"St. Louis man awake during surgery"

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I would say that's not a fair comparison. Those are dynamic factors that are usually inconsequential and fixable. This was an all or nothing phenomenon. I would say a fair comparison would be if the patient got a bad surgical site infection and it turns out the anesthesiologist didn't give the antibiotics at all.

Well the difference here is that someone wanted to convince the patient they didn't remember anything and that it was all a dream which I think is unprofessional behavior. What might be more appropriate in an equivocal case would be to ask the patient in postop if everything was OK. Leave it open ended and without suggestion.

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Well the difference here is that someone wanted to convince the patient they didn't remember anything and that it was all a dream which I think is unprofessional behavior. What might be more appropriate in an equivocal case would be to ask the patient in postop if everything was OK. Leave it open ended and without suggestion.
Yeah I'm curious how this guy woke up. Was that the immediate first thing he said? Did he wake up like absolute ****?
 
When I am supervising, it is usually 4 rooms, and no way do I look to see if the second is on. That is a basic part of the job. The person in the room is the one to blame.
 
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When I am supervising, it is usually 4 rooms, and no way do I look to see if the second is on. That is a basic part of the job. The person in the room is the one to blame.
Checking for ETCO2 is also "a basic part of the job." The "basics" are the most important things to always verify IMHO.
 
where does it say 1:4? i didnt see that part
I thought some previous comments alluded to that. I could be mistaken. Even so, my point still stands. If you have to supervise, you have to trust the crna to do the most basic of things like turn on the gas. If you can’t do that, there’s no point in supervising. You’d have to do the case yourself
 
You might only be hearing about this because he is a new grad. Could be he was called to the room and started making a big deal about it and letting the surgeons and the nurses know all about it. A more seasoned doc might just “keep calm and carry on” give some versed, give a ton of propofol at the end of the case so he is out of it when he gets to PACU, then see if the patient mentions anything. Just a bad dream buddy.
just saying....

If this was in one of my ORs I would have given a large dose of versed followed by a large-ish dose of ketamine and maybe some droperidol. You might actually get some retrograde amnesia out of that, or at least make them forget how bad it was and wake up a little less sad/angry.
 
I thought some previous comments alluded to that. I could be mistaken. Even so, my point still stands. If you have to supervise, you have to trust the crna to do the most basic of things like turn on the gas. If you can’t do that, there’s no point in supervising. You’d have to do the case yourself

I almost always turn the gas on myself before I leave the room. Why? While I cannot prevent all bad things from happening but I can work hard to make them a lot less likely.
 
Does automatic record keeping remove a safeguard in vigilance? Or does it free up a menial task so that you can concentrate on taking care of the patient?🤔. Not sure if it plays into this scenario but it could
 
Sequester the CRNA’s phone.

Lots happens before recall. Would be hard to miss the BP and heart rate jump.

Reminds me that there’s a number of ways to get burned in our field. Neuromuscular blocking agents are an independent risk factor for recall (and maybe not needed for a hernia repair). Sometimes wonder if succinylcholine should make a comeback... (there are some that hate it at my shop). Sux seems to be in the doghouse with the next gen of folks who’ve only known anesthesia post sugammadex.
 
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I thought some previous comments alluded to that. I could be mistaken. Even so, my point still stands. If you have to supervise, you have to trust the crna to do the most basic of things like turn on the gas. If you can’t do that, there’s no point in supervising. You’d have to do the case yourself

Sequester the CRNA’s phone.

Lots happens before recall. Would be hard to miss the BP and heart rate jump. As a side note, this is a reminder that neuromuscular blocking agents are a risk factor for recall (and maybe not needed for a hernia repair). Would be fun to see succinylcholine make a comeback... seems to be in the doghouse with the next gen of folks who’ve only known anesthesia post sugammadex.
I am NOT a fan of SUX because of the myalgias many patients experience postop for 24-72 hours. This is a common issue we tend to ignore because many of us don't follow up the next day or 48 hours later. But, IMHO, this is a real issue in terms of patient satisfaction so I always take that into account before reaching for the SUX.

" The incidence of postoperative myalgia due to succinylcholine varies, being as high as 90% and generally thought to be approximately 50% [4, 9]. The myalgias have been described as similar to the pain or muscle soreness experienced after a significant physical activity [10]. The duration and intensity of this discomfort is highly variable."

