Severe Hypotension During Lumbar Fusion Surgery

[Aether2000]

Had an interesting case 4 days ago in which the patient, in her early 60s with non-ischemic cardiomyopathy, distant history of CHF, pacemaker capturing at all heart rates, clean coronaries, and a TTE demonstrating a LVEF 60%. She was morbidly obese with a BMI of 42. A-line and CVL placed after uneventful induction. Turned prone on a Wilson frame without difficulty and without any initial hemodynamic response to this position. Approximately 40 min later, and about 10 min after the surgical incision, she developed the first of many episodes of progressively increasing hypotension without bradycardia. There was no response to ephedrine (100mg) or phenylephrine at all (2mg). Vasopressin did help with the hypotension initially but required increasing boluses up to 5mg at a time, then switched to epinephrine boluses and started a dopamine and epi drip over the next hour. The ETCO2 was 10-12 during much of the hour, with BP dipping as low as 35/20 on the a-line that correlated to manual BP. Safe-passage neuromonitoring was abandoned after we could no longer sustain BP with subsequent discontinuation of propofol infusion and the sevoflurane was also discontinued with the last half-hour of anesthesia being versed/oxygen. The surgeon rapidly finished the interbody fusion and closed before the pedicle screws could be placed. She was turned supine, and almost immediately the BP improved markedly although still required a few more epi boluses in addition to the drips. Blood gases 25 min before the end of surgery revealed pH of 7.18, PaO2 of 90, PaCO2 of 42, Hgb 11. More crystalloid and bicarb were administered. Blood gases a 10 min before the end of surgery revealed a pH of 6.91, PaO2 of 85, PaCO2 of 38, Hgb 10, and a severe metabolic acidosis. Fluid and bicarb was given but the BP resolved prior to any significant administration of these, she was ventilated overnight, extubated, and remained on levophed for 2 days. Post op Echo was unchanged from preop echo. There were no neuro or cardiac deficits, and the renal failure rapidly resolved.

Four days later, she returned to the OR and we asked the surgeon to use a Jackson table with a frame to accommodate obese patients, placed a new aline (brachial), and my colleague did a TEE pre-prone demonstrating moderate MR missed on the TTE, and the LVEF was 40% instead of the 60% by TTE. The TEE probe was left in place after the patient was turned to the prone position, and demonstrated some mild reduction in ventricular filling compared to the supine position. We continued with the surgery uneventfully, and the patient never had a dip in BP.

We speculate that the Wilson frame combined with the obesity caused compression with a significant decrease in cardiac venous return with life threatening hypotension and when a different frame was chosen, there was no such complication.

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[dhb]

ACEI?

 

[chocomorsel]

Interesting. How long did the case last? So you kept the case going even with severe, non responsive hypotension and low ETCO2 for an hour? That's ballsy to me.
Vasopressin 5mg?

When I was doing lots of spine, it was always blood loss first. There were cases where we lost a ton of blood that we knew about, and then sometimes it went into a cavity and discovered later when patient wasn't responding appropriately.

In my experience, they also get a lot of micro air emboli that can cause hypotension when going thru the CV system that has been demonstrated by TEE quite commonly in spine cases I believe.

Gotta think of spinal/neurogenic shock as well due to the surgery and possibly after the surgery due to the hypotension. It happens.

 

[Aether2000]

No ACEI. It was not consistently severe hypotension but the vasopressin/epi would buy us about 4 min before the BP was back in the 80s. We did stabilize briefly, and discussed with the surgeon about 45 min before the end of surgery, and during this period the decision to go forward with the case was made. Good thought about the blood loss and microemboli. We had a blood loss during the surgery of around 600ml.

 

[BLADEMDA]

No ACEI. It was not consistently severe hypotension but the vasopressin/epi would buy us about 4 min before the BP was back in the 80s. We did stabilize briefly, and discussed with the surgeon about 45 min before the end of surgery, and during this period the decision to go forward with the case was made. Good thought about the blood loss and microemboli. We had a blood loss during the surgery of around 600ml.

