Should an anesthesiologist be "immediately available" for peds pacu complications?

[aneftp]

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http://www.asahq.org/~/media/sites/...-recommendations-for-pediatric-anesthesia.pdf

6.1 Anesthesiologist/Physician Staff In order to apply specific expertise in the provision of pediatric anesthesia services, an anesthesiologist or other physician trained and experienced in pediatric perioperative care, including the management of postoperative complications and the provision of pediatric cardiopulmonary resuscitation, should be made immediately available to evaluate and treat any child in distress. Pediatric advanced life support (PALS) certification or equivalent training is highly recommended for anesthesia and nursing staff caring for pediatric patients

So those doing peds cases, especially solo peds cases. Is there a "free body" available to handle any potential pacu complication? I'm talking at busy peds place where they do 15 plus peds cases each day in a room. Not talking about a dedicated PACU doc. Generally healthy outpatient peds older than 6 months occasionally your chunky 5 year old/100 pounder with sleep apnea.

What's your take? Having discussing with sister who's also anesthesiologist. Group with no subsidy (except for $250K to maintain free doc on the outside). All MD but been fighting with hospital over "free doc" available for emergencies PACU 7-3PM. Solo doc does ENT cases at ASC (attached to main OR via walk way) 3 minutes away (well can probably run there in 45 seconds if needed). If they get rid of free doc, that doesn't leave much room for error.

The hospital expects the group to eat the cost of physician generating no revenue now.

 

[Noyac]

Wait, I'm not following your question.
Why are Ped's any different from any other PACU pt?

 

[aneftp]

Wait, I'm not following your question.
Why are Ped's any different from any other PACU pt?

I'm not a big fan peds ent cough hacking away screaming in pacu after a t and a. Stuff happens very quickly with pediatrics compared to adults with anesthesia for obvious reasons (maturity level, ability to communicate vs adults)

The question is: are there solo anesthesiologists doing peds and everyone is in a room and no one immediately available to tend to any emergencies should they occur in pacu.

 

[urge]

http://www.asahq.org/~/media/sites/...-recommendations-for-pediatric-anesthesia.pdf

6.1 Anesthesiologist/Physician Staff In order to apply specific expertise in the provision of pediatric anesthesia services, an anesthesiologist or other physician trained and experienced in pediatric perioperative care, including the management of postoperative complications and the provision of pediatric cardiopulmonary resuscitation, should be made immediately available to evaluate and treat any child in distress. Pediatric advanced life support (PALS) certification or equivalent training is highly recommended for anesthesia and nursing staff caring for pediatric patients

So those doing peds cases, especially solo peds cases. Is there a "free body" available to handle any potential pacu complication? I'm talking at busy peds place where they do 15 plus peds cases each day in a room. Not talking about a dedicated PACU doc. Generally healthy outpatient peds older than 6 months occasionally your chunky 5 year old/100 pounder with sleep apnea.

What's your take? Having discussing with sister who's also anesthesiologist. Group with no subsidy (except for $250K to maintain free doc on the outside). All MD but been fighting with hospital over "free doc" available for emergencies PACU 7-3PM. Solo doc does ENT cases at ASC (attached to main OR via walk way) 3 minutes away (well can probably run there in 45 seconds if needed). If they get rid of free doc, that doesn't leave much room for error.

The hospital expects the group to eat the cost of physician generating no revenue now.

You should have someone available for any patient but if you are doing ped cases I would say it is a must. Children tend to be unpredictable and have more respiratory complications where time is of the essence. Keep fighting for the subsidy.

I remember there was a tragedy at a nearby hospital some years ago when a ped case decompensated in the pacu but there was no anesthesiologist available because they were all in rooms. It was all over the news. It did not end well for the anesthesiologist who did the case.

