is available to you if need be. The GI doc understands the gravity of the situation. The patient, maybe not as much, but wants to proceed. Has had The Talk with multiple other docs.

    Is there anything else you want to know before proceeding?

    Lurch- why MAC and not GETA? What advantages are there to MAC? What disadvantages in this patient? Why vaso/epi?

    Hoya11- why neo in this patient? What potential downsides are there? Why NTG? Why do you think postop ventilation would be necessary?

    Not picking on you guys at all, but just like with the oral boards, I'm looking for an answer followed by a justification. Thanks for playing along.
     
  7. lakersbaby

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    You really think she would have "good" exercise tolerance? I highly doubt it so would you still do it in ERCP suite with machine?
    Agree with goals of care discussion, I'd feel more comfortable in the OR with resources nearby. Ketafol MAC is an idea but the risk of the patient PA pressure shooting up and worsening her RV failure would make me lean more towards tube and control of airway to avoid hypoxia/hypercarbia.

    Could we discuss with IR/GI doc the possibility of Perc drain to get the stones out and place a stent? This could prob be done under local.

    I'd want to know if there was any PFO on echo . baseline ABG.
    If ERCP the only way I'd prob go pre induction aline, check baseline ABG. Keep systemic pressures at baseline. etom/ketamine induction. Have dopamine (or whatever contractility agent), phenylephrine, NTG ready. if lateral can have TTE probe nearby to assess RV function and estimate PAP during case. Tell the surgeon not to F around. check abg post op. possibly vented to ICU or extubate if gases are near baseline.
     
  8. Lurch

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    For me this is the perfect example of an oral boards answer vs a real life answer. In my experience with these patients, induction of GA with ketamine or etomidate and paralysis with initiation of PPV causes more hemodynamic swings and potential issues than a straightforward MAC. Extubation is always an issue as well with these patients and many a PH crisis has happened on extubation. Do you pull it deep and risk obstruction, hypercarbia and hypoxemia? Do you pull it awake and risk the sympathetic, surge, coughing and bucking? Nevermind the fact that this patient will be very hard to extubate given the fact she's a pulmonary cripple. "In my hands", ketafol is a great choice. Keeps the parient spontaneously ventilating. Excellent analgesic, sedative. Overall a good choice in PH. Patient may get a little hypercarbic relative to a controlled GA but it won't be sifnificant. intrathoracic pressure and the potential for hemodynamic swings with GA are greater concerns for me.

    My usual concentration for ketafol is 1mg/cc in propofol but I want less propofol in this patient with PH. A big propofol dose is what kills these patients.


    Vaso>neo bc neo spikes PA pressure more than vaso. Epi for right and left heart support in mini boluses.
     
  9. Lurch

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    And I agree: this is an excellent clinical case with a lot to be learned.
     
  10. Colba55o

    Colba55o Junior Member
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    I want to know the skill level of the GI doc and how comfortable they are doing ERCPs with MAC. Is there a resident or fellow involved?
    This is a great case, personally I would choose GETA over MAC. Yes on the orals, saying you would do MAC for a case like this means preparing to see your examiners again in a year.
    Would like to hear other management styles for those that would go with GETA
     
  11. Hawaiian Bruin

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    GI doc is fast. But there are a bunch of stones to get out, and he also thinks he might have to put a stent in. He won't screw around unnecessarily. No trainees are involved in this case.

    I realize it's old school but we should probably examine the patient. She is normal size, normal airway. Audibly wheezing, took inhalers/nebs just now. Always wheezes. Fairly rapid, fairly shallow breaths. Says this is how she always breathes. Doesn't feel like she's working hard to breathe.

    Telemetry shows sinus rhythm with very frequent PACs. Chart review shows this is baseline.

    Does any of this affect the decision for MAC vs. GA, or alter your anesthetic plan in any other way?
     
  12. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    What sorts of things can get this patient in trouble, that aren't usually a big deal for most patients?
     
  13. Hoya11

    Hoya11 Senior Member
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    Why does this lady have elevated right heart pressures? Its because she has bad lung disease. And she has hypoxic PVC. And compensatory (at least to some degree) PHTN as a result. So you need to keep her PHTN somewhere around where it lives, not just normalize it. In the face of anesthetic induction/hypotension, Neo increases Pulm Blood flow, with stable HR. NTG to avoid overshoots of neo. Her SBP is not so high where neo would cause a problem, and because neo is ubiquitous.

    MAC i think is brave. Because wait until this lady desats on her cut-out non-rebreather mask and possibly has some pulmonary compromise in the prone position and no reserve. So im thinking just intubate up front and avoid tubing or intervening mid-way through the procedure when the attempt at spont respirations isnt going well with scope in mouth. Also shes 41 so she may require a lot of sedation and become suddenly apneic. Maybe she has some kind of wierd connective tissue disease since she has such bad lung disease and valvular disease at 41? Also a lot of the management depends on GI deftness and how fat/skinny she is.

