NA's, Please tell me this isn't common practice!

[traumaguy8]

I am an ICU RN... Scenario: Im at the bedside of a SCI patient with a halo who had hrs earlier been extubated and did not fly. 3 Anesth. residents show up for stat reintubation who all of which I knew b/c they had all previously rotated on-call through my unit (2 were 3rd yr and 1 was 2nd yr, I think). They set up a video assisted laryngoscope in preparation of a difficult tube placement. The meds were pushed and the pt was hyperoxygenated. Attempt #1- The resident at the head of the bed has a hard time finding the vocal cords and the pt begins to desat as expected. At 92 I begin to call out the pts sats and VS as any bedside RN should. As we approached mid 70's I began to call out with a more stern voice. At that point the pt began to drop rapidly and by the time I said "the patient NEEDS to be reoxygenated" the sat hit 40's. The resident tending to the video device immediately snapped back at me "THERE IS A TWO MINUTE DELAY ON THE MONITOR!" ...but my point was made and the scope was withdrawn and the pt was bagged back up. In that time I called my charge RN and told him I needed him over there ASAP. He got there, I gave a brief explanation of what happened. Attempt #2: Same issues as attempt #1 but my charge RN was calling out the VS instead. He began to "get stern" once the sat hit upper 70's and the same snappy resident barked at him " DO NOT CALL OUT ANYMORE!" Around the 60 mark, fortunately the cords were found, tube slid into place, placement verified, and pt once again being bagged back up.

First of all, I am aware that this is a difficult airway due to the halo. Second, I am aware that pts desat while being intubated. But in my (adequate) expierence, I have never seen an anesthetist let the sats approach 60 much less 40. To me, that just seems dangerous and had it not been for the bedside nurses, this pt would have probly ended up with a cerebral infarct.....Am I justified in feeling this way or stupid and this is common practice?????

[dfk, RN, CRNA]

Since I'm coming from the understanding that due to metabolic high demands (requiring 20% of C.O) and the fact that there is no O2 reserve, the brain is particularly vulnerable to hypoxia induced edema and cellular death. So from your educational background, what level of hypoxia and what length of time is considered acceptable while attempting to establish a definitive airway?

actually, you're incorrect. there is O2 reserve. it's called functional reserve capacity (FRC). in the anesthetized patient, or non-breathing and fully oxygenated patient, you burn about 3 ml/kg of oxygen per minute. so, in the 70 kg patient, you burn about 210 ml of oxygen per minute. now, the average FRC is about 2000-2500 ml, ideally full of oxygen. so, you take that number and divide by the 210, and you get anywhere from 9-12 minutes of "stress free" apnea. make sense? again, this is ideal, and not taking into account other stressors of the body. as wtbcrna stated, you have more time than one would think. the ICU is a different breed from the OR. and no matter what you've seen/experienced as an ICU RN, it pales to the CRNA and what we see on a daily basis. i'm not knocking it, i'm just saying.

[SaltyNurse]

actually, you're incorrect. there is O2 reserve. it's called functional reserve capacity (FRC). in the anesthetized patient, or non-breathing and fully oxygenated patient, you burn about 3 ml/kg of oxygen per minute. so, in the 70 kg patient, you burn about 210 ml of oxygen per minute. now, the average FRC is about 2000-2500 ml, ideally full of oxygen. so, you take that number and divide by the 210, and you get anywhere from 9-12 minutes of "stress free" apnea. make sense? again, this is ideal, and not taking into account other stressors of the body. as wtbcrna stated, you have more time than one would think. the ICU is a different breed from the OR. and no matter what you've seen/experienced as an ICU RN, it pales to the CRNA and what we see on a daily basis. i'm not knocking it, i'm just saying.

I realize my level of knowledge, as you say, pales in comparison to a CRNA. In fact, that's why I asked for clarification on the cerebral vasculature 2-minute delay that was previously referred to.

From Clinical Anesthesiology:

"If normal oxygen tension, blood flow, and glucose supply are not reestablished within 3-8 min under most conditions, ATP stores are depleted and irreversible neuronal injury begins"

The above reference did not actually address that question. Maybe you could shed some light on that subject?