 
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I almost always turn the gas on myself before I leave the room. Why? While I cannot prevent all bad things from happening but I can work hard to make them a lot less likely.
Sometimes easier said than done in the care team model. In the case of this story’s provider, may have been just as likely to miss the 10 minutes of MAP’s of 35 while awaiting surgical stimulus.
 
I am NOT a fan of SUX because of the myalgias many patients experience postop for 24-72 hours. This is a common issue we tend to ignore because many of us don't follow up the next day or 48 hours later. But, IMHO, this is a real issue in terms of patient satisfaction so I always take that into account before reaching for the SUX.

" The incidence of postoperative myalgia due to succinylcholine varies, being as high as 90% and generally thought to be approximately 50% [4, 9]. The myalgias have been described as similar to the pain or muscle soreness experienced after a significant physical activity [10]. The duration and intensity of this discomfort is highly variable."
Point well taken. I see it less (and we have a pretty robust system of postop checks including next day phone calls) but include it in my informed consent.
 
Sequester the CRNA’s phone.

Lots happens before recall. Would be hard to miss the BP and heart rate jump.

Reminds me that there’s a number of ways to get burned in our field. Neuromuscular blocking agents are an independent risk factor for recall (and maybe not needed for a hernia repair). Sometimes wonder if succinylcholine should make a comeback... (there are some that hate it at my shop). Sux seems to be in the doghouse with the next gen of folks who’ve only known anesthesia post sugammadex.

To advocate the use of sux to mitigate the risk of recall is ridiculous. Just turn the ****ing gas on.
 
To advocate the use of sux to mitigate the risk of recall is ridiculous. Just turn the ****ing gas on.
Agree that this was a case of underuse of anesthetic agent (and not an overuse of NMBA)
Simply adding that with any neuromuscular blocking agents (vs LMA/non paralytic cases) we need to be even more vigilant re: ensuring adequate depth of anesthesia. Have also reviewed cases wherein TIVA was “started” and found to be disconnected from patient or IV infiltrated. As a field we all need to maintain a healthy paranoia and in a care team model we are all more likely to get burned.
 
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Agree that this was a case of underuse of anesthetic agent (and not an overuse of NMBA)
Simply adding that with any neuromuscular blocking agents (vs LMA/non paralytic cases) we need to be even more vigilant re: ensuring adequate depth of anesthesia. Have also reviewed cases wherein TIVA was “started” and found to be disconnected from patient or IV infiltrated. As a field we all need to maintain a healthy paranoia and in a care team model we are all more likely to get burned.

Yes! I've had an iv get disconnected under the drapes and only noticed when the flood started coming my way. I'm glad the patient didn't exsanguinate
 
I'm curious which induction agents were given and whether or not anything was given IV in response to the post-intubation hemodynamics. The plaintiff's letter makes it sound like the anesthesia team solo'ed him with roc and told the surgeon to go ahead.
 
Yes! I've had an iv get disconnected under the drapes and only noticed when the flood started coming my way. I'm glad the patient didn't exsanguinate

It's interesting this might be one of those instances where running a tiva might actually allow u to catch that earlier. If thr BIS skyrockets you might figure to check your IV site before you start seeing pools of blood stain the drapes
 
It's interesting this might be one of those instances where running a tiva might actually allow u to catch that earlier. If thr BIS skyrockets you might figure to check your IV site before you start seeing pools of blood stain the drapes

Don't use bis
 
I'm curious which induction agents were given and whether or not anything was given IV in response to the post-intubation hemodynamics. The plaintiff's letter makes it sound like the anesthesia team solo'ed him with roc and told the surgeon to go ahead.
I’m curious about this as well. I would think an induction dose of prop would provide amnesia for at least 10 min or so.
 
I’m curious about this as well. I would think an induction dose of prop would provide amnesia for at least 10 min or so.
I watched the interview with the local news group. Not to be judgemental but he appears to be...on something. If that’s a pre-existing thing, could explain Prop not lasting as long as they’d hoped.
 
No. What's the point? Create more garbage for no good reason?

Zhang et al 2011 suggest BIS for TIVA is useful. Seems particularly useful for patients who use drugs like Marijuana who have been shown to require significantly higher doses of propofol. What do you reference as no difference in outcome?
 