 

[Noyac]

I'm not a big fan peds ent cough hacking away screaming in pacu after a t and a. Stuff happens very quickly with pediatrics compared to adults with anesthesia for obvious reasons (maturity level, ability to communicate vs adults)

The question is: are there solo anesthesiologists doing peds and everyone is in a room and no one immediately available to tend to any emergencies should they occur in pacu.

If someone brings a child to the PACU screaming and hollering then they get to stay with the kid till he or she settles down. No matter how long that takes. We always have someone available but if I'm that someone then I'm gonna do the next case while the kid is being dealt with by the person that knows the kid and possibly created the mess.

Maybe things are different in my group but kids don't come out of anesthesia screaming very often if at all. There is another anesthesia forum out there, and there was this discussion of T&A's and how you wake the kid up. I am a proponent of the deep extubation when appropriate. Others there were adamant about a wide awake kid, even crying or screaming if necessary. I'm just not a fan of that. Even the deep extubation is "awake" enough before going back with next case.

 

[michigangirl]

http://www.asahq.org/~/media/sites/...-recommendations-for-pediatric-anesthesia.pdf

6.1 Anesthesiologist/Physician Staff In order to apply specific expertise in the provision of pediatric anesthesia services, an anesthesiologist or other physician trained and experienced in pediatric perioperative care, including the management of postoperative complications and the provision of pediatric cardiopulmonary resuscitation, should be made immediately available to evaluate and treat any child in distress. Pediatric advanced life support (PALS) certification or equivalent training is highly recommended for anesthesia and nursing staff caring for pediatric patients

So those doing peds cases, especially solo peds cases. Is there a "free body" available to handle any potential pacu complication? I'm talking at busy peds place where they do 15 plus peds cases each day in a room. Not talking about a dedicated PACU doc. Generally healthy outpatient peds older than 6 months occasionally your chunky 5 year old/100 pounder with sleep apnea.

What's your take? Having discussing with sister who's also anesthesiologist. Group with no subsidy (except for $250K to maintain free doc on the outside). All MD but been fighting with hospital over "free doc" available for emergencies PACU 7-3PM. Solo doc does ENT cases at ASC (attached to main OR via walk way) 3 minutes away (well can probably run there in 45 seconds if needed). If they get rid of free doc, that doesn't leave much room for error.

The hospital expects the group to eat the cost of physician generating no revenue now.

Short answer. Yes. There should always be at least 1 person who is available to deal with pacu complications, adult or peds. Healthy ASA 1 kids do silly things too, even after you've dropped them off and things are fine.

 

[Hoya11]

http://www.asahq.org/~/media/sites/...-recommendations-for-pediatric-anesthesia.pdf

6.1 Anesthesiologist/Physician Staff In order to apply specific expertise in the provision of pediatric anesthesia services, an anesthesiologist or other physician trained and experienced in pediatric perioperative care, including the management of postoperative complications and the provision of pediatric cardiopulmonary resuscitation, should be made immediately available to evaluate and treat any child in distress. Pediatric advanced life support (PALS) certification or equivalent training is highly recommended for anesthesia and nursing staff caring for pediatric patients

So those doing peds cases, especially solo peds cases. Is there a "free body" available to handle any potential pacu complication? I'm talking at busy peds place where they do 15 plus peds cases each day in a room. Not talking about a dedicated PACU doc. Generally healthy outpatient peds older than 6 months occasionally your chunky 5 year old/100 pounder with sleep apnea.

What's your take? Having discussing with sister who's also anesthesiologist. Group with no subsidy (except for $250K to maintain free doc on the outside). All MD but been fighting with hospital over "free doc" available for emergencies PACU 7-3PM. Solo doc does ENT cases at ASC (attached to main OR via walk way) 3 minutes away (well can probably run there in 45 seconds if needed). If they get rid of free doc, that doesn't leave much room for error.

The hospital expects the group to eat the cost of physician generating no revenue now.