What I meant by no O2 reserve in the brain by the way, is that unlike muscle tissue, it is completely dependent on the oxygen tension in the blood stream. Since that isn't continuously monitored, all you have to go by (for continuous monitoring) is the SpO2. In a planned, non-emergent case, it is possible to hyperoxygenate a patient and that buys you time to establish a definitive airway when the patient is not ventilating. The patient in the original post was compromised from the get-go, so in your opinion, does that patient really safely have that 9-12 minutes window you cited? And back to my original question, what length of time with regard to severity of hypoxia is safe? (With the understanding that SpO2 is only a reflection, not a direct measurement of oxygen tension (not to mention other factors that affect the dissociation curve).

[bread angel]

From what you told of of the situation, I have a few thoughts.

1. The more times you attempt a fiberoptic intubation, the more difficult it becomes. Blood, mucous, edema all make it more difficult. If the patient was pre-oxygenated, I would have proceeded to get the tube in.

2. Someone calling out the sat numbers is very distracting. If the audible is on the monitor, I know what the sat is without looking.

3. I am not sure you are a patient advocate when you clearly have no idea of the difficulty the anesthesia residents were having. You are not supposed to understand what they are doing, but you need to trust the difficulty of the situation.

4. It doesn't seem like the supervisor has any idea either.

5. This is not a legal case and no one should try to make it one. Frankly, I have no interest in worrying about how a judge or jury would rule when I am in a crises situation with a patient. I just do my best and believe I can always justify it.

Please don't get me wrong. I am not chastising you for trying to do what is best. But, until you become a CRNA you really have no idea what needs to be done in such a difficult situation. My nurses assist me every day with difficult intubations and know how to assist, how to make it easier for me and ultimately, what is best for the patient.

Recently, I sat with a group of SRNAs at a dinner. To a person, they said that they realize now how little they knew as critical care nurses.

[loveanesthesia]

What I meant by no O2 reserve in the brain by the way, is that unlike muscle tissue, it is completely dependent on the oxygen tension in the blood stream. Since that isn't continuously monitored, all you have to go by (for continuous monitoring) is the SpO2. In a planned, non-emergent case, it is possible to hyperoxygenate a patient and that buys you time to establish a definitive airway when the patient is not ventilating. The patient in the original post was compromised from the get-go, so in your opinion, does that patient really safely have that 9-12 minutes window you cited? And back to my original question, what length of time with regard to severity of hypoxia is safe? (With the understanding that SpO2 is only a reflection, not a direct measurement of oxygen tension (not to mention other factors that affect the dissociation curve).

Optimally you would establish the airway prior to desaturation, but this is not an optimal situation-as is often the case in anesthesia. So then you pick the best of the bad situations understanding-the SaO2 monitor does have a 1-2 minute time delay, meaning when you see a sat of 90%-that actually happened a miniute or two ago either with the sats going up or down (I've had people get excited when they are actually ventilating but the sats aren't coming back up yet because of the time delay). Also understanding the sat monitors really aren't accurate below sats of about 80% so whether it reads 60 or 40% probably isn't too relevant, it's not good either way. Three minutes with the sats below 80% is max as far as I'm concerned, but that is actually a long time when you watch the clock. When the alarms are going off, it seems forever. The 3 minutes takes into account the 2 minute time delay for a total of 5 minutes of hypoxia.

I think the residents were well aware that the patient was desaturating, unless the audible tone was not on then maybe they need the feedback. When you are trying to intubate in this situation you keep going because now you've finally found your landmarks, and it you find cords you can be done in 20 seconds. Every time you start over you are causing more trauma in the airway. It would probably be more helpful to the resident to let them know how long the patient sats have been below 80% rather than calling out 60%, 40% etc. So saying 90 seconds, 2 minutes, etc. I would find that helpful in the situation. Once they hit 80% I know they aren't getting better until I ventilate so you aren't telling me anything I don't already know.

[wondern, ASN]

I like how you explained all this and also how you said three minutes is your max with sats below 80%. Thanks for letting us know what exactly would be most helpful to you in this case, and explaining it all so respectfully, too. Thanks from a nurse friend. :tinkbll:

[SaltyNurse]

from what you told of of the situation, i have a few thoughts.