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I am NOT a fan of SUX because of the myalgias many patients experience postop for 24-72 hours. This is a common issue we tend to ignore because many of us don't follow up the next day or 48 hours later. But, IMHO, this is a real issue in terms of patient satisfaction so I always take that into account before reaching for the SUX.

" The incidence of postoperative myalgia due to succinylcholine varies, being as high as 90% and generally thought to be approximately 50% [4, 9]. The myalgias have been described as similar to the pain or muscle soreness experienced after a significant physical activity [10]. The duration and intensity of this discomfort is highly variable."

People just need to work out instead of be couch potatoes and stuffing their faces non stop That helps with the myalgias.
Haha
 
I watched the interview with the local news group. Not to be judgemental but he appears to be...on something. If that’s a pre-existing thing, could explain Prop not lasting as long as they’d hoped.
Could be he is dealing with PTSD? And self medicating for anxiety? Why assume it’s preexisting?
 
Nope; I titrate to hemodynamics.

No. What's the point? Create more garbage for no good reason?
The BIS is mostly trash and I don't use it routinely, but I will put it on for TIVA, pump cases, ASA 5 traumas, crash GETA sections, or any other case where the volatile has a high chance of getting below 0.7 Mac.

Also, even though we all use them to some degree, vital signs are not a sensitive marker of anesthetic depth or pain unless we're at the extreme ranges.
 
Could be he is dealing with PTSD? And self medicating for anxiety? Why assume it’s preexisting?
I've had a "former" alcoholic guy come in for an EGD. I no joke gave probably 300-400mg prop or so and the scope time was less than 5 minutes, he emerged immediately like nothing happened fully bright awake when scope came out (was also thrashing the whole time too). IV was not infiltrating, and he would need a lot just to induce some sense of unconsciousness. Maybe this guy was in the same boat? Or bad prop?
 
I've had a "former" alcoholic guy come in for an EGD. I no joke gave probably 300-400mg prop or so and the scope time was less than 5 minutes, he emerged immediately like nothing happened fully bright awake when scope came out (was also thrashing the whole time too). IV was not infiltrating, and he would need a lot just to induce some sense of unconsciousness. Maybe this guy was in the same boat? Or bad prop?

Nah some people just need more. I've started giving versed to young women, bmi over 50 and muscular men because otherwise they need a ton of prop
 
Nah some people just need more. I've started giving versed to young women, bmi over 50 and muscular men because otherwise they need a ton of prop

I want to hear some of our CO colleagues here. Wasn’t there a study recently saying that since CO has legalized marijuana for the longest time, on average their induction dose of prop is higher?

I had one 20 yo who smoked everyday, it took 2 of versed 100 of fent and 500 of prop to even get him to close his eyes. It seems he was fighting it hard to ride the dragon.
 
Nah some people just need more. I've started giving versed to young women, bmi over 50 and muscular men because otherwise they need a ton of prop
Young women need alot to go down, surprisingly. 200mg on a 50kg healthy woman is nothing for induction, even with the fent
 

Reminds me of this paper, I think it’s been posted before. Prop on induction in young healthy people will be enough for amnesia, but certainly won’t be enough if you forget for 5 mins or so to turn on some gas. This paper made me much more compulsive about making sure gas is on, and in young people I now turn on gas while masking.
 
I've had a "former" alcoholic guy come in for an EGD. I no joke gave probably 300-400mg prop or so and the scope time was less than 5 minutes, he emerged immediately like nothing happened fully bright awake when scope came out (was also thrashing the whole time too). IV was not infiltrating, and he would need a lot just to induce some sense of unconsciousness. Maybe this guy was in the same boat? Or bad prop?
No, it was 13 minutes of no gas. That is a long time even for a little person like me. How long does propofol last in a 70kg person?
Come on.
 
I’m curious about this as well. I would think an induction dose of prop would provide amnesia for at least 10 min or so.

Based on what? As a bolus propofol dose loses effect by redistribution. Lit says those effects wear off in about 5 minutes, which from practical perspective means just a few minutes after intubation.
 
I’m curious about this as well. I would think an induction dose of prop would provide amnesia for at least 10 min or so.
Probably does provide amnesia for a significant amount of time. We are focusing on the “13 minutes”, the CRNA would have been ok so long as they have some prop or blasted the gas before surgical incision. They were light for a very stimulating part of surgery is the main problem here.
 
