Scary Case on Friday, Your Thoughts?

[Timeoutofmind]

The crap hit the fan, and I would be really appreciative to hear what you make of it, as there are a lot of smart posters on here:

I did a laparoscopic peritoneal dialysis catheter insertion on Friday at the VA. The pt was a 65yr old ASA 4 vet. Needs to initiate dialysis for progressive CKD 2/2 longstanding DM (finger stick OK pre-op) and HTN (also controlled pre-op). Also, numerous other comorbidities: Obese, OSA (on home CPAP at 10cm H20), COPD, CAD with h/o CABG (no active ACS), CHF (EF 45%) with ICU admission two months ago but currently controlled, HLD, multiple myloma, and factor V leiden deficency with h/o clots, seizure d/o, etc. Also, uses a lot of narcs for back pain (most recent note says oxycodone 20mg BID, and also an unspecified amount of oxycontin he is "inappropriately getting from an outside provider". Also, takes benzos daily as well.

He was satting 90% on RA in pre-op, and lungs were clear with no signs of fluid overload on exam. I didnt given any benzos pre-op.

Case was straightforward/stable. Only got 300cc of fluid. 1gram tylenol, and 150mcg Fentanyl, no dilaudid or any other narcs. Working with a smart and type A attending who likes to be there for wakeup (glad he was in this case). Reversed him, 4 strong twitches no post-tetanic fade, etc. RR 10, TV 550 or so. Suction, extubate. He's a little groggy but breathing nicely, and responsive when prompted. 10L O2 via FM as I wheel him to PACU (not on monitors). Attending says have a good weekend.

Seems OK on the trip over (about 60 secs). Park him in PACU and hook up the O2 (10L/min still) to the wall, and hes getting squirly so I quick gave him 25mcg Fentanyl from some of my leftovers from the case in my pocket before I start getting him on the monitors with the nurses, as I am anticipating having problems controlling this dudes pain post-op. Go to put the pulse ox on and his fists are clenched tight so not getting a good read on the pulse ox, and when I encourage him to loosen up hes not responsive, but appears to be breathing, although I really didnt asses his breathing during this moment as closely as I should have in retrospect and I am not 100% on this. Just has his eyes shut and almost looks to be grimacing with his facial muscles and is not responding to verbal or physical cues. I wasnt too concerned at this point, cause its not the first disoriented PACU pt I have ever had and he was pretty groggy in the OR. Nurses not worried either. As they get an ear probe I hook up ECG/BP cuff. BP reads 69/40, ECG is sinus brady at 45-50bpm (about where he was all case due to being heavily BBlocked pre-op...had given him 0.2mg of glyco early in the case to help out actually). I am not thinking the BP is real as he is clenching, etc, and re-cycle it while we are putting the ear probe on...but then when we get the probe on there is not a good signal. Within about 15 seconds while I am further fiddling with the monitors and trying to get him to respond, he brady's down hard...it was sinus the whole time and 24 was the lowest number I saw. No respiratory efforts occuring, or at least nothing substantial. I asked the nurses for an amubag, 0.5mg atropine stat, and tell them to call a code. Within 30 seconds the atropine is in the line, and I am bagging him sucessfully with oral airway in place (although hes tough). His HR goes to 170 almost instantly, before settling out in the 140s, and his BPs are around 200/130. Pulse ox is giving readings of 80 or so, and coming up with bagging. A lot of people show up, including some ICU and anesthesia docs and hes obviously looking better at this point in terms of VS, although still not responsive. So we just keep bagging, slowly bringing his sats up to 100. They think its the narcotic, and they give 0.4mg Narcan in divided doses over a few minutes and he comes around but is still not verbal, goes to ICU for observation on face mask O2. Was looking fine and talking at 30mins after when I checked on him. I'll check on him Mon too obviously. The only labs we got in the heat of the moment were an ABG that confirmed respiratory acidosis with a pCO2 of 65.

