Weaning off sedation

[chocomorsel]

Done lots of deep sedation on kids. Also see lots of things go wrong. But thanks for your insight into my experience.

Your comment shows lack of experience in pediatric anesthesia. You are welcome.

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[SurfingDoctor]

Your comment shows lack of experience in pediatric anesthesia. You are welcome.

Yep, I’m not an anesthesiologist. Never claimed to be. Thanks Maui.

 

[chocomorsel]

Yep, I’m not an anesthesiologist. Never claimed to be. Thanks Maui.

Then why the smartass comment about things you aren’t that well versed?
Again, you are welcome

Kids are delicate. You can pay lots of attention, and they can still spasm, brady and code. It happens. The fact that you said that someone wasn't paying attention and that's why the kid spasmed and desaturated, is simply most always, not the case, and it bothered me.

I don't do kids very often anymore and don't miss them turning ashen/blue on me.

Didn't mean to be a jerk about it.

 

[SurfingDoctor]

Then why the smartass comment about things you aren’t that well versed?
Again, you are welcome

Kids are delicate. You can pay lots of attention, and they can still spasm, brady and code. It happens. The fact that you said that someone wasn't paying attention and that's why the kid spasmed and desaturated, is simply most always, not the case, and it bothered me.

I don't do kids very often anymore and don't miss them turning ashen/blue on me.

Didn't mean to be a jerk about it.

I mean, I’ve only been practicing Pediatrics for over 10 years and Pediatric critical care for about 10 . I clearly have no idea what I’m talking about.

 

[chocomorsel]

I mean, I’ve only been practicing Pediatrics for over 10 years and Pediatric critical care for about 10 . I clearly have no idea what I’m talking about.

I don't know what you know, but your smart ass statement was making a lot of assumptions.

 

[SurfingDoctor]

I don't know what you know, but your smart ass statement was making a lot of assumptions.

Well, I don’t recall making any assumptions about you...

Though I also don’t recall engaging you either...

 

[deleted547339]

So much salt in this thread....

 

[SurfingDoctor]

So much salt in this thread....

 

[nimbus]

FFP is nonpartisan. He’s pretty salty in the anesthesia forum too.

 

[Bostonredsox]

What do you do when a patient has been maxed out on propofol and percedex for 7 days and for love of god can't wean him off because he starts bucking vent and gets agitated? Underlying cause has already resolved but he just wont get off sedation. We've tried giving him Seroquel, celexa but nothing. Have you guys encountered this before. What is your way of dealing with this

Trach him. then it becomes alot easier.

Not trying to be glib, and I didn't read all of the Anesthesia hate throughout the thread, but in general, any pt, week on the vent, 3-4 consecutive days of failed weaning trials after reverse of the primary cause, failing precedex.....trach. Happens every few months with a 300 pound 6'5 drunk in DTs who takes 5 people to hold him down initially, bucks the vent on 75 of propofol, versed and precedex...let him ride for a week. when hes still crazy agitated and dyssynchronus upon lightening sedation and having secretion issues on top of that.....trach.

EDIT: I also am assuming he is not just 'bucking the vent agitated" and is actually failing your trials with hemodynamic instability, precipitously worsening hypoxemia, inability to control secretions and/or protect his airway. if none of those are true and he is just "agitated" but can protect his airway and isn't a difficult airway to begin with.....just pull the tube.

 

[leviathan]

I've had to go to PACU to extubate far , far too many patients from anesthesiologists on post-op patients who they "can't extubate". To then think they're somehow more capable of extubating critically ill patients several days into an ICU stay, which is a completely different type of patient, is hard to believe. Maybe they train you guys better in the US or I'm biased by some bad apples, I don't know...

 

[Shufflin]

Trach him. then it becomes alot easier.

Not trying to be glib, and I didn't read all of the Anesthesia hate throughout the thread, but in general, any pt, week on the vent, 3-4 consecutive days of failed weaning trials after reverse of the primary cause, failing precedex.....trach. Happens every few months with a 300 pound 6'5 drunk in DTs who takes 5 people to hold him down initially, bucks the vent on 75 of propofol, versed and precedex...let him ride for a week. when hes still crazy agitated and dyssynchronus upon lightening sedation and having secretion issues on top of that.....trach.