We do meet this requirement but we are ACT. Makes you much more available to preop blocks, PACU issues ect...
You can consider hiring 2-3 CRNAs (however many rooms you have) to have one doc supervise them and at the same time be available for those issues. This might give you the flexibility you need without having to have a "free doc"

There is no one currently in the PACU even for adults in case something happens? I know places run like this but it always seemed a little strange to me, even adults for easy stuff can sometimes have issues requiring your attention.

 

[urge]

If someone brings a child to the PACU screaming and hollering then they get to stay with the kid till he or she settles down. No matter how long that takes.

If only a screaming child was our biggest concern...

 

[Noyac]

If only a screaming child was our biggest concern...

True

 

[sigrhoillusion]

True

Last week I had the WORST case of post-op emergence delirium I've ever been a part of and this is after doing peds fellowship.
It was an almost 3 year old who was getting an abdominal inclusion removed. Surgeon said he usually does them under local in the office but he cuts them off around that age cause many of them can't sit still and it can be traumatic for them, so he books them in the OR.

Plan was just to mask. Gave some oral midaz in holding. Kid was pretty calm, rolled back singing Elmo, placed mask on easily without fighting, went to sleep. I think my biggest mistake was putting an IV in but I like to give some decadron and zofran in 3+ yo cause the last thing I need is them puking tehir brains out for 4 hours in PACU. She was right around that PONV age so I figured it was pretty benign. Anyway, surgeon injects local, 5 mintues later we're done. Usually, I'd just roll the patient out but the PACU where I work isn't the best with kids, so I tend to wake them up in the OR knowing when to dial down the anesthesia. Well she woke up in an appropriate timeframe, but damn did she ever wake up like a bat out of hell. Hit her with a little propofol, but did nothing. She was rolling around screaming so much I was worried she'd break her arm as she rolled over it. Tried to give her more propofol but she had kinked her IV catheter and then proceeded to rip it out. So now I got a crying, screaming, kicking toddler with blood and propofol flying every where. Resident had her in her arms trying to calm her. She also ripped her pulse ox off. Eventually we brought her out to PACU, attempted to put her in rocker chair, she was still going nuts for 10 minutes. Got her mom and grandmom in there and still going nuts. She was satting fine, so I snuck off to grab some PRecedex. Luckily by the time I found some she had settled down some with some juice. That being said, not sure if giving nasal PRecedex at any point would have been easy.

Looking back, I probably could have held off on the pre-op Versed, cause this might have been that infamous paradoxical reaction they always talk about. She seemed relatively calm when I first talked to them (but you never know until you're rolling back and they get removed from their parent.) Secondly, probably could have avoided the IV. Sometimes I find that a lot of the kids that wake up "crazy and in pain"especially in T+As tend to be more upset with the IV than their throats. I've had several instances that they will be cranky and upset, but once they've gotten their juice, and are rehydrated, as soon as the IV comes out they settle back to their normal state. Again, she wasn't at super high risk for PONV, but as they say a little bit of prevention can save yourself from dealing with the otehr outcome. In the end, sometimes stuff jsut happens. Have done the same thing on a hundred other kids and never got the same reaction. Luckily, I'm in academics sohave enough support to sit with the kids and have the ORs continue without to many hiccups.

 

[Noyac]

I hate preop versed in kids for that very reason. I know, everyone likes it!
My contention is, if the kid is worked up before surgery I don't care because I'm putting him or her to sleep. Most pedi cases are on the shorter side and I want them to wake up clear headed so I can get mom there. Mom is the best way of settling them down in most circumstances but if they are confused from versed then it's not gonna happen.

Just curious, why would you need to give zofran and decadron to a kid for a 5 minute case that you don't need any narcotics for?

 

[aneftp]

So the General consensus is someone needs to be immediately available.

There is so much cost cutting. So much demand on the job these days. They will keep pushing the limit until something happens and than we the docs will be the scape goat.

