Sedating patient with Guillain-Barre

[toughlife]

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78 y/old male w/ dysphagia, laryngitis and LE weakness and diagnosed with GBS. Admitted for plasmapharesis tx and placement of PEG tube.

Patient is breathing spontanously, A&ox3, on NC @ 2L but in need of peg tube because of dysphagia. Gen surg at bedside ready to cut, asked nurse to give 6mg versed, 100 fentanyl. Patient goes apneic and bradies down. Anesthesia called, as usual, to rescue patient.


Any ideas as to this pt could have been managed best from an anesthetic perspective besides not letting the surgeons order any sedation?

 

[jetproppilot]

78 y/old male w/ dysphagia, laryngitis and LE weakness and diagnosed with GBS. Admitted for plasmapharesis tx and placement of PEG tube.

Patient is breathing spontanously, A&ox3, on NC @ 2L but in need of peg tube because of dysphagia. Gen surg at bedside ready to cut, asked nurse to give 6mg versed, 100 fentanyl. Patient goes apneic and bradies down. Anesthesia called, as usual, to rescue patient.


Any ideas as to this pt could have been managed best from an anesthetic perspective besides not letting the surgeons order any sedation?

YES.


This ascending paralysis dude will benefit from an anesthetic that is here now, and gone a few minutes from now.

Opiods/benzodiazepines are what this dude does not need.

And this is where an anesthesiologists point of view pays dividends.

But it is so obvious, my mom, the cafeteria worker could figure it out:

GIVE AN ANESTHETIC THAT'LL HITCHA.....BOOM.... for ten minutes....and that anesthetic is......

PROPOFOL.

No opiods needed.

No benzos needed.

Give the white stuff thru da IV 'til dude is tolerating da procedure....

....support his airway in the interim....

....and walk away when its done.

Guess thats why I make the big bucks. 😀

 

[stanleykristian]

Must concur, opioids and benzos together are bad except in GA

 

[mille125]

Must concur, opioids and benzos together are bad except in GA

are bad in this situation, but are not bad in all situations.....ie sedation for colonscopy or chronic pain procedure..................

 

[Planktonmd]

78 y/old male w/ dysphagia, laryngitis and LE weakness and diagnosed with GBS. Admitted for plasmapharesis tx and placement of PEG tube.

Patient is breathing spontanously, A&ox3, on NC @ 2L but in need of peg tube because of dysphagia. Gen surg at bedside ready to cut, asked nurse to give 6mg versed, 100 fentanyl. Patient goes apneic and bradies down. Anesthesia called, as usual, to rescue patient.


Any ideas as to this pt could have been managed best from an anesthetic perspective besides not letting the surgeons order any sedation?

This patient could be managed in a number of ways, as long as, there is someone who knows what they are doing at the head of the table.

 

[toughlife]

This patient could be managed in a number of ways, as long as, there is someone who knows what they are doing at the head of the table.

That's usually the problem. No one around who knows what they are doing.

 

[jetproppilot]

This patient could be managed in a number of ways, as long as, there is someone who knows what they are doing at the head of the table.

Very well said.

 

[urgewrx]

El Tubo


Anyone seen an endoscopy done with through and LMA? I have seen it in kids. Probably work in adults too.

 

[nvshelat]

Found this post while trying to pose a qtn on Guillain Barre, hoping you guys can help

Why is the glucose normal in patients with GBS? If proteins can get through the BBB in these patients, why can't glucose?

Same question with viral meningitis...

Now with bacterial meningitis the CSF glucose is decreased supposedly b/c the bacteria are using it for metabolism, correct?

 

[Monty Python]

78 y/old male w/ dysphagia, laryngitis and LE weakness and diagnosed with GBS. Admitted for plasmapharesis tx and placement of PEG tube.

Patient is breathing spontanously, A&ox3, on NC @ 2L but in need of peg tube because of dysphagia. Gen surg at bedside ready to cut, asked nurse to give 6mg versed, 100 fentanyl. Patient goes apneic and bradies down. Anesthesia called, as usual, to rescue patient.

Even if this person had no medical problem, those two meds in those dosages would make just about any 78 y/o go apneic.

