Sphincter Hypertonicity

[OB1🤙]

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So I had my first moment of sheer terror today. To the old hands this will likely seem minor and funny, but it scared the living shiite out of me.

Healthy dude for a laparoscopic procedure, smooth induction, chilling in the room while the surgerizers prep. Dude took his daily atenolol in AM (HTN but no CAD), HR 50s, same as preop. Chilling, chilling. Everything fine. Anesthesia is easy.

Then hear the beeps start to slow down- monitor goes from 50s, high 40s ("huh..."), low 40s, ("WTF?"), high 30s ("PANICPANICPANIC"), down to 32 ("ZOMG OH$HIT$HIT$HIT") I had a stick of ephedrine handy which I gave 10mg of, and reached for the computer to page my attending. Thankfully within seconds his HR shot back up and all was fine from that point on. Definitely drew up some atropine to have handy though.

So you old hats have probably seen this a million times and are laughing at the cute CA-1, but it was the first time that the thought crossed my mind in the OR that I was gonna have to bust out the crash cart.

So tell me, anesthesiologists young and old(er), what was your first sphincter-puckering moment?

 

[coprolalia]

Probably had the gas pressure in the abdomen a bit too high. Very common. Even oldies will vagal. Next time, you can tell the surgeon to let up on the "overdistention" of the belly. Usually it will extinguish, but if it persists a little glyco will do the trick. I would be careful about pushing epi on someone who's beta-blocked because of a bad ticker.

I've had a couple of high-pucker instances in the past few weeks, actually. Both were massive blood loss, one in a tiny young chick who required leukoreduced and irradiated blood (didn't have enough on hand). In the end, I gave her 8 units of PRBC's, two FFP's, and two platelets along with 2 g of calcium. After all that, her H/H was still 5.7/17. How I got her to the ICU alive I'm still not sure...

-copro

 

[jetproppilot]

So I had my first moment of sheer terror today. To the old hands this will likely seem minor and funny, but it scared the living shiite out of me.

Healthy dude for a laparoscopic procedure, smooth induction, chilling in the room while the surgerizers prep. Dude took his daily atenolol in AM (HTN but no CAD), HR 50s, same as preop. Chilling, chilling. Everything fine. Anesthesia is easy.

Then hear the beeps start to slow down- monitor goes from 50s, high 40s ("huh..."), low 40s, ("WTF?"), high 30s ("PANICPANICPANIC"), down to 32 ("ZOMG OH$HIT$HIT$HIT") I had a stick of ephedrine handy which I gave 10mg of, and reached for the computer to page my attending. Thankfully within seconds his HR shot back up and all was fine from that point on. Definitely drew up some atropine to have handy though.

So you old hats have probably seen this a million times and are laughing at the cute CA-1, but it was the first time that the thought crossed my mind in the OR that I was gonna have to bust out the crash cart.

So tell me, anesthesiologists young and old(er), what was your first sphincter-puckering moment?

Ironically my friend, my first CINNAMON HOLE PUCKERING MOMENT was the same.

A surgery where I'm a CA-1 and the heart rate goes from 70....60....50.....40......😱

OH MY GOD THIS DUDETTES GONNA DIE!!!!!

I push atropine (which probably wasnt needed....prolly just needed to tell the surgeons in the belly to stop for a sec...)...

....page my attending for the case who happened to be the Chair, Alan Grogono...

heart rate back to normal by the time he arrived.

I needed some new HANES PANTIES after that.

Your threshold for anxiety will change as you mature, my friend.

Heres what I can offer you:

1)Most intraoperative events can be solved by your knowledge, so use your knowledge.

2)When something really bad is REALLY happening, you've got alotta backup at your residency. Work to keep your mind clear as you make decisions when things are critical.....cuz this is the true crux of the role of an anesthesiologist.

3) It takes a WHOLE LOT to kill someone in the OR for an elective procedure, so chances are things are gonna turn out OK.

4) BELIEVE IN YOURSELF. YOU DA MAN, Hawaiin. Start believing.

Right now.

 

[OB1🤙]

Copro - this was well before any insufflation- they were still prepping the pt.

Jet- thanks for the advice, man. On days when everything goes right, it's easy to be confident, and things have gone right almost all the time. But when things go wrong- it becomes painfully obvious that there is one whole hell of a lot about this field that we have yet to learn.

But that's why residency is 3 years of anesthesia, right?

 

[jennyboo]

Ironically my friend, my first CINNAMON HOLE PUCKERING MOMENT was the same.

Me too. Just after insufflating.

 

[pgg]

So tell me, anesthesiologists young and old(er), what was your first sphincter-puckering moment?

