Is It Possible to Feel Surgical Procedure - page 2

My pt. cam back from OR, after having had a lap appy, stating he felt the entire procedure but could not move. When he awoke in PACU and told them that, they tried dosing him with Versed to cause a... Read More

  1. by   eph432girl
    My best friend (who is an ER nurse) had a C-section last week. She has had many surg on her spine (rods and fusions). She was scheduled to be under general with the section, but she had been pukin all week and her K+ was only 2.3.... so... would not do general for fear of arrthymias. She said that they started her spinal "high" because her abnormal back anatomy (rods, etc) and she could still move her legs when the section started. YIKES!!!!!! When the OB started cutting, she clearly, loudly, and quickly told him to STOP! OB Dr. told anaest to "give her some drugs"... and she said they gave her Ketamine. She was moaning the whole time, on the verge of consciousness....C-section continued.... and bada-bing-bada-boom....we got a health boy (but they did have to use forceps to get him out... forceps and a C-section..?????? Another post.... anyway, he was only 6lb, 8oz, and healthy but a little bruised).

    So, that little story scared the pants off me as far as having another C-section.

    Ok, and since the experts are reading this... I have a question about C-section medications..... After my girl was born via section 6 years ago, I yelled at my hubby to "check her armband before she leaves this room"... sorry folks, not trying to offend anyone, but have worked in hospitals TOO LONG... want MY baby banded with MY NAME....

    so, anyway... after that, the MDA gave me versed... WHY? Baby was out... they were closing..... why give me versed? Is that standard? I don't remember anything from hearing my girl cry until about 8 hours later... Did they just do that to shut me up? (is ok with me ... if that is the case... I am just curious if you put moms out to let them rest or make them shut-up:chuckle when they are like me)..

    one more thing...prior to deciding to section me... while I was trying to push... (mind you, they made me push for almost 3 hours)... my MDA told my OB that he could not get rid of my pain... he had "given me 3 delivery doses" through the epidural....then we whirled off to C-section land... which I was grateful for. What is a delivery dose and is it unusual to give 3? Lots of fun with that baby.... had siezures after I delivered.. wanted to start me on phenytoin (? I think), ended up getting lasix for fluid, BP was 200/110..Hgb dropped to 6.1 and I refused transfusion,.... etc. etc.etc......

    Thanks for the replys. I am still not sure another baby is in my future, especially when I read stories like "I could feel the cutting of the section".
    Last edit by eph432girl on Jul 11, '04
  2. by   Passin' Gas
    [QUOTE=eph432girl]My best friend (who is an ER nurse) had a C-section last week. She has had many surg on her spine (rods and fusions). She was scheduled to be under general with the section, but she had been pukin all week and her K+ was only 2.3.... so... would not do general for fear of arrthymias. She said that they started her spinal "high" because her abnormal back anatomy (rods, etc) and she could still move her legs when the section started. YIKES!!!!!! When the OB started cutting, she clearly, loudly, and quickly told him to STOP! OB Dr. told anaest to "give her some drugs"... and she said they gave her Ketamine. She was moaning the whole time, on the verge of consciousness....C-section continued.... and bada-bing-bada-boom....we got a health boy (but they did have to use forceps to get him out... forceps and a C-section..?????? Another post.... anyway, he was only 6lb, 8oz, and healthy but a little bruised).

    [font=Tahoma]First, depending on the situation, a round of K+ to bring up the potassium would be my first choice. If it was more emergent than the time to run in K+, then the SAB (subarachnoid block, aka spinal) would be second choice. I'm Monday quarterbacking here but they may have not let her sit up long enough to allow the local anesthetic to float down the spinal column and coat the lower nerves that innervate the abdomen.


    so, anyway... after that, the MDA gave me versed... WHY? Baby was out... they were closing..... why give me versed? Is that standard? I don't remember anything from hearing my girl cry until about 8 hours later... Did they just do that to shut me up? (is ok with me ... if that is the case... I am just curious if you put moms out to let them rest or make them shut-up:chuckle when they are like me)..