EDIT: I also am assuming he is not just 'bucking the vent agitated" and is actually failing your trials with hemodynamic instability, precipitously worsening hypoxemia, inability to control secretions and/or protect his airway. if none of those are true and he is just "agitated" but can protect his airway and isn't a difficult airway to begin with.....just pull the tube.

Here's a revolutionary idea. Let nature decide. Why pay millions to fight what nature is trying to do?

 

[coffeebythelake]

Here's a revolutionary idea. Let nature decide. Why pay millions to fight what nature is trying to do?

Let nature decide???? That's your wise sage advice? Please explain what is it we do that is natural? Or are you suggesting naturopathic approach to critical care medicine. Maybe some herbs and aromatherapy is what we need to liberate patients of the vent

 

[Shufflin]

Let nature decide???? That's your wise sage advice? Please explain what is it we do that is natural? Or are you suggesting naturopathic approach to critical care medicine. Maybe some herbs and aromatherapy is what we need to liberate patients of the vent

That's funny. No, I'm simply begging the ethical dilemma of limited resources vs beneficence. Where do you draw the line? It's the same dilemma faced by the transplant world, except in your case the limited resource is money, not organs. Do you simply do everything possible irregardless of the costs? If not, when do you say stop? It's a genuine ethical discussion. Much of our medical care hospital dollars are spent in intensive care.

 

[coffeebythelake]

I've had to go to PACU to extubate far , far too many patients from anesthesiologists on post-op patients who they "can't extubate".

Why do you think these patients could not be extubated in the OR? Would such examples include the lingering effects from the anesthetic after a long case in a patient with profound sleep apnea?? -- in such cases tincture of time is most appropriate. If they were truly patients that "can't extubate" they wouldn't linger in PACU they would go straight to ICU. More interestingly why are YOU going to the PACU to extubate patients?

To then think they're somehow more capable of extubating critically ill patients several days into an ICU stay, which is a completely different type of patient, is hard to believe. Maybe they train you guys better in the US or I'm biased by some bad apples, I don't know...

Those are some pretty arrogant words. Get off your high horse.
Extubation criteria in the OR is not the same as in the ICU.
In the ICU there is an acceptance that a certain number of patients will be re-intubated. If you don't end up re-intubating some you aren't being aggressive enough in your weaning strategy. That's acceptable, considering that the patient population as a whole is different: often unable to perform mental status examination, following commands, etc. You extubate based on meeting parameters (RSBI, NIF, labs, ventilating/oxygenating/protecting airway/etc...) and gestalt. You balance the risk of aggressive weaning strategy with the potential harm in keeping a patient intubated for a long period of time (progressive weakness, pneumonia, trach, etc). In the OR, we often have more than just these parameters. We often want the patient to be following commands, purposeful actions, sometimes doing math before we extubate. Sometimes if we're not happy we bring them to the PACU intubated to chill out a bit, let the anesthetic wear off further, and we reassess. We don't have the luxury of having the patient sit in the OR for hours until they are extubated. Having to re-intubate someone after coming out from the OR is not seen with the same degree of acceptance.

 

[leviathan]

Why do you think these patients could not be extubated in the OR? Would such examples include the lingering effects from the anesthetic after a long case in a patient with profound sleep apnea?? -- in such cases tincture of time is most appropriate. If they were truly patients that "can't extubate" they wouldn't linger in PACU they would go straight to ICU. More interestingly why are YOU going to the PACU to extubate patients?

No, they don't just go to ICU. That's the point. We often get consulted about wanting to bring the patient to ICU because they're too afraid to extubate. So often times the story sounds a bit soft, we tell them to send the patient to PACU instead for us to assess, and we go extubate them without any problems. Other times we agree with the assessment, though usually when it's pretty obvious we just agree to bring them over to the unit.