Mask induction of a kid for a tonsil. IV in. Tube in. Attending out. Tech steps on IV and pulls it. I'm working on a new IV. Pulse ox stops beeping but it's because the tourniquet's on that arm. Next BP comes back with a systolic in the 40s and I realize the pulse ox isn't working because I left the sevo at 8% and the kid is too hypotensive to perfuse his finger. I thought I was going to have to start chest compressions on a healthy kid who came in for an elective case.

More recently, I had 18 seconds of asystole during a crani on a teenager. Didn't brady down first, just HR of 60 to zero in ONE heartbeat. By the time I'd looked at the monitor see why the alarm was going off, felt his carotid, and told the nurse to overhead page for some help as I was moving the drapes to start chest compressions, he was back in sinus at 60. Not an EKG artifact... flat a-line, flat pulse ox, exponentially decreasing ETCO2, no carotid pulse. Never did figure out for sure what happened and it didn't recur.

 

[kraphtymac]

You should probably have told the nurse yanking on his balls to prep them to stop squeezing his little jewels so hard. That's my personal favorite brady-maker on the baby-maker.

 

[jetproppilot]

Mask induction of a kid for a tonsil. IV in. Tube in. Attending out. Tech steps on IV and pulls it. I'm working on a new IV. Pulse ox stops beeping but it's because the tourniquet's on that arm. Next BP comes back with a systolic in the 40s and I realize the pulse ox isn't working because I left the sevo at 8% and the kid is too hypotensive to perfuse his finger. I thought I was going to have to start chest compressions on a healthy kid who came in for an elective case.

More recently, I had 18 seconds of asystole during a crani on a teenager a few months ago. Didn't brady down first, just HR of 60 to zero in ONE heartbeat. By the time I'd looked at the monitor see why the alarm was going off, felt his carotid, and told the nurse to overhead page for some help as I was moving the drapes to start chest compressions, he was back in sinus at 60. Not an EKG artifact... flat a-line, flat pulse ox, exponentially decreasing ETCO2, no carotid pulse. Never did figure out for sure what happened and it didn't recur.

😱😱

And with that, I feel inner peace depositing my check.

 

[pd4emergence]

Mine was a similiar laparoscopic experience, healthy 20 something yo lady for a lap tubal. Gas goes in and almost immediately I get asystole for about two screens. No warning, no noticeable decrease in heart rate just asystole. I tell the Gyn's to let the air out and they give me a blank look. I tell them again, let the f'in air out she is asytolic and they finally got it. I give some atropine about the same time and her HR returned about the time I was starting chest compressions. We woke her up and she did fine. This was about my third month of my CA1 year.

 

[Bougie]

First humbling event:

CA-1 year, closing on first thoracic case ever. Thought bolusing a T7 epidural in a beta blocked 88 year old gomer was the same as a L4 labor epidural in an 18 year old.

12cc of 0.25% Marcaine -> la la la la maybe I can go home early -> demolished sympathetics -> bradycardia to 40s -> hypotension to 60s -> holy $hite -> epi drip -> SICU bed -> patient did fine -> white coat -> M&M conference.

 

[Hockeyguy]

Two days off wicked spincter tone...

60 something male multiple medical probs with ascending aortic anuersym disecting into RCA. S/P cabg and AVR (mechanical) two seperate occasion so this is third time in chest. Lines go in fine A-line 14 guage pre-induction. RIJ MAC cordis after induction TEE shows the anuersym large RV ef a bit low 40% not bad. Attending: "Mario pre-check four unit of blood and hang them in level one" which we hooked up to our cordis. Jeez overkill I think to myself. Surgery starts. Surgeon and fellow very carefully attempt to open sternum and .... were bleeding - big time. 3cm hole in anuersm. MAP is about 40 after 4 units a ton of epi we crash onto bypass and things slow down they reapair the hole but unfourtunatly nothing else. They start closing and we are having trouble stopping the bleeding. Final cout 35 protamine 7FFP 20 PRBS cryo and factor seven. Fully AV paced norepi maxed, epi maxed, vasopressin 4/hour. Dobutamine 5. To the unit.