    You could even do the case with an LMA, after inhalational induction with spont respirations if GI can get around the LMA and she is skinny enough to mask/breath down.
     
  14. Pooh & Annie

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    Great case!
    I've got lots of thoughts, but #1) do this kind of case ONCE without an airway and control of ventilation/O2, then let's hear if you want to try it again.
     
  15. LivetoTell

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    I think your asking for trouble doing this case under MAC. Hypercarbia is envitable. Plus, the position for an ERCP in a pulmonary cripple is another negative for less than ideal ventilation. Ketamine causes increased PVR, but not sure if it would matter. I'd probably stay away from using it.

    Pre -op Art line to help with gentle induction/ intubation and guidance through case. Etomidate and propofol for induction. LTA, maintain normocapnia. Milrinone & Vasopressin ready to go if hemodynamics sour. Extubate deep to prevent bucking/coughing, but mask assist ventilations until pt awakes. I'd prefer to do this in the main OR, better back-up and equipment if needed versus GI suite.
     
  16. urge

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    pent, sux, tube... NIPPV post op.
     
  17. Pooh & Annie

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  18. jwk

    jwk CAA, ASA-PAC Contributor
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    Not every GI suite is a sh*thole. We have a dedicated ERCP suite in our GI lab with built-in C-arm, anesthesia machine and cart, our usual OR monitor setup, and room to maneuver. Doing it in the OR would offer no advantage to us.
     
  19. lakersbaby

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    does your GI suite have a capable extra pair of hands that could help you in an emergent situation? most GI suites I know are a good distance from the OR and from any personnel that are prepared to deal with really sick people. Yes it can be done there but if given the choice I'd rather not.
     
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  20. jwk

    jwk CAA, ASA-PAC Contributor
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    Actually yes. We have enough volume that this just isn't an issue.
     
  21. fakin' the funk

    fakin' the funk ASA Member
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    ERCP's don't have to be done prone.
     
  22. Docuronium

    Docuronium ASA Member
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    Prone MAC for this patient? Holy guacamole---I guess you must be looking for something to keep your HR up.

    This patient gets intubated, and since the time I really want the art line is around induction, it gets to be placed pre-op.

    Confused about using etomidate AND propofol for induction---that's something I haven't seen before but I'm admittedly green.
     
  23. Lurch

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    As I mentioned, this strategy has worked well for me in the past. Appreciate the other opinions/discussion. It's what keeps this board interesting for me.

    We could also talk about the significance of an RV with mildly depressed function, severe enlargement, and PAP that are not even 3/4 systemic. I would take a look at the images since measurement of RV fxn is largely a qualitative assessment but assuming there is truly only a mild reduction in fxn, I would stick with my original plan of MAC.

    Would also be intersting to know what her hemodynamics and gas exchange were like at the time of the echo. As well as how far out from the echo we are.

    For the rest of you who would do general, what ventilator settings do you use? A short inspiratory time might allow for complete expiration but also might increase airway P (not a good thing in PH although high PIPs may not be a problem in a COPDer). A long inspiratory time may lead to hypercarbia or breath stacking and increased intrathoracic P. High or low TV/RR? Are you worried about peak or mean airway pressures in a PH patient?
     
  24. sethco

    sethco Senior Member
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    Still don't understand alot of posters love of Etomidate. Been about 2-3 years since I last used this drug and my private practice job is about 80-90% CT surgery. Just too many questions about safety profile of this drug
     
  25. doc05

    doc05 2K Member
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    this patient is better off with a perc drainage (cholecystostomy) at interventional radiology.
     
  26. Planktonmd

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    The best plan is to try and get someone else do this case.
     
  27. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    The meat of this case is the RV/Pulm HTN management, and I'll address my thoughts on that later (others are welcome to chime in on that), but for now- I completely agree about vomidate. As I've said before, I use etomidate exactly never, and I do super-sick hearts. Recognizing that there's no smoking gun evidence that it definitely causes harm, there is a lot of retrospective evidence that it might. Since there are other ways of inducing sick patients, I avoid it like the plague.

    For cholecystitis, maybe. But not for a bunch of stones in the bile duct.

    Ha! Well, masochist that I am, I actually like getting called for these cases. And the residents out there should strive to be the person who they call for these cases once they're done with training. I'd rather do this case than a day of cataracts. YMMV.
     
  28. urge

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    Is it? Disagree. Given only mildly depressed rv function on echo I would argue that the meat of this case is the management of her severe copd with low sats even on oxygen therapy.
     
  29. Docuronium

    Docuronium ASA Member
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    aoz8kgx8pzknypz7z38n.jpg
     
  30. urge

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    Because the heart hasn't really suffered that much from the bad lungs.

