Standing your ground

[deleted59964]

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http://www.das.uk.com/files/DASExtubation-Guidelines-Basic-Algorithm.pdf
http://www.das.uk.com/files/DASExtubation-Guidelines-Lowrisk-algorithm.pdf
http://www.das.uk.com/files/DASExtubation-Guidelines-Atrisk-algorithm.pdf

 

[deleted171991]

One thing the OP should consider is whether it would not have been easier to move this patient over to the bed, in the same left lateral position she had been in, and extubate her like that, even deep. That would have also decreased the chances of her waking up in pain due to pressure/tension on the surgical site. Maybe even give her some propofol pre-emergence, which would not have affected breathing seriously in that position.

Even with OSA, there is way less obstruction in lateral decubitus. Plus most obese or OSA patients do not sleep on their back, so their natural reflex is to turn on their side, which might create agitation if restrained.

The main question for a difficult airway is: how difficult would be to ventilate this patient if needed? The more proficient one becomes with various types of LMAs, the less stressful that question will be. Worst case scenario: she gets a very long oral airway. 🙂

 

[kingcer0x]

Yikes, absolutely would be assertive here and stand your ground, but do not engage! Hostile target! If she sucks you in and provokes a stress response in the form of a crude remark or God forbid you raise your voice, then you get trapped in the nursing/ancillary staff world of 'incident reports' and the like. Then hospital committees get involved, you know, the ones without an actual Anesthesiologist on them, and we now have the roll out of "OR Extubation Protocol". Hell, someone might pitch it to CMS and now we have a new SCIP measure.

 

[pgg]

Versed? Benadryl? Antipsychotics? Seriously?

Haldol (and droperidol, when you can get it) are amazing anti-emetics and are great at smoothing out the young strong PTSD-ish angry males.

 

[Southpaw]

You run the show at the beginning and end of the case. Don't forget that. Don't lose your cool; it'll just reflect poorly on you if you do. Calmly state your desires, and although not necessary, you're reasoning if you want. Play nice until it's time to not play nice. Although not common, you'll meet some of the laziest, angriest people of your entire life in an academic hospital. You gotta get over it, focus on doing what's right for the patient, and develop the necessary skills to make you a competent, respected anesthesiologist.

 

[Random Anesthesiologist]

Wrong. Your answer when they ask "can you hold this patient's arm while I prep?" should be simply be this: "No."

No further explanation needed. You don't need to suggest an alternate course. You don't need to come up with any other solution for them.

If you act like a doormat don't be surprised when people walk all over you.

Before anesthesiology and med school, I was in a position of authority. Now, it's different. I feel like there is a fine line to be walked as a resident, especially a CA-1. My way of saying no is offering a different solution to them at this point. If they kept pestering me, I would probably eventually just go to the "no". But it seems treating them like my toddler has a better outcome at this point in my career. IDK.

 

[anes]

Before anesthesiology and med school, I was in a position of authority. Now, it's different. I feel like there is a fine line to be walked as a resident, especially a CA-1. My way of saying no is offering a different solution to them at this point. If they kept pestering me, I would probably eventually just go to the "no". But it seems treating them like my toddler has a better outcome at this point in my career. IDK.

Just know your role and hierarchy at your particular institution. As I've said before, where I trained attending>nurses>feces>resident.

I would defer to whatever my attending would have wanted to do. It's their license on the line, not yours. If your attending wanted to move the patient first, do it. If then the patient urgently needed to be re-intubated, and you weren't able to, its their fault.

 

[Sonny Crocket]

You did the right thing. Patient safety is number 1.

 

[deleted171991]

Haldol (and droperidol, when you can get it) are amazing anti-emetics and are great at smoothing out the young strong PTSD-ish angry males.

I don't doubt that. I use droperidol as a last resort antiemetic (when available). I just don't find that they are compatible with a fast PACU discharge, which is what I am looking for.

 

[deleted171991]

Just know your role and hierarchy at your particular institution. As I've said before, where I trained attending>nurses>feces>resident.

And then, when you graduate, in most big institutions, it's still surgeon>>>>anesthesiologist who is slightly more than nurses.

 

[pgg]

I don't doubt that. I use droperidol as a last resort antiemetic (when available). I just don't find that they are compatible with a fast PACU discharge, which is what I am looking for.

I never found that droperidol hurt me much in the PACU stay. I haven't used Haldol much in that role but I'm going to try it some more. I used it once last week at our ASC and it was great.

I did learn that Haldol 5 mg in 1 mL will precipitate if you dilute it in LR though. I don't remember that ever happening before, but I think the last time I used it I was a resident. I looked it up and indeed they do list concentrations over 3 g/L as incompatible with LR. Next time I'll use NS ...

 

[deleted171991]

In my experience, 0.625 mg of droperidol in the PACU = 20 minutes nap. I am not sure how good that dose would be for preventing emergence delirium.

 

[pgg]

In my experience, 0.625 mg of droperidol in the PACU = 20 minutes nap. I am not sure how good that dose would be for preventing emergence delirium.

Oh. I (used to) give droperidol 0.625 mg an hour+ before emergence, as a PONV prophylactic drug. Its antiemetic duration of action is many hours.

Some days, I think about ordering it from a Canadian pharmacy and bringing it to the hospital myself. I miss it that much.

I'm still not entirely clear how a gaggle of meddling pharmacists had the pull to take it away from every doctor in the building. Probably because the doctors were too busy doing useful work to show up to the meeting ...

 

[deleted9493]

Does anyone use promethazine as an alternative to droperidol in situations like this?

I have with some success but not commonly enough to know if it was Phenergan or other variable(s) that made the emergence smooth.

 

[gasdoc77]

Does anyone use promethazine as an alternative to droperidol in situations like this?

I have with some success but not commonly enough to know if it was Phenergan or other variable(s) that made the emergence smooth.

I use Phenergan more often for rowdy pacu patients (that are going to be admitted) than for ponv. I seem to recall it being chemically similar to the antipsychotics. I also used to use droperidol (.625) preop for patients that had a headache.
http://www.ncbi.nlm.nih.gov/pubmed/22030187

Haloperidol is a butyrophenone derivative and functions as an inverse agonist ofdopamine. It is classified as atypical antipsychotic and haspharmacological effects similar to the phenothiazines.[4]

1. Brayfield, A, ed. (13 December 2013). "Haloperidol". Martindale: The Complete Drug Reference. London, UK: Pharmaceutical Press. Retrieved 29 May 2014.

 

[deleted9493]

I spend a fair amount of time in our pediatric cath. taking care of kids having EP studies/interventions. Often isoproterenol is used to try to activate/reactivate arrhythmias pre/post ablation and is emetogenic. To boot, they want these kids (often teens) to lie flat and be still for 1+ hours postop. In this population, I have used phenergan just prior to emergence to make the transition smooth and in my limited experience the effect is positive.

In fellowship, I had an attending who regularly gave IV scopolamine during these cases. Too often I found those kids dysphoric/wacked out postop. and still prone to vomiting.