[GmanRN]

Originally Posted by paindoc

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.

Applause Applause!!!!!:spin :

[foraneman]

[quote=smileyRn96;2392658]

Originally Posted by NeuroICURN

...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

The problem is, patient's who are having a Halo placed have BROKEN NECKS. You CANNOT administer deep sedation. If you do, and you lose the airway, you now have a broken neck that needs to be intubated. Either you do an awake nasal intubation and then put the patient to sleep for the Halo (seems to defeat the whole purpose since an awake nasal intubation is arguably as uncomfortable if not more so), or you give a little of this and that, some local, and the Halo is placed.

[smileyRn96]

[quote=foraneman;2404844]

Originally Posted by smileyRn96

The problem is, patient's who are having a Halo placed have BROKEN NECKS. You CANNOT administer deep sedation. If you do, and you lose the airway, you now have a broken neck that needs to be intubated. Either you do an awake nasal intubation and then put the patient to sleep for the Halo (seems to defeat the whole purpose since an awake nasal intubation is arguably as uncomfortable if not more so), or you give a little of this and that, some local, and the Halo is placed.

For sedation in children isn't that the claim to fame of ketamine; when dosed properly it has almost no effects on their airway????? I completely understand the issues with a broken neck and loss of an airway, and why a providor would be afraid of deep sedation. If you do a literature search you will see almost no loss of airway with ketamine use, even in combination with versed. I have done the search and cannot find one. I think this would be a great topic for a thesis/dicertation to establish better guidelines for adequate procedural sedation. While doing a literature search I saw that a hospital actually started a Pediatric Sedation Unit (PSU) to provide better quality care.
-Smiley

[foraneman]

[quote=smileyRn96;2408552]

Originally Posted by foraneman

For sedation in children isn't that the claim to fame of ketamine; when dosed properly it has almost no effects on their airway????? I completely understand the issues with a broken neck and loss of an airway, and why a providor would be afraid of deep sedation. If you do a literature search you will see almost no loss of airway with ketamine use, even in combination with versed. I have done the search and cannot find one. I think this would be a great topic for a thesis/dicertation to establish better guidelines for adequate procedural sedation. While doing a literature search I saw that a hospital actually started a Pediatric Sedation Unit (PSU) to provide better quality care.
-Smiley

It may be better to characterize Ketamine as having minimal respiratory depression effects at proper sedation doses. There are some airway concerns however. Ketamine is known to increase airway secretions. And due to the risk of aspiration, it is not recommended on patients with a full stomach, which most Halo patients are considered. It is contraindicated in any patient with an accompanying significant head injury. Emergence from ketamine can be accompanied by hallucinations and exagerated body movements which can be problematic in a cervical fracture patient. Benzodiazepines can lessence emergence issues.

[foraneman]

Originally Posted by paindoc

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.

Placement of a Halo is a unique procedure with extraordinary anesthetic implications. A failed anesthetic for Halo placement is NOT a patient "freaking out". A failed anesthetic for this procedure is oversedation with loss of airway resulting in a previously unecessary oral intubation in a patient with a cervical spine fracture. Why? Because oral intubation in cervical spine fractures risks manipulation of the neck, even with precautions to minimize movement, leading to, in a certain % of patient's, permanent spinal cord injury including quadrapalegia. OR.....you can administer a little sedation with local. Guess which one patients choose when they are informed of the risks???

[GmanRN]

This is turning into a wonderful discussion.

I now understand that oversedation could have huge consequences in the application of someone with a cervical fracture. It would be dangerous due to possible chord damage if the need for intubation should occur.

I would think that a Ramsey score of 1 would reveal that this particular patient would have been considered lightly sedated. Maybe some room for at least a little more intervention from a skilled provider like one of yourselves. Too bad none of you were in the room. She could have benefited from an expert perspective.