 

[sigrhoillusion]

I've had kids wake up from short cases with nausea just from nitrous/volatiles. Also surgein wasnt sure if it was gonna be 5 minutes or 30 minutes cause he wasnt sure how deep the thing was.

Like i said, that was my biggest regret putting in the IV and this was the worst emergence I've seen. 10 minutes of mommy time was definitely the ultimate solution.

 

[btbam]

Last week I had the WORST case of post-op emergence delirium I've ever been a part of and this is after doing peds fellowship.
It was an almost 3 year old who was getting an abdominal inclusion removed. Surgeon said he usually does them under local in the office but he cuts them off around that age cause many of them can't sit still and it can be traumatic for them, so he books them in the OR.

Plan was just to mask. Gave some oral midaz in holding. Kid was pretty calm, rolled back singing Elmo, placed mask on easily without fighting, went to sleep. I think my biggest mistake was putting an IV in but I like to give some decadron and zofran in 3+ yo cause the last thing I need is them puking tehir brains out for 4 hours in PACU. She was right around that PONV age so I figured it was pretty benign. Anyway, surgeon injects local, 5 mintues later we're done. Usually, I'd just roll the patient out but the PACU where I work isn't the best with kids, so I tend to wake them up in the OR knowing when to dial down the anesthesia. Well she woke up in an appropriate timeframe, but damn did she ever wake up like a bat out of hell. Hit her with a little propofol, but did nothing. She was rolling around screaming so much I was worried she'd break her arm as she rolled over it. Tried to give her more propofol but she had kinked her IV catheter and then proceeded to rip it out. So now I got a crying, screaming, kicking toddler with blood and propofol flying every where. Resident had her in her arms trying to calm her. She also ripped her pulse ox off. Eventually we brought her out to PACU, attempted to put her in rocker chair, she was still going nuts for 10 minutes. Got her mom and grandmom in there and still going nuts. She was satting fine, so I snuck off to grab some PRecedex. Luckily by the time I found some she had settled down some with some juice. That being said, not sure if giving nasal PRecedex at any point would have been easy.

Looking back, I probably could have held off on the pre-op Versed, cause this might have been that infamous paradoxical reaction they always talk about. She seemed relatively calm when I first talked to them (but you never know until you're rolling back and they get removed from their parent.) Secondly, probably could have avoided the IV. Sometimes I find that a lot of the kids that wake up "crazy and in pain"especially in T+As tend to be more upset with the IV than their throats. I've had several instances that they will be cranky and upset, but once they've gotten their juice, and are rehydrated, as soon as the IV comes out they settle back to their normal state. Again, she wasn't at super high risk for PONV, but as they say a little bit of prevention can save yourself from dealing with the otehr outcome. In the end, sometimes stuff jsut happens. Have done the same thing on a hundred other kids and never got the same reaction. Luckily, I'm in academics sohave enough support to sit with the kids and have the ORs continue without to many hiccups.

0.5-1 mcg/kg bolus of Precedex with 0.2 of glyco after the tube is pulled on a T+A is money.

 

[WholeLottaGame7]

I also had one of the worst cases of emergence delirium I've had a couple weeks ago. Ended up giving flumazenil in PACU for the first time ever, which seemed to do the trick. I've thought about it before but never actually pulled the trigger. But this kid had had like almost 2mcg/kg of precedex, multiple doses of fentanyl and morphine, had been put back down with propofol once, etc.

Midazolam is a double-edged sword. Kids have less emergence delirium if they're not anxious going back, but if it's a shorter case the midaz will definitely burn you on the back end. If they have an IV, I prefer precedex. The problem with intranasal precedex is the slow onset time, not feasible for a busy ENT day.

 

[deleted59964]

Last week I had the WORST case of post-op emergence delirium I've ever been a part of and this is after doing peds fellowship.
..

thanks for your post, there is a huge bias toward people only posting their successes here - so your post is refreshing.
this cochrane review suggests midazolam pre med actually reduces risk over all - so I'm not too sure you did anything to contribute (except give an anesthetic).