You must enjoy being “poor” or “solid middle class” in your country of socialized healthcare and no CRNAs.
Can I join you in your cardboard or manufactured home so I can be almost poor too?
Absolutely!
We do alright. Im not sure youd love may snow though...
One of the provinces has mentioned brining in CRNAs recently and as far back as 10 years ago but still no sign. Im sure something like that will happen eventually.
We do have family practice anesthesia which irks some people a bit that they can essentially go rural do whatever cases they like and bill the same as us with like 10-11months extra training. But at least they dont compete with us. Really our college is very strong for each speciality and no one really treads on our toes
 
Absolutely!
We do alright. Im not sure youd love may snow though...
One of the provinces has mentioned brining in CRNAs recently and as far back as 10 years ago but still no sign. Im sure something like that will happen eventually.
We do have family practice anesthesia which irks some people a bit that they can essentially go rural do whatever cases they like and bill the same as us with like 10-11months extra training. But at least they dont compete with us. Really our college is very strong for each speciality and no one really treads on our toes

Family practice anesthesia seems weird, and I guess that fills the role of midlevel anesthesia providers like we have in America. I'm surprised there isn't more patient selection involved with their cases
 
Another case of awareness. That I have personally witnessed. Emerging a young patient after a Tonsillectomy adenoidectomy. Prop succ tube. Case takes 30-35 minutes. Surgeon gets tonsil out and says we are almost done. Turn down the gas. Notice at about 7 minutes patient is not breathing. Check twitches 0/4 twitches turn up the vapor adminster 2 of midazolam. Presumed psuedocholinesterase deficiency. Patient recovers 7 hours later extubated states she only remembers me saying to her you are going back to sleep. Which I definitely said. Patient was happy I addressed her during that time.
 
Does automatic record keeping remove a safeguard in vigilance? Or does it free up a menial task so that you can concentrate on taking care of the patient?🤔. Not sure if it plays into this scenario but it could
The best thing about the automatic record keeping is the reduction in falsified records.

Anyone who has supervised/directed or given breaks/relief to people in a place with paper charts knows what a powerful magnet for bull**** paper is.

New residents frequently have to be un-trained from the habit of click click click while ignoring the patient. Seems odd to have to train them to ignore the computer and pay attention to the patient but that seems to be the case pretty often early in the CA1 year.
 
I am NOT a fan of SUX because of the myalgias many patients experience postop for 24-72 hours. This is a common issue we tend to ignore because many of us don't follow up the next day or 48 hours later. But, IMHO, this is a real issue in terms of patient satisfaction so I always take that into account before reaching for the SUX.
I'm a card carrying member of the Succinylcholine Haters Society. When it's actually indicated (eg RSI, laryngospasm) there's no substitute but I need a compelling reason to use it.

I've told this story before, but I had an ORIF for gnarly comminuted radial and ulnar fractures about 25 years ago, and worse than the pain of the break (can still hear the crack and crunch in my brain), the pain of the ER doc "examining" it, and the pain of the surgery ... were the whole body muscle aches from succinylcholine. I thought maybe I'd fallen off the OR table and needed CPR. That stuff sucks.
 
I'm a card carrying member of the Succinylcholine Haters Society. When it's actually indicated (eg RSI, laryngospasm) there's no substitute but I need a compelling reason to use it.

I've told this story before, but I had an ORIF for gnarly comminuted radial and ulnar fractures about 25 years ago, and worse than the pain of the break (can still hear the crack and crunch in my brain), the pain of the ER doc "examining" it, and the pain of the surgery ... were the whole body muscle aches from succinylcholine. I thought maybe I'd fallen off the OR table and needed CPR. That stuff sucks.
Post gamma. I rarely use succ. And I often council our residents that succ is rarely indicated except rsi, rapid intubation, etc...
 
very lucky they are only suing for 25000 DOLLARS.

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does that even cover lawyer fees...
 
You must enjoy being “poor” or “solid middle class” in your country of socialized healthcare and no CRNAs.
Can I join you in your cardboard or manufactured home so I can be almost poor too?
Hey, there are MD only practices in TX too. TX is far from being a place where socialized HC will fly
 
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