    [font=Tahoma]I offer moms the option of a 'little something to take the edge off' after delivery. She gets to count fingers and toes, hugs and kisses, photo ops done, baby out. Now, the surgeon is closing, focus is back on herself. It's a weird feeling to have your torso on down numb, can't move, might have some funny sensations, yeah, a little Versed helps ease things.


    one more thing...prior to deciding to section me... while I was trying to push... (mind you, they made me push for almost 3 hours)... my MDA told my OB that he could not get rid of my pain... he had "given me 3 delivery doses" through the epidural....then we whirled off to C-section land... which I was grateful for. What is a delivery dose and is it unusual to give 3?

    [font=Tahoma]There's a delicate balance between sensory block (blocking pain) and motor block (blocking the ability of the muscles to move). With a labor epidural, we use lower concentrations of local anesthetic, sometimes even just an opioid e.g. fentanyl for pain control. We want to leave muscles able to function...helps when baby is descending down birth canal and definitely when it's time to push. When women get dilated to 8-9 cm, that's more stretching of the tissue, epidurals don't work quite as well for that type of pain at lower concentrations. Plus in early labor, lumbar nerves are transmitting uterine pain, so those need to be blocked. Later in labor, as the baby moves down, the sacral nerves need to be blocked. So a 'top up' dose or 'delivery dose' can be several things. Simply more volume to fill up the epidural space and 'cover' the sacral nerves, it may be a higher concentration to get a 'denser' or more sensory block, it may include opioids plus more local anesthetic to cover the pain. It's basically dealer's choice and definitely depends on the situation as to what is used for a 'delivery dose'. My educated guess is you were experiencing CPD, cephalopelvic disproportion, and the baby was not descending.

    PG
    Last edit by Passin' Gas on Jul 11, '04 : Reason: clarification of my replies
  3. by   Audreyfay
    Someone posted earlier about a special on TLC about anesthesia awareness. I continue to look for it, but have not seen it run again.

    There is another thread about just this in the CRNA section:

    http://allnurses.com/forums/showthread.php?t=67058
  4. by   eph432girl
    Passingas....


    Thanks for taking the time to reply and explain in detail.... I hope to one day be able to explain for others as you have done for me....(am off to take the NET today, so I have a long way to go ... but CRNA is the goal).

    Bless you,
    Christine
  5. by   jwk
    Quote from eph432girl
    My best friend (who is an ER nurse) had a C-section last week. She has had many surg on her spine (rods and fusions). She was scheduled to be under general with the section, but she had been pukin all week and her K+ was only 2.3.... so... would not do general for fear of arrthymias. She said that they started her spinal "high" because her abnormal back anatomy (rods, etc) and she could still move her legs when the section started. YIKES!!!!!! When the OB started cutting, she clearly, loudly, and quickly told him to STOP! OB Dr. told anaest to "give her some drugs"... and she said they gave her Ketamine. She was moaning the whole time, on the verge of consciousness....C-section continued.... and bada-bing-bada-boom....we got a health boy (but they did have to use forceps to get him out... forceps and a C-section..?????? Another post.... anyway, he was only 6lb, 8oz, and healthy but a little bruised).

    So, that little story scared the pants off me as far as having another C-section.

    Ok, and since the experts are reading this... I have a question about C-section medications..... After my girl was born via section 6 years ago, I yelled at my hubby to "check her armband before she leaves this room"... sorry folks, not trying to offend anyone, but have worked in hospitals TOO LONG... want MY baby banded with MY NAME....

    so, anyway... after that, the MDA gave me versed... WHY? Baby was out... they were closing..... why give me versed? Is that standard? I don't remember anything from hearing my girl cry until about 8 hours later... Did they just do that to shut me up? (is ok with me ... if that is the case... I am just curious if you put moms out to let them rest or make them shut-up:chuckle when they are like me)..

    one more thing...prior to deciding to section me... while I was trying to push... (mind you, they made me push for almost 3 hours)... my MDA told my OB that he could not get rid of my pain... he had "given me 3 delivery doses" through the epidural....then we whirled off to C-section land... which I was grateful for. What is a delivery dose and is it unusual to give 3? Lots of fun with that baby.... had siezures after I delivered.. wanted to start me on phenytoin (? I think), ended up getting lasix for fluid, BP was 200/110..Hgb dropped to 6.1 and I refused transfusion,.... etc. etc.etc......