All I can say is WOW. If anything bad happened postop you boys would be toast. The ABG confirmed what you should have known for most of the case. With that degree of hypotension 10 minutes after the incision I'm warning the surgeon. After 30 minutes and massive doses of pressors I'm cancelling the case. TEE probe after turning supine. Re-evaluate the cause of severe hypotension. Restore BP and normalize vitals/ABG prior to resuming the surgery (if you resume at all).

I'm glad it worked out for you though. I'll remember the Wilson table as a possible cause of hypotension in extremely obese patients.

 

[Aether2000]

True. We were already in the case before the case went totally south. The point of the case is to illustrate that sometimes the choice of the frame can make all the difference in the world. After 10 min post incision we did warn the surgeon, and the patient did briefly stabilize. After 30 min we did ask the surgeon to close.

 

[Globulinus]

Brave. I would also call the surgeon after 10-15 min into the struggle to abort.
What kind of pacemaker? Dual or single chamber? What was indication? Malfunction of resynchronization therapy could manifest as acute heart failure.
Another wild guess would be not recognized mainstem. Happens. Hypoxia > heart failure..
If volume was not a problem, vasodilation appears to be was addressed, it must be the pump.

 

[drmwvr]

Approximately 40 min later, and about 10 min after the surgical incision, she developed the first of many episodes of progressively increasing hypotension without bradycardia. There was no response to ephedrine (100mg) or phenylephrine at all (2mg). Vasopressin did help with the hypotension initially but required increasing boluses up to 5mg at a time, then switched to epinephrine boluses and started a dopamine and epi drip over the next hour. The ETCO2 was 10-12 during much of the hour, with BP dipping as low as 35/20 on the a-line that correlated to manual BP. Safe-passage neuromonitoring was abandoned after we could no longer sustain BP with subsequent discontinuation of propofol infusion and the sevoflurane was also discontinued with the last half-hour of anesthesia being versed/oxygen.

Volume anyone?

Edit: For the love of God...

I might add...not an unusual presentation in chronic pain/ chronic opioid use.

 

[nimbus]

We had a similar incident during a total hip that had to be aborted midstream. The BP plummeted to 20s systolic and patient developed tombstone ST elevations.

Subsequent cardiac workup was negative. The patient was brought to the operating room 5 days later for the completion of the procedure. That time a preinduction Aline was placed. Patient had general anesthesia, was positioned and during prep, ancef 2gm was given. Immediately she developed a diffuse rash and her BP plummeted again to 29/20 with ST segment elevation. This time it was clear that she had an anaphylactic reaction to cefazolin. She was resuscitated with epinephrine total bolus dose of 2mg and the ST elevation normalized with correction of her blood pressure. She was treated with Benadryl, decadron, and Pepcid, and an epinephrine infusion and the case was completed. The epi infusion was weaned off in pacu and the patient did well.

So add anaphylaxis to the differential. During the first procedure, the reaction was delayed and the patient was already draped so a rash was not obvious and neither was the diagnosis.

 

[pgg]

The ETCO2 was 10-12 during much of the hour, with BP dipping as low as 35/20 on the a-line that correlated to manual BP.

If I saw those numbers during a code with CPR in progress, I would tell the guy pounding on the chest to do better compressions. Maybe he's tired and someone else needs to take a turn.

It would be hard to defend tolerating that for an hour during elective surgery. This could've ended very badly.

Easy to second guess MMQB this but that case probably should've been aborted and full efforts put to resuscitation.

 

[Planktonmd]

The Wilson frame was obviously causing too much pressure on the abdomen and basically obstructing Caval blood return. Someone might have placed the pads too close to each other which puts most of the weight on the midline instead of spreading them to allow the pressure to be on the sides of the abdomen.

 

[deleted59964]

Had an interesting case 4 days ago .......
We speculate that the Wilson frame combined with the obesity caused compression with a significant decrease in cardiac venous return with life threatening hypotension and when a different frame was chosen, there was no such complication.

thanks for your post, SDN is full of heroes that always have perfect cases - your experience is instructive.

 

[T-burglar]

We had a case with these vitals also that came through our QA committee. The end tidal was 20ish and no measureable pressure for 30 minutes before the anesthesiologist noticed. The patient died of MSOF in the ICU. It was a routine prone spine case.