My attending was completely respectful and supportive, and in no way threw me under the bus. However, he seemed to chalk it up firmly to the 25mcg of fentanyl, and ultimately said while it wasn't some totally unreasonable or crazy thing to do, he thought it was unwise, and he doesn't give it in the PACU he only does dilaudid esp in these types of pts etc. My attending also noted that the bradycardia may have been precipitated by the fentanyl.

I guess that "horses before zebras" type considerations win out here, and the most likely explanation was that the fentayl lead to hypoventilation and hypoxia, which I was late in detecting, of which the extreme bradycardia was a late manifestation. But have you seen OSA people who are that exquiselty sensitive to narcs!? Even though he is pounding narcs outpt? And he deteriorated so rapidly it was no more than 3 mins after the 25mcg...

I wondered in retrospect if he could have seized as the primary etiology (I am not sure how well his seizure d/o was controlled pre-op) and thus was apneic. As I mentioned earlier his fists were at one point clenched and he was unresponsive, and also he did seem quite post-ictal/confused after he woke up with narcan and was moaning loudly for a bit. (However, on the other hand you could contribute the seizure to hypoxia.)

Also, it seems like his HR going from 25 to 175 from 0.5mg atropine was too large a change, and I am not sure what to make of it.

Sorry its such a long post. Thanks for your thoughts...its was just such a stressful/intense occurrence for a guy just finishing up CA1 year, and I am trying to process it and think about how it will change my future practice.

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[deleted9493]

If he's taking 20mg of oxycodone twice a day, 25mcg of fentanyl in this situation is not going to make him frankly hypoxic/hypercarbic and prone to seizing. Sometimes we do the best that we can and patients have complicated postoperative courses--it doesn't mean that you did anything wrong.

It sounds as though you acted appropriately. Fentanyl will be hepatically inactivated and makes sense as a narcotic of choice here.

Peritoneal dialysis catheters take time to mature and the question of his current renal function remains.

 

[nap$ter]

hard to guess, but sounds like hypoxia in transport, delay with monitor placement, possible hypoxic seizure, followed by brady/hypotension.

25 of fentanyl extremely unlikely to have changed anything.

 

[urge]

I have to agree on hypoxia during transport. The 25mcgs of fent is icing on the cake.

People are not very good assessing whether pts are breathing or not. That's why they require capnographs all over the hosp.

 

[Intrathecal]

I also think it was the fentanyl. Especially if he was breathing at RR of 10 at the end of the case still with volatile agent onboard. What was the MAC of the agent at this point?

Remember that volatile anesthetics actually increase RR and decrease TV? I've found that once the agent wears off, the RR is significantly less. Did he respond to commands or at least open his eyes when requested before you extubated him?

Renal failure patients are extremely touchy. Also this type of surgery is generally not too painful and even with this patient's h/o chronic opioid use, I think the amount given in this case was excessive. Especially since he came around after narcan was given.

I think it's just a case of opioid overdose.

 

[dhb]

I put my money on obstruction during transport leading to hypoxia/hypercarbia did you have an oral airway in place during transport? maybe the only intervention that would have altered the course. Unlikely that the fentanyl is to blame here although it didn't help either.

 

[saratoga733]

you really have no idea how much narcs he took that day... as u mentioned he was inappropriately sourcing oxycontin, right? maybe he took some extra hits to offset anxiety and post-op pain. if surgeon gave local anes these procedures tend to be not very painful.

 

[BLADEMDA]

This won't be the last patient who crumps on you in the pacu. Here a few tidbits:

1. High risk for obstruction on the way to the pacu. I've seen more than a few CRNAs leave the room with a saturation of 99 percent and then in pacu the reading is 80.

2. OSA patients can be quite senstive to narcotics. I've seen a few stop breathing after the CRNA gives 50 mics of Fentanyl in the holding area or OR.

3. Atropine can cause a severe tachycardia in patents. I've seen heart rates well in excess of 150 after IV atropine. My preference is Glycopyrrolate unless its an emergency or severe bradycardia.