1. the more times you attempt a fiberoptic intubation, the more difficult it becomes. blood, mucous, edema all make it more difficult. (even "just nurses" know this) if the patient was pre-oxygenated, i would have proceeded to get the tube in. oh? at your facility, crnas respond to emergent difficult airways? curious.

2. someone calling out the sat numbers is very distracting. if the audible is on the monitor, i know what the sat is without looking.

yes, i agree that repetitiously calling out sats is very distracting. maybe it's just me, but i find the continous alarm ringing (especially when it goes from warning to danger! mode) to be infinitely more annoying and distracting. in fact, there is no purpose for a monitor to continue to alarm when there is someone there to monitor it and is addressing the problem. are you saying you really rely on and prefer a ringing alarm while you are sweating bullets trying to intubate?

3. i am not sure you are a patient advocate when you clearly have no idea of the difficulty the anesthesia residents were having. you are not supposed to understand what they are doing, but you need to trust the difficulty of the situation.

are you kidding me? you really don't think that it was obvious to the op that the resident that was having obvious difficulty? i think it's pretty safe to say that the op and any nurse with half a brain would "trust the difficulty of the situation". it would be inappropriate for the bedside nurse to try to dictate what equipment or technique to use, however, the bedside nurse should basically know what is going on with the patient and speak up when the patient is at risk. what would happen to patients if nurses never questioned or intervened on behalf of their patients' safety? particularly in the context of a noob doctor. we don't know if the resident in the op's situation has established good judgement, we don't know how experienced he is with emergent difficult airways. now before you even go there, i am not saying that a nurse is smarter, better, blah, blah blah than a resident.

4. it doesn't seem like the supervisor has any idea either.

5. this is not a legal case and no one should try to make it one. frankly, i have no interest in worrying about how a judge or jury would rule when i am in a crises situation with a patient. i just do my best and believe i can always justify it.

if there had been a bad outcome, you can bet there would be a lawsuit. and really? if you truly think you are safe and can always justify (to a jury, not yourself) your decisions, i dare you to cancel your liability insurance.

please don't get me wrong. i am not chastising you for trying to do what is best. but, until you become a crna you really have no idea what needs to be done in such a difficult situation. my nurses assist me every day with difficult intubations and know how to assist, how to make it easier for me and ultimately, what is best for the patient.

critical care nurses should know what to do in that situation. not to bark orders at the resident/doctor doing the procedure- but to appropriately monitor their patient and function effectively in a cooperative effort. sounds like what you're describing when you refer to your nurses. thank goodness they know what to do and they aren't even crnas (amazing). but then again, you don't need anyone to let you know the patient has been severely hypoxic for the last 5 minutes while you're on a fishing expedition because you've got the ringing alarm.

recently, i sat with a group of srnas at a dinner. to a person, they said that they realize now how little they knew as critical care nurses.

as do advanced practice nurses when they complete med school and a residency. one would hope the education amounts to something. hopefully your point here isn't to condescend to those pitifully ignorant non-crna nurses.

[loveanesthesia]

SaltyNurse,

I'm glad you spoke your mind because obviously you were offended by the post you reference. I will tell you that CRNAs do responded to emergency intubation situations in many hospitals, maybe not in your hospital, but in many others.

[bread angel]

My, my Salty Nurse, you do seem to have some issues. Yes, in my practice I am called upon to manage difficult airways, to intubate these patients and to assist others, if they need it. I can assure you that I have done more difficult intubations and airway management than you have had years in nursing.

I will not lower myself to discuss the CRNA vs. all others argument. Suffice it to say, I have been in exactly that same situation as the residents in the original post. What one needs is help, support, gentle suggestions and more help. Calling the nursing supervisor is not a way to help. Calling an anesthesia attending or a surgeon to do a tracheostomy and having a cricothroidotomy set open and ready to use would come under the category of help.

The University of Pittsburgh has a great simulator course on difficult airways, where anyone who may have to manage one, can participate in the educational experience. It would be a wonderful idea if the critical care nurses took this course, because there is nothing better than a pair of "educated hands" in a crises situation.