 

[vector2]

What was the fluid management and blood loss like when the hypotension first occurred early in the case? 95 times out of 100, a huge vasopressor challenge that works for a couple minutes and then wears off quickly is a sign of hypovolemia and decreased cardiac output. Also, if she was pacemaker dependent, it's possible that her paced HR was unable to keep up with the decreased preload to maintain CO.

 

[Arch Guillotti]

We had a case with these vitals also that came through our QA committee. The end tidal was 20ish and no measureable pressure for 30 minutes before the anesthesiologist noticed. The patient died of MSOF in the ICU. It was a routine prone spine case.

What is MSOF?

 

[anbuitachi]

the second you said wilson frame, i knew itd be the wilson frame. that stuff is rough on the fat patients

What is MSOF?

multi system organ failure

 

[244913]

Had an interesting case 4 days ago in which the patient, in her early 60s with non-ischemic cardiomyopathy, distant history of CHF, pacemaker capturing at all heart rates, clean coronaries, and a TTE demonstrating a LVEF 60%. She was morbidly obese with a BMI of 42. A-line and CVL placed after uneventful induction. Turned prone on a Wilson frame without difficulty and without any initial hemodynamic response to this position. Approximately 40 min later, and about 10 min after the surgical incision, she developed the first of many episodes of progressively increasing hypotension without bradycardia. There was no response to ephedrine (100mg) or phenylephrine at all (2mg). Vasopressin did help with the hypotension initially but required increasing boluses up to 5mg at a time, then switched to epinephrine boluses and started a dopamine and epi drip over the next hour. The ETCO2 was 10-12 during much of the hour, with BP dipping as low as 35/20 on the a-line that correlated to manual BP. Safe-passage neuromonitoring was abandoned after we could no longer sustain BP with subsequent discontinuation of propofol infusion and the sevoflurane was also discontinued with the last half-hour of anesthesia being versed/oxygen. The surgeon rapidly finished the interbody fusion and closed before the pedicle screws could be placed. She was turned supine, and almost immediately the BP improved markedly although still required a few more epi boluses in addition to the drips. Blood gases 25 min before the end of surgery revealed pH of 7.18, PaO2 of 90, PaCO2 of 42, Hgb 11. More crystalloid and bicarb were administered. Blood gases a 10 min before the end of surgery revealed a pH of 6.91, PaO2 of 85, PaCO2 of 38, Hgb 10, and a severe metabolic acidosis. Fluid and bicarb was given but the BP resolved prior to any significant administration of these, she was ventilated overnight, extubated, and remained on levophed for 2 days. Post op Echo was unchanged from preop echo. There were no neuro or cardiac deficits, and the renal failure rapidly resolved.

Four days later, she returned to the OR and we asked the surgeon to use a Jackson table with a frame to accommodate obese patients, placed a new aline (brachial), and my colleague did a TEE pre-prone demonstrating moderate MR missed on the TTE, and the LVEF was 40% instead of the 60% by TTE. The TEE probe was left in place after the patient was turned to the prone position, and demonstrated some mild reduction in ventricular filling compared to the supine position. We continued with the surgery uneventfully, and the patient never had a dip in BP.

We speculate that the Wilson frame combined with the obesity caused compression with a significant decrease in cardiac venous return with life threatening hypotension and when a different frame was chosen, there was no such complication.

Had this happen in residency, scoliosis surgery in an OTW healthy young person, Wilson frame, refractory hypoTN caused by reduced VR, ended up with anoxic brain injury

 

[Aether2000]

Our initial response was volume....gave 1 liter over around 8 minutes without any response. The hypotension occurred prior to any blood loss and with 0.8 MAC sevo. We continued volume resuscitation throughout the case. The pacer was interesting...pacing and capturing up to 93 per min. The AICD had been turned off months previously.

 

[Urzuz]

We had a case with these vitals also that came through our QA committee. The end tidal was 20ish and no measureable pressure for 30 minutes before the anesthesiologist noticed. The patient died of MSOF in the ICU. It was a routine prone spine case.

