Anesthesia for HALO placement.

Take what I say with a grain of salt because I'm a med surg nurse on a trauma unit, not a CRNA. I've seen many halo placements, at the bedside, with the MD, floor nurse and the othotics guy (the guy who measure the patient and supplies the actual halo).

They get some routine pain meds like morphine and ativan, and local anesthetic and usually goes well and doesn't seem to hurt the patients all that much. They do describe the weird sensation of having their skull "drilled into", which might have freaked her out. The fact they were doing conscious sedation, rather than at the bedside leads me to believe that they might have been expecting some drama queen type behavior.

I think the possiblity of a severe panic attack reaction, especially given the age and lack of adult coping skills, should not be ruled out.

Unfortunately, this is fairly common. It could have been done better but that would have required an anesthesia person to administer sedation or a RN with deep sedation qualifications to administer more meds. These folks are not alwasy available at the drop of a hat. I'd caution anyone that wants to write up something b/c it didn't sit right with them. You need to know the circumstances. A better approach might have been to talk with the neuro RN or your charge RN or even the surgeon himself. You need to get an understanding of why something was done a certain way before reporting it. Writing up someone is just going to **** people off and make things a bit more difficult for everyone. Unless it is totally warranted of course.

I agree with Tweety. I work in a level 1 trauma center on a PCU. It is quite common for NES to place the halo at the bedside. As a matter of fact, just last week I participated in the placement of two.

Neither pt. received conscious sedation. Both received 4 mg of morphine and lots of lido. There was little upset during one placement, but at the other (a 19 year old girl), she clung to me and became hysterical. I forced her to look into my eyes and breathe. I just allowed her to squeeze my fingers as hard as she needed to, and every time she started to yell or cry out, I reminded her to look at me. It worked. She didn't thank me afterwards, lol, but I know it was effective.

Sounds like the perfect storm for PTSD (Post Traumatic Stress Disorder). Why not use deeper sedation, ketamine or something of the like depending on age and medical history. A child should not have to endure this type of torture when there are perfectly good ways of handling this situation. Remembering that this is probably the beginning of a long road to recovery for this child.
Also, I always ask myself would I do the same thing if this were my wife, my son, my daughter....I am sure you get the point.
If I were in this situation, I would not write it up. I would find out more about the policies on moderate sedation and halo placement and get involved to improve practice. Maybe they will let them bite a leather strap or have a gulp of whisky (if 21 or <)
-Smiley

Honestly....sounds like the patient probably freaked out a little and it was probably more anxiety (and drama), than anything else.

I've done more halo braces at the bedside than I remotely care to discuss. We do ours with the neurosurgeon, the orthotics guy and us (we're conscious sedation certified). I've never had this type of reaction from a patient. Frankly, I'm a fan of fentanyl and a little versed....along with the lido, of course. However, there's no need for deeper sedation. Most remember it...but I wouldn't call it a recipe for PTSD. And whoever recommended ketamine....ugh.

Most patient's report some discomfort (it's darn near impossible to get rid of all the pain of the procedure), but overall, it's a well tolerated procedure. Some patients require the hand holding and distraction/relaxation techniques, but hey, that's what we're here for anyway, right?

Just my 2 cents.

Well tolerated is usually the opinion of the one administering or assisting in the assault on the patient. Rarely does any nurse, anesthesiologist, AA, or CRNA ask the following questions after the procedure:
1. Was the level of sedation tolerable for the amount of pain involved or do you feel you could have benefitted from additional sedation at the time?
2. Would you consent to do the procedure exactly the same way again with the same amount of sedation?
3. Do you think the anesthesia provider's assessment of the amount of sedation required was in sync with what you felt was needed at the time?
4. If your anesthesia provider wrote "well tolerated" for the procedure and the anesthesia, would you agree with that assessment?

Until we stop extrapolating our biased interpretations onto "well tolerated", we are effectively guilty of determining outcomes based on our side of the experience, rather than the patient's. While survival of the procedure is an important facet of the procedure usually described by the euphemism "well tolerated", there are other attributes of assessment that are equally or more important from the patient's perspective. A patient freaking out during a procedure is a failed anesthetic.

[quote=NeuroICURN;2390957]...but I wouldn't call it a recipe for PTSD. And whoever recommended ketamine....ugh.

I brought up ketamine, and it was a question "why not..." Why not in a child? IV ketamine onset 30 sec and duration 5-10min vs fentanyl onset 1-2 min duration 30min-60min, and versed onset 2-5min duration 2-6 hrs....Is it explicitly contraindicated with spinal fractures? I have used it for orthopedic injuries in children and it was quite effective. So again I pose the question why not and "ugh" is not an answer. I look foward to the information.
As far as PTSD, it is not so much just the halo, but compound it with what the child has been through already. Staff can get desensitized to the gravity of a situation. Do you believe there is no effect on the child?
-Smiley