Your take of the law is also way off, but I have learned years ago that there is no margin in arguing with the uninformed. A good friend of mine is a CRNA, JD and teaches classes on the topic. Also, a there is an excellent blog on law by another CRNA, JD. I go to these people for my legal information, because their legal research is accurate and not based on non-legal opinions.

[Richard_Head]

Just finished browsing through this thread and my 2 cents: When an anesthesia resident is in the process of intubating a patient, who is legally responsible for the outcome of that process? The anesthesia resident. If they tell you to zip it because they are working hard, accomodate them and do so. Continuing to announce VS during a difficult airway intervention is probably not helpful. Did the patient have an adverse outcome? As someone posted the audible that accompanies SPO2 has a tone that changes with SPO2 level, any one familiar with airway instrumentation knows this and makes note of the tone. As for the physiology questions, brief periods of desaturation/apnea are generally well tolerated. As someone pointed out the FRC can be a useful O2 reserve in the apneic patient if the patient received a 100% O2 pre-ox prior to induction. I have yet to see a patient tolerate 9 min of apnea depiste what the textbooks say.

[bread angel]

I would like to add something else to this discussion. It has been my policy to give the professionals in a specialty the benefit of a doubt when they are performing their functions. I would never tell an x-ray tech how to do their setting, because this is not an area of my expertise. Even though I practice with surgeons, I respect their education enough not to offer my opinion on their surgical technique or judgment. Also, because I started anesthesia prior to the critical care requirement, I make no effort to tell those nurses how to do critical care nursing. I don't think it is too much for an anesthesia professional to expect the same in return. By the way, there are times when I miss an IV and I am pleased to give one of the nurses a chance to do it. But, when they do it, I want it taped and positioned for anesthesia purposes, because it can be a lifeline.

[ssrhythm]

Lots of great points have been expressed here. I understand your patient advocate position, and I appreciate the fact that you stood up for what you think is right. That said, read over all the comments and try to understand what each person is saying.

As far as brain vs muscle vs other tissue is concerned, yes, the brain tissue has a metabolic demand about 7 times that of other body tissue. Cerebral metabolic demand is directly related to the amount of neuronal firing and the frequency of that firing. Cerebral flow is autoregulated and is closely tied to metabolic demand and is greatly effected by PCO2 changes. I don't know what drugs were or were not pushed, but certain drugs can decrease cerebral metabolic demand. ATP production under anaerobic conditions is primarily the same in the brain or other body tissues, but because of the previously mentioned increased metabolic demand of the brain, it is not nearly as well tolerated for any significant length of time. Again, when CMRO2 > O2 supply, you get into that anaerobic production of ATP. So many variables exist that determine CMRO2 vs O2 supply that it isn't even reasonable to go into at what point that line was or would have been crossed. That said, autoregulatory mechanisms of the brain and body will put a much larger percentage of oxygenated blood into the brain at the expense of every other system in the body minus the heart when the need arises. Take all of that and stir it up in the bowl with the fact that a very difficult situation was at hand and the anesthesia resident, who has the most extensive knowledge of all that I've just described and was the one with the scope and had the most intimate knowledge of what was going on in the larynx at the time...I'd have to say that it was his/her call to make. The entire situation you described is much, much more complex than "the sat is dropping and the airway isn't in so bag the patient." The patient seemed very near the point of crossing over into the can not intubate/can not ventilate category. Focus from all supportive staff, especially your CC supervisor, should have been on preparing for an emergency circothyroidotomy and placement of an emergency tracheostomy. Assuming that three health-care professionals training in anesthesia were oblivious to the dire situation and unaware of the falling spo2 per pulse oximetry was inaccurate, and the response to that assumption was not productive. Again, I commend you for taking the actions you thought to be appropriate, but understand that helping prepare for the next step in difficult airway management would be much more helpful than implying to them that they need to manage their attempts differently by aggressively calling out the sat readings that each of them were acutely aware of. Teamwork is a great thing.

[foraneman]

The preferred technique in a patient with a Halo is awake nasal intubation. Putting this patient to sleep and paralyzing him is ill advised and, speaking of lawsuits, indefensible.