Those are some pretty arrogant words. Get off your high horse.
Extubation criteria in the OR is not the same as in the ICU.
In the ICU there is an acceptance that a certain number of patients will be re-intubated. If you don't end up re-intubating some you aren't being aggressive enough in your weaning strategy. That's acceptable, considering that the patient population as a whole is different: often unable to perform mental status examination, following commands, etc. You extubate based on meeting parameters (RSBI, NIF, labs, ventilating/oxygenating/protecting airway/etc...) and gestalt. You balance the risk of aggressive weaning strategy with the potential harm in keeping a patient intubated for a long period of time (progressive weakness, pneumonia, trach, etc). In the OR, we often have more than just these parameters. We often want the patient to be following commands, purposeful actions, sometimes doing math before we extubate. Sometimes if we're not happy we bring them to the PACU intubated to chill out a bit, let the anesthetic wear off further, and we reassess. We don't have the luxury of having the patient sit in the OR for hours until they are extubated. Having to re-intubate someone after coming out from the OR is not seen with the same degree of acceptance.

Ironic that you're calling me arrogant; I'm simply responding to the attitude expressed in here by others. Bottom line, the point is the type of extubations done after an OR case don't necessarily lend to being better at extubating ICU patients. As you said, very different patient population, so that's arrogant to presume you're better at weaning or extubating a patient who's been in the ICU for a week.

 

[chocomorsel]

I've had to go to PACU to extubate far , far too many patients from anesthesiologists on post-op patients who they "can't extubate". To then think they're somehow more capable of extubating critically ill patients several days into an ICU stay, which is a completely different type of patient, is hard to believe. Maybe they train you guys better in the US or I'm biased by some bad apples, I don't know...

In what country are you extubating patients for anesthesiologists? That’s very weird. Once a patient stays intubated the anesthesiologist usually goes back later to extubate.

I find that very odd to have to call another specialist to extubate. Unless they are extremely busy and can’t come back?

 

[coffeebythelake]

Ironic that you're calling me arrogant

Let's summarize.
YOU said my profession needs better training
I said YOU are arrogant for doing so.
Please explain how I am ironic.

I'm simply responding to the attitude expressed in here by others.

Very mature.
So no one can have a thoughtful discussion because you've also decided to adopt this attitude.
your tit for tat, "you're arrogant.... no you're arrogant!!" response is... classic. last time i saw that was on the school playground.

Bottom line, the point is the type of extubations done after an OR case don't necessarily lend to being better at extubating ICU patients. As you said, very different patient population, so that's arrogant to presume you're better at weaning or extubating a patient who's been in the ICU for a week.

the BOTTOM LINE is what I said. go over my comments in this post. Is there something about my explanation of ICU vs OR extubation criteria that doesn't jive with you? what have i said that is arrogant?

I am concerned the attitude you've expressed here reflects some underlying issues, and hopefully this is not something you bring to work with you. Frankly this is a hostile approach you've taken, an "us versus them" mentality.

 

[chocomorsel]

Do anesthesiologists not practice CCM in Canada? I thought that America was the only exception to this rule. Everywhere else trained them to be Intensivists.

 

[CCM-MD]

Do anesthesiologists not practice CCM in Canada? I thought that America was the only exception to this rule. Everywhere else trained them to be Intensivists.

They do. Anesthesiology is a 5 year residency and CCM is a 2 year fellowship.

IM, EM, Anesthesia, and surgery all complete the same 2 year multidisciplinary CCM fellowship.

 

[jdh71]

That's funny. No, I'm simply begging the ethical dilemma of limited resources vs beneficence. Where do you draw the line? It's the same dilemma faced by the transplant world, except in your case the limited resource is money, not organs. Do you simply do everything possible irregardless of the costs? If not, when do you say stop? It's a genuine ethical discussion. Much of our medical care hospital dollars are spent in intensive care.

I just ask, "Is she hot?"

If not, and almost always, then I do my best to pull the plug.

If yes, then I do everything I can to save her.

She's usually crazy AF tho and in for a Molly and GHB OD or similar

 

[jdh71]

In what country are you extubating patients for anesthesiologists? That’s very weird. Once a patient stays intubated the anesthesiologist usually goes back later to extubate.

I find that very odd to have to call another specialist to extubate. Unless they are extremely busy and can’t come back?