Next day. LVAD placement 17 yo w/ postpartum cardiomyopathy. EF less than 20% lvad for bridge to transplant. See her the night before looks terrible like a stiff breeze could send her over the edge. Huge pleural effesions anosarcic ets. One "positional" 20 guage iv both ij and subclavians clotted from multiple lines/infections. No a-line and not intubated though sating in the low 90s tachypenic etc. MICU attending bites my head off when I suggest blood gas and intubation at least a good IV. Fine go home call my attending he's like whatever all LVAD are trainwreck we'll deal with it - cool. IN the am she looks a litlle worse now shes hypotensive syst in the 90s intern has given her 5 litres of fluid wich has topped her lungs off nicely. To OR with NO SEDATION pre oxygenate and by the grace off God and 20 sticks I hit an A-line. As I am securing it she arrests. Flatline asytolic blue instantanously. I run to the head of the bed intubate attending gives epi, tech doing chest compreesions she comes back crashes on to bypass arrests again as surgeons get the chest open but they just give direct massage becasue no response to epi. LVAD in then the fun starts. Pul edema pouring out - i mean pouring 100 lasix iv 3-4 litres urine and about 3 litres pulmoranry edema out of the et tube. Getting difficult to ventilate. Get her up to the unit. Everyone thinks she has a blown pupil. Two days later extubated 2 NC, 7 litres fluid off kidney working great LVAD doing good. She tells me the last thing she remembers is Dr C (thats me) yelling WTF!!!! Crazy case if shes not 17 she dead.

 

[jetproppilot]

Two days off wicked spincter tone...

60 something male multiple medical probs with ascending aortic anuersym disecting into RCA. S/P cabg and AVR (mechanical) two seperate occasion so this is third time in chest. Lines go in fine A-line 14 guage pre-induction. RIJ MAC cordis after induction TEE shows the anuersym large RV ef a bit low 40% not bad. Attending: "Mario pre-check four unit of blood and hang them in level one" which we hooked up to our cordis. Jeez overkill I think to myself. Surgery starts. Surgeon and fellow very carefully attempt to open sternum and .... were bleeding - big time. 3cm hole in anuersm. MAP is about 40 after 4 units a ton of epi we crash onto bypass and things slow down they reapair the hole but unfourtunatly nothing else. They start closing and we are having trouble stopping the bleeding. Final cout 35 protamine 7FFP 20 PRBS cryo and factor seven. Fully AV paced norepi maxed, epi maxed, vasopressin 4/hour. Dobutamine 5. To the unit.

Next day. LVAD placement 17 yo w/ postpartum cardiomyopathy. EF less than 20% lvad for bridge to transplant. See her the night before looks terrible like a stiff breeze could send her over the edge. Huge pleural effesions anosarcic ets. One "positional" 20 guage iv both ij and subclavians clotted from multiple lines/infections. No a-line and not intubated though sating in the low 90s tachypenic etc. MICU attending bites my head off when I suggest blood gas and intubation at least a good IV. Fine go home call my attending he's like whatever all LVAD are trainwreck we'll deal with it - cool. IN the am she looks a litlle worse now shes hypotensive syst in the 90s intern has given her 5 litres of fluid wich has topped her lungs off nicely. To OR with NO SEDATION pre oxygenate and by the grace off God and 20 sticks I hit an A-line. As I am securing it she arrests. Flatline asytolic blue instantanously. I run to the head of the bed intubate attending gives epi, tech doing chest compreesions she comes back crashes on to bypass arrests again as surgeons get the chest open but they just give direct massage becasue no response to epi. LVAD in then the fun starts. Pul edema pouring out - i mean pouring 100 lasix iv 3-4 litres urine and about 3 litres pulmoranry edema out of the et tube. Getting difficult to ventilate. Get her up to the unit. Everyone thinks she has a blown pupil. Two days later extubated 2 NC, 7 litres fluid off kidney working great LVAD doing good. She tells me the last thing she remembers is Dr C (thats me) yelling WTF!!!! Crazy case if shes not 17 she dead.

i love my private practice job.

 

[Laryngospasm]

Mask induction of a kid for a tonsil. IV in. Tube in. Attending out. Tech steps on IV and pulls it. I'm working on a new IV. Pulse ox stops beeping but it's because the tourniquet's on that arm. Next BP comes back with a systolic in the 40s and I realize the pulse ox isn't working because I left the sevo at 8% and the kid is too hypotensive to perfuse his finger. I thought I was going to have to start chest compressions on a healthy kid who came in for an elective case.

More recently, I had 18 seconds of asystole during a crani on a teenager. Didn't brady down first, just HR of 60 to zero in ONE heartbeat. By the time I'd looked at the monitor see why the alarm was going off, felt his carotid, and told the nurse to overhead page for some help as I was moving the drapes to start chest compressions, he was back in sinus at 60. Not an EKG artifact... flat a-line, flat pulse ox, exponentially decreasing ETCO2, no carotid pulse. Never did figure out for sure what happened and it didn't recur.

Did the surgeon say what he was doing at the time? This can happen from brainstem compression. If he was doing this and didnt say anything you should kick his ass.

 

[pgg]

Did the surgeon say what he was doing at the time? This can happen from brainstem compression. If he was doing this and didnt say anything you should kick his ass.