    Thanks for the replys. I am still not sure another baby is in my future, especially when I read stories like "I could feel the cutting of the section".
    Our hospital / anesthesia group does 17,000 (yes, seventeen thousand) deliveries a year, roughly 25-30% of those are C-Sections.

    SAB or epidural in a patient with extensive spinal instrumentation is not a good choice. There's too much anatomic variation / disruption to think that this would work well.

    If this was a "scheduled" C-Section, it should have been delayed. Giving KCl this late might make your lab values better, but does nothing for intra-cellular K+, so is near worthless at this point.

    It sounds a little like your friend may have had a "patchy" block - Ketamine probably would not be sufficient by itself, plus the surgeon's would be screaming about inadequate relaxation. We probably would have done a general from the start, scheduled, urgent, or emergent. For the scheduled C/S only, we MIGHT have tried an epidural (not SAB) just to see if we could get an adequate block, with general as a backup. Running people "on the edge" with poor block and trying to make up for it with sedation is a very dangerous technique. Again, a general would have been a better option.

    Forceps are not used often on C-Sections, but we see it occasionally. I think it happens more often with surgeons who insist on making a ridiculously small "cosmetic" incision, and then struggle for ten minutes getting the baby out after the uterine incision has been made.

    Valium is a better choice than Versed. Versed has a retrograde as well as an antegrade amnestic effect, whereas Valium tends to be just antegrade. Moms can see the baby and remember the experience, then get Valium and snooze. An even better choice, at least initially, is some Fentanyl IV. A lot of moms get a little squirmy with all the tugging and pulling - discomfort, but not necessarily sharp pain. Fentanyl takes the edge off with no amnestic effects. I rarely need to use anything besides that.

    If your MDA gave you three "delivery doses", he was foolish. What he did was give you a toxic level of local anesthetic, which might have contributed to your seizures. If he truly gave you three delivery doses while you were pushing, you should have 1) gotten very comfortable and 2) probably were unable to push. If you didn't get comfortable after the first, what he should have done is reposition or REPLACE the epidural. I might give a second bolus injection AFTER repositioning the epidural catheter, but would never give a third.

    You didn't mention it, but it sounds like you were at least pre-eclamptic, so your seizures may have been from that. Was that ever discussed with you?
    Last edit by jwk on Jul 12, '04
  6. by   Jill1215
    I watched a show on the discovery health channel once called Anesthesia Gone Wrong. It said there are 75,000 cases of this per year. There were interviews with multiple victims, one of which had knee replacement surgery feeling EVERYTHING! There is a book about this called Silent Scream. I think this is the scariest thing I have ever heard about. When I watched the discovery show it really unnerved me.
  7. by   jwk
    Quote from Jill1215
    I watched a show on the discovery health channel once called Anesthesia Gone Wrong. It said there are 75,000 cases of this per year. There were interviews with multiple victims, one of which had knee replacement surgery feeling EVERYTHING! There is a book about this called Silent Scream. I think this is the scariest thing I have ever heard about. When I watched the discovery show it really unnerved me.
    Please understand that this is a VERY RARE event. Much of this "problem" is stirred up by the manufacturers of "awareness monitors" in order to sell more of their product. Their sales tactics and questionable research are well-known in our specialty. In a recent Letter to the Editor in the ASA Newsletter, a writer suggested that if a certain anesthesiologist who is well known as a proponent of awareness monitors had a 0.5% incidence of awareness in his patients, perhaps he should learn a different anesthetic technique.

    What's really scary is the false sense of security that these monitors give to both the public and anesthesia providers. These monitors can falsely show a patient to be deeply anesthetized when in fact they are wide awake. What good is that?