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007084.pub2/pdf/abstract

 

[sigrhoillusion]

0.5-1 mcg/kg bolus of Precedex with 0.2 of glyco after the tube is pulled on a T+A is money.

Yea not the biggest fan of using precedex for routine T+As. Again, never had emergence delirium that was as bad as this one, but it would have been my go to if she had an IV still. That being said to crack open a vial of precedex for the small peds dose on every T+A just doesn't seem necessary or cost effective.

 

[deleted162650]

I've found that their favorite cartoon on YouTube on my phone while rolling back to the OR is superior to Midaz

 

[Noyac]

0.5-1 mcg/kg bolus of Precedex with 0.2 of glyco after the tube is pulled on a T+A is money.

So is a touch of propofol.

 

[Hoya11]

Last week I had the WORST case of post-op emergence delirium I've ever been a part of and this is after doing peds fellowship.
It was an almost 3 year old who was getting an abdominal inclusion removed. Surgeon said he usually does them under local in the office but he cuts them off around that age cause many of them can't sit still and it can be traumatic for them, so he books them in the OR.

Plan was just to mask. Gave some oral midaz in holding. Kid was pretty calm, rolled back singing Elmo, placed mask on easily without fighting, went to sleep. I think my biggest mistake was putting an IV in but I like to give some decadron and zofran in 3+ yo cause the last thing I need is them puking tehir brains out for 4 hours in PACU. She was right around that PONV age so I figured it was pretty benign. Anyway, surgeon injects local, 5 mintues later we're done. Usually, I'd just roll the patient out but the PACU where I work isn't the best with kids, so I tend to wake them up in the OR knowing when to dial down the anesthesia. Well she woke up in an appropriate timeframe, but damn did she ever wake up like a bat out of hell. Hit her with a little propofol, but did nothing. She was rolling around screaming so much I was worried she'd break her arm as she rolled over it. Tried to give her more propofol but she had kinked her IV catheter and then proceeded to rip it out. So now I got a crying, screaming, kicking toddler with blood and propofol flying every where. Resident had her in her arms trying to calm her. She also ripped her pulse ox off. Eventually we brought her out to PACU, attempted to put her in rocker chair, she was still going nuts for 10 minutes. Got her mom and grandmom in there and still going nuts. She was satting fine, so I snuck off to grab some PRecedex. Luckily by the time I found some she had settled down some with some juice. That being said, not sure if giving nasal PRecedex at any point would have been easy.

Looking back, I probably could have held off on the pre-op Versed, cause this might have been that infamous paradoxical reaction they always talk about. She seemed relatively calm when I first talked to them (but you never know until you're rolling back and they get removed from their parent.) Secondly, probably could have avoided the IV. Sometimes I find that a lot of the kids that wake up "crazy and in pain"especially in T+As tend to be more upset with the IV than their throats. I've had several instances that they will be cranky and upset, but once they've gotten their juice, and are rehydrated, as soon as the IV comes out they settle back to their normal state. Again, she wasn't at super high risk for PONV, but as they say a little bit of prevention can save yourself from dealing with the otehr outcome. In the end, sometimes stuff jsut happens. Have done the same thing on a hundred other kids and never got the same reaction. Luckily, I'm in academics sohave enough support to sit with the kids and have the ORs continue without to many hiccups.

Putting an IV in a 3 yo under GA is never something to beat yourself up over. Unless I knew and trusted the surgeon I would have also put an IV in....

This sounds like something that was not avoidable by you.

Maybe the oral midaz had not set in enough upon induction, the kid went to sleep somewhat with it, at the end of the short case woke up with enough versed on board to cause confusion/disinhibition but not enough to cause deep anxiolysis and sedation? Random thought..