How does an anesthesiologist take 30 minutes to notice that the patient doesn't have a blood pressure?

I hope he got fired and stripped of his license. Embarrassing.

 

[Monty Python]

How does an anesthesiologist take 30 minutes to notice that the patient doesn't have a blood pressure?

I hope he got fired and stripped of his license. Embarrassing.

I'm going to guess this went unnoticed for 30 minutes due to automated electronic charting, versus having to look at the monitors to then chart those numbers with paper and pen. I've personally noticed several coworkers "zone out" because of electronic charting, whereas back in the day of paper and pen charting they were more attuned to case nuances in a more timely manner.

 

[Urzuz]

I'm going to guess this went unnoticed for 30 minutes due to automated electronic charting, versus having to look at the monitors to then chart those numbers with paper and pen. I've personally noticed several coworkers "zone out" because of electronic charting, whereas back in the day of paper and pen charting they were more attuned to case nuances in a more timely manner.

Even with paper charts people would go hours without charting a single thing and just scribble down some nonsense at the end of the case. Electronic charting doesn't fully explain how it went unnoticed for THIRTY MINUTES that a patient didn't have a blood pressure.

 

[dhb]

Even with paper charts people would go hours without charting a single thing and just scribble down some nonsense at the end of the case. Electronic charting doesn't fully explain how it went unnoticed for THIRTY MINUTES that a patient didn't have a blood pressure.

The things you see when you look a charts 😱

 

[Hoya11]

Had an interesting case 4 days ago in which the patient, in her early 60s with non-ischemic cardiomyopathy, distant history of CHF, pacemaker capturing at all heart rates, clean coronaries, and a TTE demonstrating a LVEF 60%. She was morbidly obese with a BMI of 42. A-line and CVL placed after uneventful induction. Turned prone on a Wilson frame without difficulty and without any initial hemodynamic response to this position. Approximately 40 min later, and about 10 min after the surgical incision, she developed the first of many episodes of progressively increasing hypotension without bradycardia. There was no response to ephedrine (100mg) or phenylephrine at all (2mg). Vasopressin did help with the hypotension initially but required increasing boluses up to 5mg at a time, then switched to epinephrine boluses and started a dopamine and epi drip over the next hour. The ETCO2 was 10-12 during much of the hour, with BP dipping as low as 35/20 on the a-line that correlated to manual BP. Safe-passage neuromonitoring was abandoned after we could no longer sustain BP with subsequent discontinuation of propofol infusion and the sevoflurane was also discontinued with the last half-hour of anesthesia being versed/oxygen. The surgeon rapidly finished the interbody fusion and closed before the pedicle screws could be placed. She was turned supine, and almost immediately the BP improved markedly although still required a few more epi boluses in addition to the drips. Blood gases 25 min before the end of surgery revealed pH of 7.18, PaO2 of 90, PaCO2 of 42, Hgb 11. More crystalloid and bicarb were administered. Blood gases a 10 min before the end of surgery revealed a pH of 6.91, PaO2 of 85, PaCO2 of 38, Hgb 10, and a severe metabolic acidosis. Fluid and bicarb was given but the BP resolved prior to any significant administration of these, she was ventilated overnight, extubated, and remained on levophed for 2 days. Post op Echo was unchanged from preop echo. There were no neuro or cardiac deficits, and the renal failure rapidly resolved.

Four days later, she returned to the OR and we asked the surgeon to use a Jackson table with a frame to accommodate obese patients, placed a new aline (brachial), and my colleague did a TEE pre-prone demonstrating moderate MR missed on the TTE, and the LVEF was 40% instead of the 60% by TTE. The TEE probe was left in place after the patient was turned to the prone position, and demonstrated some mild reduction in ventricular filling compared to the supine position. We continued with the surgery uneventfully, and the patient never had a dip in BP.