    Every time a TV show or magazine runs a piece about anesthesia mishaps, it takes months for us to undo the PR damage they have caused. It simply is not the horrendous problem that it is made out to be.
  8. by   Audreyfay
    I find it interesting how every profession has some untrue horror stories about some part of their function. The media is something else. Sensationalism. Still, it scares the heck out of me! :imbar
  9. by   loisane
    Quote from Jill1215
    I watched a show on the discovery health channel once called Anesthesia Gone Wrong. It said there are 75,000 cases of this per year. There were interviews with multiple victims, one of which had knee replacement surgery feeling EVERYTHING! There is a book about this called Silent Scream. I think this is the scariest thing I have ever heard about. When I watched the discovery show it really unnerved me.
    Many people feel these numbers are grossly inflated. The people who sell the brainwave machines have a vested interest in this.

    Here is a source, that includes a review of the current stats on this complication. Remember, it varies with patient population (trauma, OB, cardiac). The best overall estimate is 0.1-0.2% of general anesthetics.

    Sigalovsky N. 2003. Awareness under general anesthesia. AANA J. 2003 Oct;71(5):373-9.


    loisane crna
  10. by   Passin' Gas
    [QUOTE=jwk]
    Valium is a better choice than Versed. Versed has a retrograde as well as an antegrade amnestic effect, whereas Valium tends to be just antegrade. Moms can see the baby and remember the experience, then get Valium and snooze. An even better choice, at least initially, is some Fentanyl IV. A lot of moms get a little squirmy with all the tugging and pulling - discomfort, but not necessarily sharp pain. Fentanyl takes the edge off with no amnestic effects. I rarely need to use anything besides that.

    QUOTE]

    The research doesn't support reliable retrograde amnesia with either agent.

    1: J Clin Anesth. 2004 May;16(3):177-83.

    Preoperative intravenous midazolam: benefits beyond anxiolysis.
    Bauer KP, Dom PM, Ramirez AM, O'Flaherty JE.
    Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA.

    STUDY OBJECTIVE: To evaluate the effect of midazolam on the global perioperative experience, including patient satisfaction, postoperative nausea and vomiting, postoperative pain, and perioperative anxiety and amnesia. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: Ambulatory surgical center affiliated with a tertiary-care hospital. PATIENTS: 88 ASA physical status I, II, and III patients scheduled for outpatient surgery. INTERVENTIONS: Patients were randomized into two groups to receive either 0.04 mg/kg of midazolam or placebo intravenously (IV) 20 minutes preoperatively. MEASUREMENTS: Perioperative measurements included blood pressure, heart rate, and oxygen saturation and the patient's level of anxiety; type of anesthetic administered; the anesthesiologist's guess at the treatment arm; perioperative dosages of fentanyl, morphine, and ondansetron; recovery room length of stay; frequency of nausea and vomiting, and level of postoperative pain in the 24 hours after surgery; the patient's overall satisfaction with the anesthetic, and whether the patient would recommend the premedication to a friend. MAIN RESULTS: Patient demographics, type of surgery/anesthesia, vital signs, case duration, recovery duration, and postoperative pain were all similar between the midazolam and placebo groups. As expected, IV midazolam was an effective anxiolytic. There was no evidence of retrograde amnesia. Fewer patients in the midazolam group suffered from postoperative nausea than did those in the placebo group (25%vs. 50%;p = 0.03), despite receiving similar perioperative antiemetic and opioid administration. Similarly, fewer patients in the midazolam group experienced postoperative vomiting than placebo group patients (8%vs. 21%), although this difference did not reach statistical significance. Only 42% of patients in the placebo group would recommend their premedication to a friend, compared with 85% of patients in the midazolam group (p < 0.001). CONCLUSIONS: In addition to the known anxiolytic effects of midazolam, midazolam premedication is an effective way to reduce the frequency of postoperative nausea, and perhaps vomiting, and increase patient satisfaction.