4. No matter the type of surgery ASA4 cases can be quite challenging. High risk patients are just seconds away from death or major morbidity. Even if you do everything correctly bad outcomes can and do occur in these types of patients.

 

[cincincyreds]

This won't be the last patient who crumps on you in the pacu. Here a few tidbits:

1. High risk for obstruction on the way to the pacu. I've seen more than a few CRNAs leave the room with a saturation of 99 percent and then in pacu the reading is 80.

2. OSA patients can be quite senstive to narcotics. I've seen a few stop breathing after the CRNA gives 50 mics of Fentanyl in the holding area or OR.

3. Atropine can cause a severe tachycardia in patents. I've seen heart rates well in excess of 150 after IV atropine. My preference is Glycopyrrolate unless its an emergency or severe bradycardia.

4. No matter the type of surgery ASA4 cases can be quite challenging. High risk patients are just seconds away from death or major morbidity. Even if you do everything correctly bad outcomes can and do occur in these types of patients.

Agreed with all the above. This is a case to learn from and really see how quickly a ESRD patient with OSA can crump. Not that you did it, but I would be a little wary of shoving a nasal trumpet down a patient's nares who is on dialysis. They can bleed like stinck. Whenever you are in these situations, don't be afraid to ask for help because you will need a tube and also line these patients up quickly.

 

[seinfeld]

Agreed with all the above. This is a case to learn from and really see how quickly a ESRD patient with OSA can crump. Not that you did it, but I would be a little wary of shoving a nasal trumpet down a patient's nares who is on dialysis. They can bleed like stinck. Whenever you are in these situations, don't be afraid to ask for help because you will need a tube and also line these patients up quickly.

I will second and third all that has been said by the above attendings.

Bad things happen even when you do it all the right way.

Pain is a life sustaining mechanism and intraopertive hemodynamic responses to stimulation does not mean they will have pain post op (hate when people give a ton of narc's for Laparscopic procedures)

A combative patient with a hx of Significant Cardiac or Pulm disease means they are having cardiopulm issues until proven otherwise.

 

[KungPOWChicken]

How awake was this guy on extubation? Was he following he following commands, eyes open. My guess is extubated too early resulting in obstruction not recognized resulting hypoxia/ hypercarbia in a patient with little reserve (pulmonary htn/chf). Equals code. Don't give narcotics to treat agitation in a patient who you haven't made a full assessment of and is not talking to you. Lesson learned.

 

[Icefrog]

Could neostigmine overdose have contributed? I know you said strong twitches/no fade, but perhaps you tested prior to the neo having taken full effect. It is possible that a greater than therapeutic dose of neostigmine can cause altered mental status, agitation could be from muscle weakness, muscle cramping (possibly contributing to the fist clenching in your case), bradycardia, and then muscle weakness leading to respiratory failure.

 

[HollATme]

I'm a CA-1 as well. I personally don't like to give elderly patients (frail or not) too much narcotics, especially for short cases that may not be too painful. Lower MAC requirements. 100-150mcg fentanyl and that's it for these short cases. Of course, it's all case-dependent, big cases will probably require more. I do not like giving long-acting narcotics to OSA patients.

I wait for them to open their eyes and open their mouth upon command before extubating. More so with a history of OSA. VSS, good tidal volumes, normal RR, etc.

If I see sats that aren't ideal. I wait for them to be more awake. I give O2 and do jaw thrusts. I *might* stick an ORAL airway (I really do not like nasal trumpets much) if they are out of it. If they can spit it out, fine. They're at least alert enough to do that.