That was my first thought but she was nowhere near the brainstem ... this was a guy who had sinusitis that tracked back into his head. The crani was for "pus on brain" but it was all frontal and parietal. My two thoughts at the time were that he got a sudden bolus of pus (and all its associated toxins and cytokines and evil spirits) into one of the dural veins, or that the loading dose of phenytoin he'd received about 30 minutes earlier left a bolus in the tubing and I'd later inadvertently pushed a big hit of that. I couldn't really think of a good reason why he'd have had a profound vagal response to anything we were doing.

 

[Intubate]

Mine was a similiar laparoscopic experience, healthy 20 something yo lady for a lap tubal. Gas goes in and almost immediately I get asystole for about two screens. No warning, no noticeable decrease in heart rate just asystole. I tell the Gyn's to let the air out and they give me a blank look. I tell them again, let the f'in air out she is asytolic and they finally got it. I give some atropine about the same time and her HR returned about the time I was starting chest compressions. We woke her up and she did fine. This was about my third month of my CA1 year.

We all do this, but its unnecessary. Giving an IV drug to someone with no circulation is pointless. Stop the insufflation and start compressions (usually they come back before you start), then have someone give the drugs-- otherwise its just sitting in the vein.

 

[Planktonmd]

Two days off wicked spincter tone...

60 something male multiple medical probs with ascending aortic anuersym disecting into RCA. S/P cabg and AVR (mechanical) two seperate occasion so this is third time in chest. Lines go in fine A-line 14 guage pre-induction. RIJ MAC cordis after induction TEE shows the anuersym large RV ef a bit low 40% not bad. Attending: "Mario pre-check four unit of blood and hang them in level one" which we hooked up to our cordis. Jeez overkill I think to myself. Surgery starts. Surgeon and fellow very carefully attempt to open sternum and .... were bleeding - big time. 3cm hole in anuersm. MAP is about 40 after 4 units a ton of epi we crash onto bypass and things slow down they reapair the hole but unfourtunatly nothing else. They start closing and we are having trouble stopping the bleeding. Final cout 35 protamine 7FFP 20 PRBS cryo and factor seven. Fully AV paced norepi maxed, epi maxed, vasopressin 4/hour. Dobutamine 5. To the unit.

Next day. LVAD placement 17 yo w/ postpartum cardiomyopathy. EF less than 20% lvad for bridge to transplant. See her the night before looks terrible like a stiff breeze could send her over the edge. Huge pleural effesions anosarcic ets. One "positional" 20 guage iv both ij and subclavians clotted from multiple lines/infections. No a-line and not intubated though sating in the low 90s tachypenic etc. MICU attending bites my head off when I suggest blood gas and intubation at least a good IV. Fine go home call my attending he's like whatever all LVAD are trainwreck we'll deal with it - cool. IN the am she looks a litlle worse now shes hypotensive syst in the 90s intern has given her 5 litres of fluid wich has topped her lungs off nicely. To OR with NO SEDATION pre oxygenate and by the grace off God and 20 sticks I hit an A-line. As I am securing it she arrests. Flatline asytolic blue instantanously. I run to the head of the bed intubate attending gives epi, tech doing chest compreesions she comes back crashes on to bypass arrests again as surgeons get the chest open but they just give direct massage becasue no response to epi. LVAD in then the fun starts. Pul edema pouring out - i mean pouring 100 lasix iv 3-4 litres urine and about 3 litres pulmoranry edema out of the et tube. Getting difficult to ventilate. Get her up to the unit. Everyone thinks she has a blown pupil. Two days later extubated 2 NC, 7 litres fluid off kidney working great LVAD doing good. She tells me the last thing she remembers is Dr C (thats me) yelling WTF!!!! Crazy case if shes not 17 she dead.

When you hear these horror stories you can't help but wonder:
Which one is more dangerous: the diseaes that we treat or the crazy interventions that we do?

 

[militarymd]

So tell me, anesthesiologists young and old(er), what was your first sphincter-puckering moment?

Was just a CA-1...one of my first Saturdays.

First case was an intracranial anuerysm clipping with an inexperienced N-surgeon...case lasted about 15 hours.

We did eeg monitoring...burst suppression...the hold deal....didn't know what I was doing...just what my attending told me to do....

Dr. R. Dutton...currently at Shock Trauma...walks me through the case...I'm sure his sphincter was tighter than mine...because I was too untrained to know any better.

Anyways, case was uneventful.

After dropping the lady off in the unit, we get an addon.....butt abscess in a sick old lady with DKA.

Dr. Dutton said we're doing this case with a tetracaine hypobaric spinal with the patient in the jack knife position...I said "ok".....

AFter I put the spinal in, Dr. Dutton says in a very tired voice "call me if you have to start CPR".

Guess what I was doing 10 minutes later?