    Masui. 1999 Jan;48(1):73-5.
    The effect of midazolam on the memory during cesarean section and the modulation by flumazenil
    Takano M, Takano Y, Sato I.
    Department of Anesthesiology, Koshigaya Hospital, Dokkyo University, School of Medicine.

    In 30 patients (ASA-1) for elective Cesarean section who had given informed consent, characteristics of amnesia induced by midazolam (M) and their modulation by flumazenil (F) were examined. Spinal anesthesia was performed with dibucaine. After the delivery, the baby was shown to the mother. Then 21 patients were given bolus intravenous injection of M until the patient got into sleep and the inhalation of nitrous oxide mixed with oxygen was started. At the end of surgery bolus injection of F 0.1 mg was cumulatively repeated until the patient awoke. Nine patients were given only nitrous oxide and oxygen inhalation after the delivery. The remembrance of the baby face and the doses of M and F were compared. In group given M, 14 patients recalled their baby's face whereas 7 did not. The average doses of M and F in patients with memory were 69 micrograms.kg-1 and 2.5 micrograms.kg-1, respectively, whereas the average dose of M and F in patients without memory were 94 micrograms.kg-1 and 4.2 micrograms.kg-1, respectively. In the patients without M injection, all could recall the face of the baby. These results suggest that M could produce retrograde amnesia, when combined with nitrous oxide inhalation, which is not reversed by F.


    Does midazolam cause retrograde amnesia, and can that amnesia be reversed by flumazenil? Emphasis that this is a Case report
    http://www.anesthesia-analgesia.org/...print/85/1/211




    Anesthesiology. 1993 Jan;78(1):51-5.
    Midazolam enhances anterograde but not retrograde amnesia in pediatric patients.
    Twersky RS, Hartung J, Berger BJ, McClain J, Beaton C.
    Long Island College Hospital, Ambulatory Surgical Unit, Brooklyn, New York.

    BACKGROUND: Midazolam sedation has been shown to diminish recall of one to four cards shown prior to induction of general anesthesia in pediatric patients. This promising but limited finding prompted us to investigate the effect of midazolam sedation on retrograde and anterograde recall and recognition in children scheduled for elective surgery. METHODS: Forty patients aged 4-10 yr were randomized using a double-blind study design to receive either 0.2 mg/kg intranasal midazolam or 0.2 ml/5 kg placebo (distilled water) using a Devilbiss #286 atomizer. To assess postoperative memory of preoperative events, recall and recognition tasks were performed using a series of picture cards designed for this purpose. Retrograde amnesia was measured by postoperative recall and recognition of cards shown prior to midazolam/placebo administration, and anterograde amnesia was measured by postoperative recall and recognition of cards shown during the interval between midazolam/placebo administration and induction of general anesthesia. RESULTS: Compared to placebo, the midazolam group experienced a significant postoperative reduction in ability to both recall (P < .003) and recognize (P < .001) cards shown subsequent to midazolam/placebo administration (anterograde amnesia). In distinction, there was no difference between groups in postoperative ability to recall or recognize cards shown prior to midazolam/placebo administration (retrograde amnesia). CONCLUSIONS: These results support and extend the inference that midazolam diminishes anterograde recall. In addition, our findings indicate that midazolam diminishes anterograde recognition, thereby providing partial anterograde amnesia without affecting retrograde memory in pediatric patients.



    Mil Med. 1999 Jun;164(6):442-3.

    A fugue-like state associated with diazepam use.
    Simmer ED.
    Second Marine Division, Camp Lejeune, NC 28542, USA.

    Diazepam is a long-acting benzodiazepine. Although diazepam is commonly associated with a variety of side effects, it is generally not believed to cause fugue-like states or retrograde amnesia. This report presents the case of an active duty patient who developed a brief fugue-like state with retrograde amnesia. This was associated with the short-term oral use of diazepam. There was no other apparent cause for his symptoms, which resolved within 24 hours after the diazepam was discontinued. This case suggests that short-term use of diazepam can lead to a brief fugue-like state with retrograde amnesia that has not been reported previously.
    Publication Types: Case Reports

    1: Psychopharmacol Ser. 1988;6:146-65. (old article)

    Benzodiazepine-induced amnesia and anaesthetic practice: a review.
    O'Boyle CA.
    Department of Psychology, Royal College of Surgeons in Ireland, Dublin.