I had a patient come into preop on a weekend call. Was quite altered. It was an emergency case, so had to do it. I fully assessed neuro status. Was a similar ASA4, OSA, etc. We took the patient to OR, uneventful course. Extubated with my above criteria, then in OR started to desat to the upper 80s. I kept him in the OR and did some jaw thrust maneuvers as the guy was likely obstructing. Helped a little, got his sats to 94. I figured the guy needed non-invasive PPV. So, called PACU RN for RT to bring a CPAP equipment. While on my way to PACU, everything was ready to go. Sats were down to 86 and he was obstructing. The whole time I transported (short distance) I did the chin left and jaw thrust, he remained on O2 by FM as well. Anyways, no narcotics were given in PACU. I figured his AMS was due to a respiratory cause. I asked my attending if we should get an ABG, but we elected not to and did a wait-and-see if his status improved on CPAP. Checked in 30 mins later, much improved. Hour later, he was AOx3 and speaking clear as day. He was much better at that point than he ever had been during my interaction with him in preop.

Eventually, he was good to go and shipped to the floor.

Of course, I'm always learning ways to refine my thought process, differentials, and my approach to these differentials. So, feel free to fire away.

 

[Gern Blansten]

This won't be the last patient who crumps on you in the pacu. Here a few tidbits:

1. High risk for obstruction on the way to the pacu. I've seen more than a few CRNAs leave the room with a saturation of 99 percent and then in pacu the reading is 80.

2. OSA patients can be quite senstive to narcotics. I've seen a few stop breathing after the CRNA gives 50 mics of Fentanyl in the holding area or OR.

3. Atropine can cause a severe tachycardia in patents. I've seen heart rates well in excess of 150 after IV atropine. My preference is Glycopyrrolate unless its an emergency or severe bradycardia.

4. No matter the type of surgery ASA4 cases can be quite challenging. High risk patients are just seconds away from death or major morbidity. Even if you do everything correctly bad outcomes can and do occur in these types of patients.

Nice summary. I agree with all of this. This case will make you appreciate how quickly a stable situation can turn into an unstable one.

 

[nap$ter]

Could neostigmine overdose have contributed? I know you said strong twitches/no fade, but perhaps you tested prior to the neo having taken full effect. It is possible that a greater than therapeutic dose of neostigmine can cause altered mental status, agitation could be from muscle weakness, muscle cramping (possibly contributing to the fist clenching in your case), bradycardia, and then muscle weakness leading to respiratory failure.

paradoxical muscle weakness from neostigmine overdose is unproven academic dogma IMHO. all evidence is confounded by the presence of paralytic.

residual neuromuscular weakness despite neostigmine administration is a proven possibility.

 

[Mac4]

1. Patient in PACU getting squirly? It could be due to pain but rule out hypoxia/hypercarbia first. Do not give narcotics until you have good vitals.

2. When BP reading low or pulse ox tracing poor, do not spend the next five minutes messing around with cables/sensors. Check the patient's color and carotid pulses. Do not blame the equipment when your patient is actually decompensating. I hate it when CRNAs are continues flushing the a-lines to get a better reading when the cuff BP is 61/40.

 

[BLADEMDA]

1. Patient in PACU getting squirly? It could be due to pain but rule out hypoxia/hypercarbia first. Do not give narcotics until you have good vitals.

2. When BP reading low or pulse ox tracing poor, do not spend the next five minutes messing around with cables/sensors. Check the patient's color and carotid pulses. Do not blame the equipment when your patient is actually decompensating. I hate it when CRNAs are continues flushing the a-lines to get a better reading when the cuff BP is 61/40.

OR getting called "stat" to the operating room because ALL the monitors are not working properly,
Fortunately, Epi, Vasopressin and Chest compressions brought the monitors back online.

 

[Mman]

Park him in PACU and hook up the O2 (10L/min still) to the wall, and hes getting squirly so I quick gave him 25mcg Fentanyl from some of my leftovers from the case in my pocket before I start getting him on the monitors with the nurses, as I am anticipating having problems controlling this dudes pain post-op.

Why were you anticipating problems controlling pain? It's a PD cath, they don't hurt. I understand the chronic pain issues, but in the grand scheme of things this still shouldn't hurt much. I'd make him be awake and specifically asking for pain meds before getting any in PACU as opposed to giving them because he looks squirrelly before hooking up monitors.