We speculate that the Wilson frame combined with the obesity caused compression with a significant decrease in cardiac venous return with life threatening hypotension and when a different frame was chosen, there was no such complication.

so your giving epi boluses, abandoning neuromonitoring, you have not only persistent hypotension but decreased lung perfusion, why are you not flipping the patient over and abandoning this elective case? Had you done this, you would have seen that positioning was the cause of your problems. 60yo person with EF 40% should not have such persistent hypotension - you should have been feverishly looking for the cause.. and NOT ok tolerating such hypotension/hypoperfusion for so long in the name of spinal pain relieving surgery.. cringe..

 

[anbuitachi]

How does an anesthesiologist take 30 minutes to notice that the patient doesn't have a blood pressure?

I hope he got fired and stripped of his license. Embarrassing.

I've seen anesthesiologists turn the sound down to zero. And they aren't looking at the screen most of the time.. so not surprised

 

[Aether2000]

The patient had a dip in bp transiently 10 min after incision then stabilized ....thus the decision to proceed. Believe me we were looking at several potential causes, and did express several times to the surgeon the need to get out. Sometimes you play the cards that are dealt to you, and work to the best of your ability to stabilize and diagnose simultaneously.

 

[deleted875186]

How does an anesthesiologist take 30 minutes to notice that the patient doesn't have a blood pressure?

I hope he got fired and stripped of his license. Embarrassing.

Whenever I give breaks I notice most people at my hospital have the alarms paused for the whole case.... I usually do the opposite and set tight alarms for most cases, worrying that I’ll zone out on some of these boring cases.

 

[pgg]

Whenever I give breaks I notice most people at my hospital have the alarms paused for the whole case.... I usually do the opposite and set tight alarms for most cases, worrying that I’ll zone out on some of these boring cases.

Some people put the monitor on CPB mode. It drives me crazy how they deliberately disable safety equipment. In the paper chart era, these were the same people who would pre-chart the entire case, including PACU turnover. Of course these patients always had picture perfect vital signs. On paper, anyway.

 

[MoMoGesiologist]

Some people put the monitor on CPB mode. It drives me crazy how they deliberately disable safety equipment. In the paper chart era, these were the same people who would pre-chart the entire case, including PACU turnover. Of course these patients always had picture perfect vital signs. On paper, anyway.

Well you know what they say, documentation is gonna save you if there's a bad outcome!

 

[Psai]

Some people put the monitor on CPB mode. It drives me crazy how they deliberately disable safety equipment. In the paper chart era, these were the same people who would pre-chart the entire case, including PACU turnover. Of course these patients always had picture perfect vital signs. On paper, anyway.

That sounds smart, if it isnt documented, it didnt happen.

 

[soon2bdone]

ETCO2 of 10-12 with hypotension and basically no response to pressors and you continue with the case? How does anyone with any common sense allow this to continue for that length of time? You bad mouth AAs and CRNAs but yet this happens.... #whensecondscount I guess

 

[deleted171991]

True. We were already in the case before the case went totally south. The point of the case is to illustrate that sometimes the choice of the frame can make all the difference in the world. After 10 min post incision we did warn the surgeon, and the patient did briefly stabilize. After 30 min we did ask the surgeon to close.

Cover the wound, turn the patient stat, figure out what's wrong. This would have been a many million dollar-lawsuit in a non-cap state.

 

[deleted171991]

ETCO2 of 10-12 with hypotension and basically no response to pressors and you continue with the case? How does anyone with any common sense allow this to continue for that length of time? You bad mouth AAs and CRNAs but yet this happens.... #whensecondscount I guess

You should have stayed happy and QUIET with your 8 year-old incognito account. 😉

Last time I checked, this section was called Physician/Resident forums. And be happy that the ASA doesn't have the balls to call it #whenIQcounts.

 

[MoMoGesiologist]

And be happy that the ASA doesn't have the balls to call it #whenIQcounts.

I can't believe you said that! I can't repeat it at work but I sure as heck am going to think it in my head and just smile when I work with the doctor wanna-bees

 

[Psai]

ETCO2 of 10-12 with hypotension and basically no response to pressors and you continue with the case? How does anyone with any common sense allow this to continue for that length of time? You bad mouth AAs and CRNAs but yet this happens.... #whensecondscount I guess

When do we badmouth AAs? We like them. Don't act like you're on their side homeboy.