    Anaesthetic practice is the only clinical context in which amnesia is a valued property of benzodiazepine drugs, since decreased recall considerably enhances patient tolerance and acceptance or surgical and diagnostic procedures. Research on the amnesic effects of diazepam, midazolam, lorazepam and flunitrazepam, administered via oral, i.v. or i.m. routes to patients undergoing surgical or diagnostic procedures is reviewed. The degree of anterograde amnesia is a function of the drug, the route of administration and the population of patients being assessed. Retrograde amnesia has not been conclusively demonstrated. Amnesia is more profound for cutaneous-tactile and auditory than for visual stimuli, but actual surgical events, or emotionally laden material, are more likely to be recalled than artificial stimuli. Evidence that the benzodiazepines prevent affective and cognitive processing under general anaesthesia and decrease traumatic postoperative recall of intra-operative events is reviewed. The explanatory value of modern theories of memory for research on benzodiazepine-induced amnesia, and the research potential of the surgical setting are outlined. The development of non-sedative anxiolytics and specific benzodiazepine antagonists provides the tools for assessing the contribution of sedative and anxiolytic properties of drugs to their amnesic effects.
  11. by   eph432girl
    You didn't mention it, but it sounds like you were at least pre-eclamptic, so your seizures may have been from that. Was that ever discussed with you?[/QUOTE]

    yes - more like eclamptic. I was on bed rest for last 4 weeks, admitted for NST and 24hr prot/ccl the week before I delivered. I TOLD MY OB during my routing prenatal visits that my H&H was dropping and he finally started listening to me when I hit 8gm around my 7th month (and then yelled at me saying that I could not afford to lose any blood volume -- I even brought him printouts from my lab!!!!!!). BPs were through the roof and I always had 3+ protein on dip urines. (BP is now and has always been about 90/65).This was my first (and only) child, so they started my induction Friday afternoon with Cervadil. Pitocin started Saturday morning and ran ALL DANG DAY and through the night.:angryfire I got SOOO excited when membranes ruptured thinking that they would not let me labor more than 24 hours with ruptured membranes due to increased risk of infection for me and baby.... but NO... learned that was what ANCEF was for... 32 hours later finally get a section!!!! They did not give me Mg++ to prevent seizures b/c they were trying to get my labor going... Seizures post delivery and the TONS of water retention (hence Lasix - 3-4+ pitting edema) were from being eclamptic. Day 6 of hosital stay, OB Dr.got genius idea to make NEURO come check me before discharge (I think to pass the buck.... make someone else sign off when in all actuality, seizures were from eclampsia.... i know... CYA).
    I am in no way bashing the MDA -- I am grateful to him because he got rid of a LOT of the pain and HE "convinced" OB to do a section...i am just very leary of ever doing it again:chuckle ... ok... scared to death, but I want another despite everything.....

    thanks for the explanations twk

    Christine
  12. by   jwk
    Quote from Passin' Gas
    The research doesn't support reliable retrograde amnesia with either agent.
    Thanks for the literature review.

    In my experience, there is a higher incidence of retrograde amnesia with Versed than there is Valium. We have far fewer complaints when Valium is used. As I said in my other post, I prefer not to use either one anyway - I'd rather use fentanyl. I save the Valium for those patients who aren't really hurting but just can't seem to get settled down.

    Then there's always Ketamine - it's a great drug when you've gone through the fentanyl and valium and your patient still has poly-lordy syndrome (oh lordy, lordy, lordy).
  13. by   cnyrn
    I could feel the ob suturing me after the last c-section, could feel the yanking and tugging, not exactly pain but pressure and pulling (had a spinal) very disturbing.

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