Just my monday morning QB'ing, though, but IMHO it's always important to have an estimation for how much a procedure should hurt postop to help guide care and clue you in when something unexpected is happening.

 

[IlDestriero]

OSA and nasal trumpets go together like peanutbutter and jelly.

 

[Timeoutofmind]

Per my colleague on call this weekend, I guess the guy went home the next day and was fine. In response to a few different specific questions:

1. Pt was responsive and following commands before and after extubation and my attending was present. I do not think we extubated too early based on his following commands, good TV/RR, etc. He was groggy, but totally responsive to commands and verbal.

2. Expired Sevo was at 0.1 or so when he was breathing at 10-15bpm prior to extubation.

3. SpO2 was actually 100% for a full one to two minutes after extubation without my assisting his airway in the OR, prior to wheeling to the PACU.

4. Oral airway was in on transport to and throughout PACU stay. He was sitting up almost at 90 degress on the way there, to help his respiratory mechanics as he was obese.

5. I dont think neostigmine OD is probable, as I gave him a standard reversal dose.

After thinking about it quite a bit over the weekend, and reading your comments, I agree that the most probable explanation is that the pt was obstructing significantly more than I was appreciating on transport, and was already very hypoxemic on arrival to PACU....it just seems strange that he was able to maintain his sats at literally 100% without asistance in the OR and was following commands, and in the 60 secs to maybe 120 secs at most it took to wheel him to PACU (with oral airway in place), he totally quit maintaining his airway to the point of severe hypoxemia, especially because he did not look dusky or blue at all on arrival or in the brief period when we were fiddling with the pulse ox. Doesnt it? Maybe you had to be there, but its not like this is the first obese/OSA pt I have ever had, and something just seemed different here...

I really dont know how much the 25mcg of Fentanyl added in the whole picture, as he decompensated virtually immediately after it was given it seems unlikely to have played a large role, but I guess it may have tipped the balance. In any case, as you have pointed out, it was not a good idea to give it in this case until he was wide awake and verbally asking for it. I just thought in the face of his massive outpt opiod use, such a dose was a drop in the bucket...lesson learned.

In retrospect, a lot of lessons were learned. The number one of which is RESPECT THE AIRWAY, and be at all times mindful of the pts airway when not on monitors. Anesthesia is life and death, every day. Pretty humbling experience.

 

[nap$ter]

thanks for the productive post - i like your attitude and the reminder for humility.

the presence or absence of cyanosis is not really all that helpful - it's pretty subjective and variable. color has to be taken in context with all other variables/data.

i've seen bluish looking patients with sats of 98, and pink ones with sats of 60. certainly blue warrants action/investigation, but color alone doesn't credit/discredit an oxygenation issue.

 

[WholeLottaGame7]

OSA and nasal trumpets go together like peanutbutter and jelly.

Yeah, I like me some nasal trumpets. Except in those patients you're going to anticoagulate. I mean, don't go gouging around in there. But if it's someone I'm concerned about, I will put it in empirically. Especially because some of our longer OR-PACU trips can take a few minutes and I can't exactly jaw thrust and push the bed at the same time. We also have some portable SpO2 monitors I've used on occasion if I'm worried but don't want a full transport monitor.

 

[Oggg]

Did you pre oxygenate him with 100% oxygen prior to extubating? If so, you wouldn't expect him to desaturate for 2-10 minutes, just like when you pre oxygenate during induction.

 

[pgg]

1. Pt was responsive and following commands before and after extubation and my attending was present. I do not think we extubated too early based on his following commands, good TV/RR, etc. He was groggy, but totally responsive to commands and verbal.

[...]

4. Oral airway was in on transport to and throughout PACU stay.

He was awake yet tolerating an oral airway? Maybe he wasn't as awake as you thought he was?

Thanks for posting.

 

[Pooh & Annie]

Did you pre oxygenate him with 100% oxygen prior to extubating? If so, you wouldn't expect him to desaturate for 2-10 minutes, just like when you pre oxygenate during induction.