 

[Aether2000]

There will be no lawsuit, and my state is a non-cap state. The patient had no injury. This case was presented to afford others a rare look (outside of a courtroom) at details of a difficult anesthetic due to a rare, non-anesthetic complication, in order to bring awareness that morbid obesity plus a Wilson frame can lead to severe hypotension. I appreciate the comments.

 

[deleted171991]

Of course. No damage, no lawsuit. But this was such a near miss.

Your post is much appreciated, but it's also about how not to do things, no offense. After 1-2 minutes of EtCO2 at 10, I would have been all over the surgeon to turn the patient. I guess I don't have your guts or experience.

 

[Noyac]

Well the OP has taken a beating here and deserves it. But the goofball that outed himself as a nurse probably didn’t deserve to be banned. He/she had a point and this case tells us all that dumb sh\t can still happen even with the better clinician at the head of the table.

OP, what was the base deficit or lactate of the ABG’s? I prefer base deficit in this situation btw.

 

[Aether2000]

-15

 

[Noyac]

-15

 

[Orin]

Turned prone on a Wilson frame without difficulty and without any initial hemodynamic response to this position. Approximately 40 min later, and about 10 min after the surgical incision, she developed the first of many episodes of progressively increasing hypotension without bradycardia.

It does sound like the frame contributed to things. Still, if it was just the frame and her habitus, I would've expected more robust changes early on with positioning. I assume blood loss/vasodilation played a role in it getting worse, and then you were just heading down the slippery slope when her pH tanked.

What was the physical size of the surgical team and how were they positioned? I'm picturing an intermittent lean/downward pressure as they started retracting deeper, leading to intermittent increases in intra-abdominal pressure/cutting off venous return/etc.

There were some older papers looking at the hemodynamic effects of a Wilson frame I think, but I don't know if they were in obese patients.

 

[T-burglar]

How did it happen that a patient was in shock for 30 minutes without anyone noticing? I don’t have an explanation. 99% of being a safe and competent anesthetist is simply paying attention.

I personally have a very short list of things i do before every case. And number one is set the alarms. The other is make sure I have everything i need to mask ventilate anything up to a BMI of 1000.

I agree that the OP has had enough criticism at this point, he gets it. I'm not sold on the frame being the primary issue if the hypotension only occurred very late in the case. Prone cases with really fat patients where you can't paralyze and who probably have cardiovascular disease are actually the exact cases where I've seen this kind of thing happen. Caval compression, high airway/intrathoracic pressures (no paralysis and fat), poor CV reserve, and vascular disease related pressor resistance, high dose propofol to prevent movement.

Once the ETCO2 drops the patient is actively in "true" shock. Only takes a few minutes with such a high dose of shock for death to be certain. If you wait too long you may be able to get the circulation back later, but if the dose of shock was profound enough they will develop multisystem failure later and die even with decent appearing hemodynamics.

 

[Aether2000]

The surgeons were placing some pressure on the spine but they were not huge or muscular surgeons. They were indeed looking into the wound. As for not noticing shock, nothing could be further from the truth. The list of possibles in the differential diagnosis were being evaluated while repeatedly informing the surgeons of the situation and the need to rapidly close. Vigorous aggressive treatment was being employed to maintain blood pressure including 10mg epi, bicarb, vasopressin, dopamine, calcium, steroid boluses, fluids, and levophed. I admit we were very fortunate but also admit it never occurred to me the frame was the issue. When the frame was changed during the next surgery, the patient was Rock Solid and had no blood pressure fluctuations at all.

 

[chocomorsel]

We had a case with these vitals also that came through our QA committee. The end tidal was 20ish and no measureable pressure for 30 minutes before the anesthesiologist noticed. The patient died of MSOF in the ICU. It was a routine prone spine case.

Many anesthesiologists turn off alarms on their monitors. I found this out when I used to rotate at many different hospitals in the same town. I was told it was quite common from the nurses and anesthesia techs.
Me personally, I like alarms for the most part. Cuz sometimes sitting there for hours can lead to boredom and inatention.
Was also told many times that I was one of the few who induced after placing monitors and preoxygenating.
Well, guess I am OCD a bit.