 

[militarymd]

El Tubo


Anyone seen an endoscopy done with through and LMA? I have seen it in kids. Probably work in adults too.

sure...a lot of peds folks will do room air generals for scopes & stuff....WHILE putting contrast into the stomach via a og tube....

just don't tell the ASA

 

[militarymd]

Found this post while trying to pose a qtn on Guillain Barre, hoping you guys can help

Why is the glucose normal in patients with GBS? If proteins can get through the BBB in these patients, why can't glucose?

Same question with viral meningitis...

Now with bacterial meningitis the CSF glucose is decreased supposedly b/c the bacteria are using it for metabolism, correct?

disruption of metabolic transport mechs.

 

[fakin' the funk]

Even if this person had no medical problem, those two meds in those dosages would make just about any 78 y/o go apneic.

How about 2mg midazolam +/- remi (assuming they called the anesthesiologist)?

 

[Planktonmd]

Found this post while trying to pose a qtn on Guillain Barre, hoping you guys can help

Why is the glucose normal in patients with GBS? If proteins can get through the BBB in these patients, why can't glucose?

Same question with viral meningitis...

Now with bacterial meningitis the CSF glucose is decreased supposedly b/c the bacteria are using it for metabolism, correct?

Low glucose is suggestive of bacterial meningitis but many other things can cause it as well:
Decreased CSF glucose is characteristically but not invariably found in tuberculous, fungal and amebic meningitis (Naegleria) as well as in bacterial meningitis. Glucose is usually normal in viral meningitis, but in herpes or mumps meningoencephalitis, lymphocytic choriomeningitis, and enteroviruses, glucose may be low. Sarcoidosis and neurosyphilis are reported causes of low CSF glucose. Other very uncommon causes of low CSF glucose include meningeal cysticercosis, trichinosis, and with the chemical meningitis which accompanies intrathecal therapy. Low CSF glucose may also occur in subarachnoid hemorrhage and neoplasia (eg, medulloblastoma). Low CSF glucose may be found in CNS leukemia. Decrease has led to the diagnosis of insulinoma presenting with CNS symptoms. Rheumatoid meningitis and lupus myelopathy may cause low CSF glucose.

 

[Noyac]

How about Special K

A little propofol and a little ketamine would be my approach.

 

[Noyac]

El Tubo


Anyone seen an endoscopy done with through and LMA? I have seen it in kids. Probably work in adults too.

No but I have done bronch's thru an LMA on kids. Works very well.

 

[jetproppilot]

No but I have done bronch's thru an LMA on kids. Works very well.

Me too.

 

[lobelsteve]

6mg Versed must be a typo.

Anyone giving that dose as a bedside procedure is an A$$hat. I push Fentanyl and Versed all day in chronic pain patients. Not a gasman so no propofol for me. Most opioid tolerant folks take 2 and 2 for RF, GRC blocks, and LSB's or 4 and 4 for 3 level discograms or SCS implants.

6mg sounds a bit outside the standard of care, unless administerd to a junkie having the procedure done.

 

[militarymd]

6mg Versed must be a typo.

Anyone giving that dose as a bedside procedure is an A$$hat. I push Fentanyl and Versed all day in chronic pain patients. Not a gasman so no propofol for me. Most opioid tolerant folks take 2 and 2 for RF, GRC blocks, and LSB's or 4 and 4 for 3 level discograms or SCS implants.

6mg sounds a bit outside the standard of care, unless administerd to a junkie having the procedure done.

I love the way how that phrase gets thrown around so much.

 

[Laryngospasm]

Propofol, like Jet said.

 

[nvshelat]

Thanks Mil & Plank

👍

 

[seinfeld]

I assume this guy was in the ICU? I think many non anesthesiologists assume that if the patient is in the ICU he is somehow in a protected environment where any patient complications can easily and quickly be managed. For surgeons they also assume that the in order to get help from anesthesia the patient needs to go to the OR. not necessarily true (based on practice norms at your facility) I generally am more happy to get called to help/advise before the patient is coding. From what i have seen the only speciality who can manage both basic and advanced support quickly is ours.(versus the medicine code team for which ABC stands for ABG, Blood glucose, and Can i get some narcan.) This is why i think anesthesiologists should have a bigger presence in the ICU, what ever that may be.

 

[toughlife]

6mg of midaz is what what ordered by the gen surg resident and given to pt as confirmed by nurse. Patient was in stepdown ICU.