    We are the ones who are about to suffer her bad lungs post op.
     
  31. Gastrapathy

    Gastrapathy no longer apathetic
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    Just a couple of points:
    Draining the GB won't solve anything. It's rare that the cystic can drain the CBD.

    Trans hepatic biliary drainage via IR is really only feasible if there are dilated intrahepatics. Almost always, this gals only option is ERCP or lap common duct exploration. If she's having a chole anyway, the outcomes are the same for a properly equipped expert lap surgeon.

    Fluoro is often much better in my lab than the OR (5/6 places I've practiced). You want me done fast, let me have a home game.

    Many of us will do ERCPs supine or left lateral. I don't like left lateral because it makes the fluoro much harder to interpret.

    We shouldn't care if you do MAC or GETA.

    Trainee involvement is my call.
     
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  32. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    Yes, it's both.
     
    #31 Hawaiian Bruin, Aug 16, 2015
    Last edited: Aug 16, 2015
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  33. pgg

    pgg Laugh at me, will they?
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    Thanks for joining in, gastrapathy. :)
     
  34. Planktonmd

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    I used to think this way too: " they want me to do the crappy cases... I must be a genius..." until one day I realized that there are a few people who never do any crappy cases, they manage to always dump them on someone else, mainly me, and they get paid and treated the same or better than me!
    Those guys get to go home early everyday and have a very low stress life, while I get to deal with disasters all day!
     
  35. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    I was gonna try and tackle these issues separately but since they're so interconnected, f it, let's just dive into everything. Hopefully it stays coherent.

    As to the airway issue and choice of MAC vs. GA- let's assume the GI insists on doing the case prone. I think it is absolutely crucial to have an ETT in for this case, because we cannot allow the patient to hypoventilate and get hypercarbic and more hypoxemic. This isn't an in-and-out EGD, it's a complex ERCP with possible stenting. Let's do the patient, her heart, and ourselves a favor and optimize the respiratory situation.

    Yes, you'd rather not instrument a bad COPDer's airway and put them on a vent if you don't have to. But I think you have to here. And she walked in (slowly) off the street- she didn't start in overt respiratory failure, so there is a better than even chance that she'll be extubatable at the end. If the airways get reactive and she doesn't declare herself ready when everything is done, you can vent temporarily in the PACU if necessary. I don't think the way you ventilate matters much for this short case, just make sure you don't breath stack and keep pressures reasonable and you'll be OK.

    So on to the heart. When I say this right heart was massive, I mean it was truly enormous. As expected, there was flattening of the interventricular septum both is systole and diastole (pressure and volume overload), and the LV was small and D-shaped. One of those hearts where the RV has dilated into space normally occupied by the LV, decreasing the LVEDV and stroke volume.

    The TR was a strong moderate, had i read the echo I would have called it mod-severe, which makes it necessary to take the read of "mild RV dysfunction" with a grain of salt- the RV has a low-pressure popoff to work with. Also, while the PASP by echo was "only" 2/3rds systemic, those estimates often underestimate the true RVSP. So I thought that I'd better treat this heart like one that is very capable of going down the pulmonary hypertension death spiral. Moreover, with all the PACs, the effective heart rate of perfusing beats was actually a fair bit lower than the EKG rate, which didn't help anything.

    So as we all know, what makes pulmonary hypertension so dangerous is the death spiral of RV ischemia. The RV is normally perfused both is systole and diastole, unlike the LV (only in diastole). As PH and RVH progress, and pulmonary pressures approach systemic pressures, the RV starts losing that systolic perfusion, and only gets effective blood flow in diastole. If our BP goes down and the strained RV gets ischemic, its output drops (further decreasing BP and exacerbating ischemia) and it dilates, further reducing the LV chamber size (because of ventricular interdependence- only so much room in the pericardium) and decreasing the LV stroke volume- further decreasing BP and exacerbating ischemia. It's tough to bring patients with this physiology back from a code.

    So our hemodynamic goals are: maintain diastolic perfusion (maintain SVR), while minimizing RV afterload (reduce PVR). We also want to maintain preload and avoid significant bradycardia. Fortunately there won't be fluid shifts during this nonsurgical case, so that's one less variable to deal with. And again, since hypoxia/hypercarbia will increase PVR, we want to control the ventilation to make sure those variables are optimized.

    For those who have played with vasopressors in the heart room while you have a swan in, you've seen that with alpha agonists, the pulmonary pressures go up with every bolus. Usually this is OK, since systemic pressures should concomitantly rise, but this isn't always the case with sick patients. Norepi is better than phynelephrine IMO, since you the the RV a little beta bone.

    Vasopressin is an ideal pressor for these patients. It has the desirable properties of raising the SVR (and therefore coronary perfusion pressure) without raising the PVR, optimizing RV perfusion. PA pressures should not change with boluses or infusions of vaso.