Good point. And unless you're using an accelerometer, he might have some residual paralytic. Transport monitors have probably saved some obese/partially paralyzed lives. If they're chatting with you en route that's a different story.
90% on room air prior to the case is not a good sign either. Im conservative with a-lines, but this might have been a good case for an a-line. Not only for the probable abgs, but for hemodynamics. This guy probably has a narrow window of safe BPs.

Glad it turned out ok. Unfortunately I wouldn't be surprised if the guy had some sub clinical cerebrocortical and/or myocardial damage. I think that happens more than we're able to initially tell in these chronically ill patients with little/no reserve.

 

[Intrathecal]

Even preoxygenating with 100% O2 at the end of the case, due to nature of surgery, ie laparoscopy, there is decreased FRC and more atelectasis in the lungs causing a much quicker desat. It's a poor analogy comparing as the time you have until desaturation on induction, because now on emergence the patient has been under GA with impaired respiratory function, has been mechanically ventilated and developed atelectasis regardless of the type of surgery. Not to mention the addition of narcotics, residual volatile anesthetics, decreasing minute ventilation and respiratory drive. The patient will desaturate much faster regardless of type of surgery, when compared to pre-induction.

Also a couple of important pieces of data that would be helpful in this patient... when did he last take the oxycontin? How long was the case? A lot of times when I interview chronic pain patients presenting for surgery, they would have taken their regular dose of narcotic right before coming into the hospital, be it the surgeon's recommendation or their own. Sometimes they haven't taken it for a long time... this helps in gauging how much narcotic to give intraop and post op.

Another thing I have found helpful when transporting a patient to PACU on face mask, you can observe misting in the mask to make sure patient is still maintaining a patent airway. Even with a nasal cannula you can in majority of cases see misting if they are nasal breathers. Regardless of the method used, it is our job to make sure the patient is maintaining a patent airway on the way to PACU.

 

[Ronin786]

OR getting called "stat" to the operating room because ALL the monitors are not working properly,
Fortunately, Epi, Vasopressin and Chest compressions brought the monitors back online.

Did this really happen?

 

[pgg]

Did this really happen?

No doubt. I've seen someone rearrange ECG leads to fix ST segment depression.

Even preoxygenating with 100% O2 at the end of the case, due to nature of surgery, ie laparoscopy, there is decreased FRC and more atelectasis in the lungs causing a much quicker desat.

I wake people up on 80% oxygen, specifically to reduce the risk of additional absorption atelectasis if they hypoventilate or obstruct after extubation. I don't think it's really much of a risk in most patients, but I think it can be significant in the obese OSA patients.

 

[BLADEMDA]

Did this really happen?

The CRNA had 30 years of clinical experience. Yet, she couldn't tell the patient was arresting vs a faulty piece of equipment? Fortunately, she is now retired.

 

[IlDestriero]

He was awake yet tolerating an oral airway? Maybe he wasn't as awake as you thought he was?

Thanks for posting.

That was my thought as well.

 

[IlDestriero]

The CRNA had 30 years of clinical experience. Yet, she couldn't tell the patient was arresting from a faulty piece of equipment? Fortunately, she is now retired.

I saw a few very senior CRNAs in the Navy with repeated examples of very poor clinical judgement. Perhaps that's why they stayed in. It's hard to be fired from the .mil.
If you are dangerous in the real world, you'll be looking for a new job as soon as the Anesthesiologists figure it out. In the .mil they just say, "go take over his/her room". If we made those grotesque errors in judgement, we'd be standing tall before the man.
Only the best for our boys in uniform...

 

[Planktonmd]

This patient had post-op exacerbation of chronic respiratory failure due to GA, possible atelectasis and residual muscle relaxation.
Very simple.
With a saturation of 90% pre-op you should have expected when he wakes up from GA he is going to have a problem.
It would have been a good idea to get an ABG pre-op.
It takes hours to days for your FRC to recover after a general anesthetic and if you are barely hanging there it's almost certain that you will have respiratory failure post-op.
You also attempted to treat hypoventilation by giving more oxygen which can improve the saturation numbers temporarily while the CO2 continues to rise, and the patient gradually becomes comatose due to hypercapnea, which is what you witnessed.