Ill just say the way I handle these cases for what its worth:

heavy oral versed or none - meaning closer to 1mg/kg oral, get it in early

i typically wait until it has set in enough that I can carry the kid in barely conscious
mask down, iv

how does it "burn you on the backend" to have a snowed (sleeping/chilled out) kid in the recovery room from a heavy preop oral dose and a short case?

My feeling is who cares, let the kid sleep for a few hours, its still a surgery requiring GA which is unpleasant to go through so have the first memory be at home after you have been napping many hours after surgery.

After an hour or two, I will go over to the sleeping kid and lightly stimulate them in front of parents lifting their chin gently and calling their name. they will temporarily wake up, i will say discharge the kid home, parents carry the kid inside and put on the couch, he wakes up later at home. We dont do a huge volume but I could see this approach being limited by filling up the PACU at other institutions.

with a history of PONV in a kid i do a scop patch

If hes not premedicated for whatever reason, which has its own advantages, or even if he is premedicated and wakes up wild, i agree with precedex but fentanyl is my first line especially for this age group. Just keep giving 10 at a time until he lays down. I personally havent had to go to dex in > 5 years. But this above case sounds like the case you only see that often

 

[anesthesiadoc]

I can't think of a time where I regretted having an IV in a kid. The IV, while annoying the kid on wake up, doesn't cause emergence delirium, and gives you a way to treat it. Agree on the Midaz issue. I very rarely premedicate a kid unless they're violent/combative kids, unable to cooperate/on the autism spectrum who I think we won't be able to overpower in the room, or kids who have enough of a shunt/cardiomyopathy where they won't behave when the Sevo train hits 8%. Even for short procedures, I'm a big fan of 50 mcg/kg IV morphine on induction. It decreases your volatile requirement so if you're proactive in cutting back the gas shouldn't significantly prolong wake up and the kids seem to be much smoother in the PACU. If you are in a group with minimal luxury perfusion (not many extra people who could spring into action in the PACU), makes sense to tailor your practice to create low maintenance PACU stays for your kids. That means, for me at least, no deep extubations (as I know that human nature and production pressure lead to the temptation to send stage 2'ish kids to the recovery room, which is Russian roulette without a designated PACU presence). My rule is, if you're not confident that you could leave the kid alone in a hallway for 5 minutes without bad things happening, you have no business leaving the OR. May be conservative but I can look parents in the eye preop and tell them I'm giving the attention I would want for my own boys. So far so good. 😉


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[sigrhoillusion]

Putting an IV in a 3 yo under GA is never something to beat yourself up over. Unless I knew and trusted the surgeon I would have also put an IV in....

This sounds like something that was not avoidable by you.

Maybe the oral midaz had not set in enough upon induction, the kid went to sleep somewhat with it, at the end of the short case woke up with enough versed on board to cause confusion/disinhibition but not enough to cause deep anxiolysis and sedation? Random thought..

Ill just say the way I handle these cases for what its worth:

heavy oral versed or none - meaning closer to 1mg/kg oral, get it in early

i typically wait until it has set in enough that I can carry the kid in barely conscious
mask down, iv

how does it "burn you on the backend" to have a snowed (sleeping/chilled out) kid in the recovery room from a heavy preop oral dose and a short case?

My feeling is who cares, let the kid sleep for a few hours, its still a surgery requiring GA which is unpleasant to go through so have the first memory be at home after you have been napping many hours after surgery.