    Other things to have around for patients like these- milrinone is in many ways a good drug for these folks. Increases RV contractility and decreases PA pressures. It does so at the cost of some SVR though, so important to have some pressor around to counteract that. Vaso again is ideal, but a little norepi is also good with milrinone.

    Epi standing by if you really get into trouble, but keep it as a last resort- you hate to take a borderline ischemic RV and ask it to beat stronger and faster unless you really have to.

    I'll stop there for now. All other comments welcome.
     
  36. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    You know what, I think you're absolutely right about this, though it isn't about being a genius, just about accepting and enjoying the challenge of getting tough cases done, rather than find ways out of doing them.

    I file it under "no good deed goes unpunished," and go about my day. I think the professional satisfaction is worth it, but I will freely admit there have been times when I was involved in some disaster when I would otherwise have been surfing, and not super happy about it.

    But in this environment, it's probably better to be seen as an integral part of the surgical machinery, rather than a replaceable cog.
     
  37. Tee Cell

    Tee Cell New Member
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    Wow great case. I was about to ask about airway exam and the size of the patient. I don't think I saw it mentioned. Regardless I don't think I would do this under MAC for the reasons mentioned. I considered an LMA although I don't know how feasible it is to do an ercp with one in. It sure would ease my comfort in neing able to extubate the pt. I am curious as to the the effect of prone positioning on PA pressures though if anyone would like to comment.
     
  38. pgg

    pgg Laugh at me, will they?
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    Don't fall in the trap of deriving your sense of self-satisfaction and fulfillment based on how much money other people are making for how much work. That way lies madness. There will always be some lazy POS chump out-earning, out-schmoozing, out-living, and out-whatevering you someplace.

    Anything worth doing is hard. The best people (at anything) are the best because they embrace and seek out hard things to do.

    If you do lots of hard cases you'll be stronger for it, and you'll do them well. That lazy case-dodger who always seems to dump them on you will, someday, get a hard case he can't dump, and because he's weak, he'll bone it up.

    If it's just risk you're fixated on ... a bunch of hard cases done well is lower risk than one hard case done poorly.

    If it's money/respect/adoration you're fixated on ... you shoulda been an i-banker. :)
     
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  39. amyl

    amyl ASA Member
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    Aline. Intubate. Main OR bc the gi nurses suck where I am.... Pressors as needed to maintain bp.
    I don't like these in a Mac. Ercp can unexpectedly take hours. Sick people usually. I've also seen a little brief flash sepsis from them mucking around in there. Of course discussion with pt n family regarding post op Icu and intubation etc.
     
  40. Hawaiian Bruin

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    So to finish the case- I've actually had to do this case twice, once a while back for the original procedure and stent placement, then again recently for stent removal and fishing out a few more stones.

    The first time, I did put in an a-line. The frequent PACs really made that decision for me, because I could tell by the pulse ox tracing that many beats were not perfusing, and I didn't know if I could trust the NIBP in that setting.

    Went to sleep with gentle propofol titrated in slowly. Had it been a surgical case expected to last awhile i might have worked some ketamine in there too, but not for an outpatient case where postop lucidity is important. Hemodynamics stayed OK, systemic BP started around 120s, I intubated as it got to the 90s, (took around 120mg in 30mg aliquots). Bumps of vaso as needed. Aline pressures did correlate with NIBP. I had a VScan with me (handheld echo) to dx problems if things got hairy, but fortunately they never did. I was able to extubate without any trouble and she went home happy after some postop nebs.

    The second time, I didn't put the a-line in and the case proceeded without difficulty with the same technique. Routine ERCP!

    One of those cases where you plan for the worst and hope for the best. I figured I'd bring it up as a thought-provoking case.
     
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  41. dhb

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    This was imho the most important part of the clinical picture, you just can't get these patient to die even if you try hard.
    If the patient was in no acute distress i don't think i would have had a problem with a Mac with no aline.
    Second look in a patient with a stent should be 10-15 min max.
     
  42. Consigliere

    10+ Year Member

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    Oh boy are you delusional; you are the most replaceable of replaceable cogs. As soon as a cheaper alternative manifests itself, you're toast. Your explanation, rationale, and handling of this case are indeed eloquent. Guess what though? No one cares. Any CRNA could have done this case and if they executed the pt., so what? Everyone would have said "well, he was really sick and would probably have died anyway."
     
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  43. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    Consigliere's view of anesthesiology:
    [​IMG]
    Anesthesiology as seen by me in my practice:
    [​IMG]
     
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  44. Consigliere

    10+ Year Member

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    Both views look pretty bad ass!
     
  45. Docuronium

    Docuronium ASA Member
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    Yeah, but in one you're getting blasted.
     
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