I extubate all the time patients that anesthesia don't or won't. I'm a cynic. It's late in the day and folks want to go home, and I can get around to extubating later, like whenever, especially if the patient was slated for the ICU anyway. It's not extubating FOR the anesthesiologist though, at least not from my perspective. I'd be kind of funny if they stayed on their service and they came back in the morning and did the extubation. But definitely happens all the time. I don't even mind that much, especially if I'm on nights. It's uaullay a quick and easy CC time consult.

 

[chocomorsel]

I extubate all the time patients that anesthesia don't or won't. I'm a cynic. It's late in the day and folks want to go home, and I can get around to extubating later, like whenever, especially if the patient was slated for the ICU anyway. It's not extubating FOR the anesthesiologist though, at least not from my perspective. I'd be kind of funny if they stayed on their service and they came back in the morning and did the extubation. But definitely happens all the time. I don't even mind that much, especially if I'm on nights. It's uaullay a quick and easy CC time consult.

I find that odd. I don't do it. If I am leaving and the patient is still intubated, then they need the tube.
But I guess sometimes things can get hectic in the OR.

 

[leviathan]

Let's summarize.
YOU said my profession needs better training
I said YOU are arrogant for doing so.
Please explain how I am ironic.



Very mature.
So no one can have a thoughtful discussion because you've also decided to adopt this attitude.
your tit for tat, "you're arrogant.... no you're arrogant!!" response is... classic. last time i saw that was on the school playground.



the BOTTOM LINE is what I said. go over my comments in this post. Is there something about my explanation of ICU vs OR extubation criteria that doesn't jive with you? what have i said that is arrogant?

I am concerned the attitude you've expressed here reflects some underlying issues, and hopefully this is not something you bring to work with you. Frankly this is a hostile approach you've taken, an "us versus them" mentality.

The only arrogance and 'us vs them' in this forum is FFP claiming he's better at extubating than his intensivist colleagues who don't have an anesthesia background. You are defending him, and therefore agreeing with his stance, which makes you arrogant as well. I'd also like you to point out where I said you need better training.

The bottom line is that you hold the same views as me. You aren't comfortable nor trained to extubate more critically ill patients or patients who have severe comorbidities. That's what part of an ICU fellowship is for. So to pretend you can do a better job weaning them 7 days later is even more arrogant. Try to be more professional and don't use ad hominem attacks, or I won't respond to you again.

 

[IMGASMD]

What do you do when a patient has been maxed out on propofol and percedex for 7 days and for love of god can't wean him off because he starts bucking vent and gets agitated? Underlying cause has already resolved but he just wont get off sedation. We've tried giving him Seroquel, celexa but nothing. Have you guys encountered this before. What is your way of dealing with this

So this is the OP.

We can all agree something is amiss? A patient who’s maxed out on two strong hypnotics. One induces general anesthesia, the other can smooth out just about any patients. Two drugs that Anesthesiologists, most likely to use on a daily basis. I am still not sure what maxed out on propofol looks like.

Anyway, I know I am beating a dead horse. If it was my family in ICU I had a choice of who to take care of them, when “underlying cause has already resolved,” unable to extubate due to unable to “get off sedation.”

In this particular order.
Anesthesia CCM, IM CCM, anesthesia (PGY4), Anesthesia (PGY3),
toss up IM Chief Resident (PGY4/3) vs Anesthesia (PGY2).

The list ends there. I would not have IM PGY-2 touch my family who has been difficult to extubate, excluded medical reasons, with a 10 foot pole.

The original ask was for a patient, medical problems already resolved. Do I think anesthesia ccm can extubate him/her better? Yes.

 

[jdh71]

Heh

 

[coffeebythelake]

The only arrogance and 'us vs them' in this forum is FFP claiming he's better at extubating than his intensivist colleagues who don't have an anesthesia background. You are defending him, and therefore agreeing with his stance, which makes you arrogant as well. I'd also like you to point out where I said you need better training.

The bottom line is that you hold the same views as me. You aren't comfortable nor trained to extubate more critically ill patients or patients who have severe comorbidities. That's what part of an ICU fellowship is for. So to pretend you can do a better job weaning them 7 days later is even more arrogant. Try to be more professional and don't use ad hominem attacks, or I won't respond to you again.