After an hour or two, I will go over to the sleeping kid and lightly stimulate them in front of parents lifting their chin gently and calling their name. they will temporarily wake up, i will say discharge the kid home, parents carry the kid inside and put on the couch, he wakes up later at home. We dont do a huge volume but I could see this approach being limited by filling up the PACU at other institutions.

with a history of PONV in a kid i do a scop patch

If hes not premedicated for whatever reason, which has its own advantages, or even if he is premedicated and wakes up wild, i agree with precedex but fentanyl is my first line especially for this age group. Just keep giving 10 at a time until he lays down. I personally havent had to go to dex in > 5 years. But this above case sounds like the case you only see that often

Yea I'm not beating myself up to much about it. Just figured I'd post it since it just happened and this thread popped up. I was just more worried that this little girl was gonna seriously hurt herself. She was contorting like an olympic gymnast on her arm and I really thought she might break it. I actually was more concerned about my resident since it was her first day of pediatrics and she look mortified. 3 year old going all exorcist on her and getting blood all over her scrubs. Poor thing probably never wants to do peds or have children ever.... LOL

 

[btbam]

Yea not the biggest fan of using precedex for routine T+As. Again, never had emergence delirium that was as bad as this one, but it would have been my go to if she had an IV still. That being said to crack open a vial of precedex for the small peds dose on every T+A just doesn't seem necessary or cost effective.

Or just dilute out one of the 200mcg/2cc vials into 4mcg/cc and draw off the 50cc syringe all day.

 

[Mman]

So the General consensus is someone needs to be immediately available.

There is so much cost cutting. So much demand on the job these days. They will keep pushing the limit until something happens and than we the docs will be the scape goat.

I don't have it in front of me and I'm too lazy this post holiday day to look it up, but I am fairly certain that CMS requires an anesthesiologist to be immediately available until able to be d/c from PACU.

 

[urge]

Or just dilute out one of the 200mcg/2cc vials into 4mcg/cc and draw off the 50cc syringe all day.

Sharing drugs between patients is not exactly standard of care. I would discourage this practice.

 

[btbam]

Sharing drugs between patients is not exactly standard of care. I would discourage this practice.

Drawing off a clean syringe with a non controlled substance?

 

[anesthesiadoc]

Joint commission may still ding you for multi dose vial use on multiple patients. We've cut out that practice at my shop, even though it hurts on the cost containment side of things.


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[IlDestriero]

Most of my group gives Precedex 0.5 mcg/kg for T&As. They can still have delirium but it doesn't seem as bad per the PACU nurses. Often I think it's a behavioral problem anyway and not emergence delirium.
The big house has dozens of Anesthesiologists and CRNAs coming and going that are immediately available to come to a PACU emergency. That's not necessarily the case at the ASC. We don't have an extra body there and haven't for decades.


--
Il Destriero

 

[sigrhoillusion]

Joint commission may still ding you for multi dose vial use on multiple patients. We've cut out that practice at my shop, even though it hurts on the cost containment side of things.


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Exactly.

Joint C will ding you for double (triple, quadruple...) dipping on the Ofirmev and Precedex. Same way they would if you were to divide a 100cc propofol to 10 patients in a GI center. ASA was really big on the "one patient, one vial, one syringe" thing a few years ago, especially when that one GI center got busted on NUMEROUS health violations.

Pharmacy here is really cracking down on IV acetaminaphen use, and has specific parameters on who can give and receive it due to costs. Anesthesia is starting to be effected, but we have the easiest non-restricted access to it since it's still in our carts. But rumor has it (although it'sb een a few months now) that they will eventually remove them. Precedex is only in a few rooms where it would be expected to be used more often in order to curb costs.

 

[deleted9493]

Has anyone else seen personality changes in kids receiving dexamethasone? I have had a couple of patients (both grade school age boys) who had gotten decadron for prior procedures and had anger/rage issues for 36-48hrs after...changes not fitting the typical emergence delirium profile. Removing the steroid from their regimen was the only thing that I changed and had no issues in both cases. It's anecdotal experience that I've not known what to do with...particularly since studies that I see only speak to dexamethasone as it relates to delirium.

 

[urge]

Drawing off a clean syringe with a non controlled substance?

You can work it out with your pharmacist to split the vial into syringes so that you are not throwing most of the drug away.

It is a dual problem. Cost allocation is one. Only one patient gets "charged" for the drug but no the other, for accounting purposes. The other is potential for contamination.