 

[drmwvr]

the only alerts I leave active are those on the ventilator and the pulse-ox tone. All HR and BP, and low sat are off. Way too much artifact in those to be of any use to me. I know the risk I take and accept it.

But this:
told many times that I was one of the few who induced after placing monitors and preoxygenating.


Is a disgrace.

 

[chocomorsel]

The surgeons were placing some pressure on the spine but they were not huge or muscular surgeons. They were indeed looking into the wound. As for not noticing shock, nothing could be further from the truth. The list of possibles in the differential diagnosis were being evaluated while repeatedly informing the surgeons of the situation and the need to rapidly close. Vigorous aggressive treatment was being employed to maintain blood pressure including 10mg epi, bicarb, vasopressin, dopamine, calcium, steroid boluses, fluids, and levophed. I admit we were very fortunate but also admit it never occurred to me the frame was the issue. When the frame was changed during the next surgery, the patient was Rock Solid and had no blood pressure fluctuations at all.

What was the surgeons respond when you told him your patient was crumping and you couldn’t fix him and he or she needed to stop Yesterday?

Is this an dingus surgeon? Who don’t care about patients?
I had a a patient who spiraled one time and I couldn’t get him back and told the surgeon we needed to flip him now and he took 7 minutes before we flipped and started coding him. He was a complete dingus but he also was knee deep in the spine with exposed cord so he was trying to close it as much as he could. Turned out it was a massive PE and patient didn’t make it.

Point is, sometimes when s hit is bad, it sometimes needs to turn into a screaming match with certain surgeons in order to be heard and do what’s safe for patient. You gotta he very stern with some of them.

 

[chocomorsel]

the only alerts I leave active are those on the ventilator and the pulse-ox tone. All HR and BP, and low sat are off. Way too much artifact in those to be of any use to me. I know the risk I take and accept it.

But this:
told many times that I was one of the few who induced after placing monitors and preoxygenating.


Is a disgrace.

Except aren’t you an AA working under someone else’s license? Or are you an independent CRNA?

 

[anbuitachi]

the only alerts I leave active are those on the ventilator and the pulse-ox tone. All HR and BP, and low sat are off. Way too much artifact in those to be of any use to me. I know the risk I take and accept it.

But this:
told many times that I was one of the few who induced after placing monitors and preoxygenating.


Is a disgrace.

Yea as I rotated thru more places you notice how different things are out there. Alarms set to zeros.. no preoxygenate prior to induction.. never seen the no monitor one though. I think that's pretty important as we've cancelled cases bunch of times prior to induction. Usually EKG changes like new lbbb or new fib w rvr etc

 

[venacontracta]

OP, what was the base deficit or lactate of the ABG’s? I prefer base deficit in this situation btw.

Can you expound a bit on how you think about base excess vs. lactate as indicators in this situation? They often track together but I have no doubt there's specific reasons each may be better for different cases.

 

[pgg]

But the goofball that outed himself as a nurse probably didn’t deserve to be banned. He/she had a point and this case tells us all that dumb sh\t can still happen even with the better clinician at the head of the table.

We typically withhold comment on moderator actions, but in this case I'll just say that bans, except for newly registered obvious troll accounts, usually aren't done because of a single post. General posting history, previous warnings, and (least obviously visible of all) connections to other accounts with trollish histories factor in. Often we don't make the forensic connections between an old troll and an innocent seeming account until it catches our attention for something less innocent.

As a rule we don't just ban nurses for being nurses, or stating true things that make us look deservedly bad. Long history however has given us a short fuse to move CRNAs who come here to educate us up the warn/ban ladder.

 

[deleted171991]

Many anesthesiologists turn off alarms on their monitors. I found this out when I used to rotate at many different hospitals in the same town. I was told it was quite common from the nurses and anesthesia techs.
Me personally, I like alarms for the most part. Cuz sometimes sitting there for hours can lead to boredom and inatention.
Was also told many times that I was one of the few who induced after placing monitors and preoxygenating.
Well, guess I am OCD a bit.

I would probably fire an anesthesia provider who turns off an essential alarm, such as low EtCO2 or BP in a GA case.