Your logical fallacies are astounding. What you called an "ad hominem" attack is me calling you out for saying that anesthesiologists are poorly trained. Perhaps to avoid ad hominem I should attack "you and people like you". Oh wait-- that's what you did and that is worse!

I am not pretending anything nor am I defending FFP. Where in this thread did I do this? Why don't you pull up a QUOTE of mine to support your allegations, otherwise you are just blowing smoke out your rear end.

Since you've mastered the art of making your arguments convoluted,
Let me put it in words you can understand --
YOU ATTACKED MY SPECIALTY AND I CALLED YOU ARROGANT FOR IT.

Awaiting your response, Mr. Moderator Emeritus

 

[leviathan]

OK, let me summarize this because clearly you're having trouble understanding this exchange.
1. FFP said he is better at weaning ICU patients off the vent and extubating than non-anesthesia intensivists because of his anesthesia background.
2. I replied saying that's not my personal experience, since I often have anesthesia calling me to take their patients to the ICU for concerns around extubation, and I end up extubating them in PACU immediately (or in ICU if they come straight to ICU). If they're having trouble extubating patients even on day 0 and need my help, then how does that correlate to them doing a better job on day 7 with someone in multi-organ failure with critical illness polyneuropathy/myopathy, delirium, etc.
3. I questioned if maybe American anesthesiologists have better training than Canadian anesthesiologists at weaning sicker patients off the vent (maybe more time in ICU?) as one explanation for why my experience is different than what FFP claims to be able to do. This is what you bolded and suggested that makes me arrogant?
4. You called me arrogant and said I'm attacking anesthesiologists, yet in the next minute wrote a statement agreeing that what you do is different than us. That's like calling me arrogant for saying a psychiatrist can't do an appendectomy.

English is a tricky language, but I still don't understand where you think I attacked your specialty. You must have a huge chip on your shoulder or some sort of inferiority complex.

 

[chocomorsel]

@leviathan, I honestly didn’t see the arrogance or whatever in your statement. Maybe there was a little sarcasm?
I really think there was a “lost in translation” moment w @eikenhein.
Kiss and makeup over the net? I mean I did today w a nurse, so it’s possible.

 

[deleted547339]

Can we just all agree that the OP’s patient isn’t getting great care? K? Thanks.

 

[SpacemanSpifff]

Can we just all agree that the OP’s patient isn’t getting great care? K? Thanks.

@leviathan, I honestly didn’t see the arrogance or whatever in your statement. Maybe there was a little sarcasm?
I really think there was a “lost in translation” moment w @eikenhein.
Kiss and makeup over the net? I mean I did today w a nurse, so it’s possible.

The lack of professional communication on this forum has been disheartening lately.

 

[chocomorsel]

The lack of professional communication on this forum has been disheartening lately.

I know. Been involved in some spats myself. A lot of arrogant attitudes on here. So many egos.

 

[Robotic Wis-Hipple]

Ugh, so over all of the specialty fighting and “hand” measuring. I know my medicine training doesn’t hold a candle to an IM Intensivist, but I don’t understand why everyone seems to be unable to accept that anyone else may have more experience in something.

But what I hate hearing, and has been said in this thread is some variation of this;

“I give/perform light/conscious, moderate, or deep sedation regularly so therefore I could do your job”. It’s just plain wrong.

I’ll declare that managing sedation does not imply you can perform general anesthesia. Though related, there is clearly nuance that separates. And likewise, though we extubate far more patients acutely, I’d also agree that there’s nuance and a skill set that leads to differences in extubating a MICU Pt after days of sedation that clearly you do more of than I do.

So there’s clearly differences in the training, the acquired skill sets (that may or may not lead to different levels of aggression in extubating etc), and the patient scenarios we each deal with. I don’t think that’s a shocking declaration.

In regards to the Anesthesia vs Non-Anesthesia CCM spat I’m not going to get into it because I’m not CCM and have no interest in practicing CCM. I’m just glad all you folks enjoy it and dedicate your life to it and I think we can learn from each other if we hold the salt a bit.