 

[EdPierce]

some people like this with very poor health that may have gone unrecognized for a long time may just crump off of the ventilator like this for multifactorial reasons, residual anesthetic/narcotic/osa/relaxant not reversed completely/loss of drive on vent/tired muscles if breathing spontaneously against the tube, etc...

the bottom line is when you have one of these train wreck people they need TLC to come off the vent, TIME more than anything. A carefully planned anesthetic, such as with an inhalational induction, spontaneously breathing tube, no relaxant, dex infusion, 50mcg fent max may help avoid this post-vent crumping. but in the end you just have to get out of the situation, dont bag and wait and bag and wait for them to turn around. recognize they are having trouble, prop, sux, tube them, put them on a vent in the pacu/icu - not the end of the world, move on

 

[gasflea]

I have a ?. Background: I am IM PGY-3 switching to Anesthesia when I finish residency in 39 days. (Who's counting?) So I know essentially zero about anesthesia at this point.

But I know that if this same character came through the ED I would be roasted for putting him on 10L O2 if he is saturating 90s... So how can you balance the need for postop oxygenation with the risk of suppressing his respirations if you give too much O2? Would it be reasonable to ventilate him so he's at his baseline pCO2 at end of case and give him 2-4L O2 with a continuous SpO2 monitor in place for transport?

This has been a great discussion BTW (as always).

 

[Mman]

Would it be reasonable to ventilate him so he's at his baseline pCO2 at end of case and give him 2-4L O2 with a continuous SpO2 monitor in place for transport?

This has been a great discussion BTW (as always).

They will never be at their baseline at the end of the case because of narcotics and residual effects of anesthetic drugs. They are guaranteed to be worse postop, at least temporarily. But you can't leave them all intubated. Gotta try to extubate some that might not fly because you never know if you don't try.

So at the end of the case, if his pCO2 is at his room air baseline, he won't breathe. And part of extubation criteria is having a patient spontaneously breathing. So you need their pCO2 to build up enough to stimulate them to breathe. But if it's too high they'll get CO2 narcosis.


It's just a fine line to walk and we do it every day. The worse the patient's baseline, the finer the line you walk. Sometimes you have to bite the bullet and leave them intubated for a period of time in PACU or ICU because it's the right thing to do.

 

[pgg]

I have a ?. Background: I am IM PGY-3 switching to Anesthesia when I finish residency in 39 days. (Who's counting?) So I know essentially zero about anesthesia at this point.

But I know that if this same character came through the ED I would be roasted for putting him on 10L O2 if he is saturating 90s... So how can you balance the need for postop oxygenation with the risk of suppressing his respirations if you give too much O2? Would it be reasonable to ventilate him so he's at his baseline pCO2 at end of case and give him 2-4L O2 with a continuous SpO2 monitor in place for transport?

This has been a great discussion BTW (as always).

The problem wasn't really the O2, though it probably concealed the real problem for a while. Suppression of hypoxic drive with supplemental O2 in CO2 retainers is a myth. As Planktonmd wrote above, the risk is that a hypoventilating patient can be temporarily made to look OK with supplemental O2 - meanwhile CO2 climbs until hypercapnia becomes a problem.

Oxygen is fine, you just have to make sure the patient is breathing adequately.

The problem as I and other suspect is that this patient wasn't really awake and breathing adequately when they left the OR. There can be a lot of pressure from OR staff, who are all looking at you at the end of the case, to hurry up and get out of the room. They have all-important paperwork to do, a floor to mop, coffee to get, etc. With these patients the right thing to do sometimes is just sit there in the OR, endure the stares, and wait for them to wake up. 5 more minutes in the OR might save a flail in the PACU.