Brenna's Dad 5,375 Views
Joined: Feb 7, '02;
Posts: 386 (1% Liked)
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Since no one took me up on it last year, I will offer it here....
I want to know whether keeping the endotracheal cuff pressure less than 30 cm H2O during surgery results in a decreased incidence of sore throat. Of course, you will have to control for ease of intubation, # of attempts, etc.
It appears that most Anesthesia practitioners inflate the balloon of the endotracheal tube by feel. Very few use a manometer, although this has long been the standard of care in ICU settings to prevent tracheal necrosis.
In training we were frequently called up to the ICU to place A lines in edematous impossible pts. Excellent experience!!
Although we sometimes tried the Doppler to locate the pulse, I never really felt this was helpful. US probably would have been. I thought I was somewhat proficient with the Sonosite when finding veins in the ICU before anesthesia school.
But part of me must agree with underdog. Using "the force" often seems to be the best method.
Interesting thread here. Some very good argumentd from Nitecap about BSN school and the differences in clinical experience.
However, less stress as a CRNA than an MDA.... me thinks not...
Yes, sorry 0.06mg/kg. Thank you.
First off, the drug is astramorph.
Second, although I used to push epidural narcotics back in my glory days as a med-surg nurse, knowing what I know now, I have to say it wasn't a very good idea. Just way too many potential complications.
I'm sorry, but this topic is lame and very much overdone.
If you have serious fade with tetany, it may be best to leave the tube in. In the afore mentioned case, I would probably max out my Neostigmine dose, which I consider to be 0.6 mg/kg, and then apply a little tincture of time.
As we all know, we are usually giving reversals at the end of a case and I often think in this age of "fast on-fast off" anesthetics, that we probably aren't seeing peak effect of reversals, at least according to textbook onset times, by the time we are thinking about pulling the tube. I do agree with others, if they look weak, they are weak.
In the afore mentioned case however, you are also in a bit of a quandary, since what you are seeing clinically, is not jiving with what you are seeing with your twitcher. ie. Classically, a five second head lift was considered a clinical sign of adequate reversal, the patient has adequate VTs, etc.
I would not resedate unless I planned on keeping the patient intubated for a long period of time, ie. unknown pseudocholinesterase deficiency. A good explanation of why the OETT remains in place and adequate pain relief with narcotics, with perhaps a wee bit of versed in those anxious patients is all that is needed until you are confident to extubate.
Exactly Big Dave...so what's the point?
I didn't train with the BIS, but have begun using it in my new practice. I must echo what many have said here. I just don't trust it.
I would estimate that I get erroneous readings more than 10% of the time. By erroneous, I mean the BIS just isn't reflecting what I see clinically.
It seems like too expensive a tool to 1. confirm what I think is going on clinically, or 2. for me to say, hmmm, I guess the BIS isn't working during this case.
I wonder whether BIS would accept any liablity for awareness that occurred when using their product?
I don't think the question was whether Neo caused fetal comprise, but that it decreased uterine artery blood flow.
In school, we were taught to give 5cc of LA for a 5 foot woman and then 1 cc per 2 inches of high thereafter. It wasn't long before this recipe got me into a little bit of trouble with high blocks in tall women. Nothing too serious, just low BP and having to give Ephedrine.
Nowdays, if I'm doing a pure epidural technique I will hardly ever give more than 5 or 6 cc with 100 mcg of Fentanyl. Of course, this is after the 3cc I give as a test dose.
Do you find Sufentanil provides any great pain relief? Off the top of my head, due to it's lipid solubulity it might work a little quicker.
Although I have never used Ropivicaine, I thought it was suppose to spare motor to a greater extent than Marcaine?
Seems strange that a patient would suffer a respiratory arrest after 100 mcg of Fentanyl in a Post Operative environment. It seems the real issue here was more than likely inadequately trained recovery nurses or a total lack thereof. If this was the case, Dr. Tucker should indeed be liable.
I gave the patient 15 mg of esmolol, bringing her HR back into the 130s. Ten minutes later she was again in the 180s complaining of feeling unwell, dizzy, and slightly SOB.
I was hesitant to administer a further dose of esmolol since I had learned in school that there were case reports of esmolol causing profound persistant fetal bradycardia. It's at this time that I gave the patient 1 mg of Metoprolol, which fairly quickly brought her HR into the 90s, making her previous symptoms disappear. No further episodes occurred during the C-section, the baby was delivered healthy with good apgars and a normal HR.
From the brief research I completed this previous weekend, it seems like Metoprolol might not have been the best choice since, like all extensively liver metabolized drugs, it is fat soluble and crosses the placenta easily. Propranolol has been the drug of choice in the past, since it has extensive tissue binding and therefore does not cross as readily. Another choice if available, might be Atenolol, a more water soluble drug, however, it is my understanding that IV Atenolol is not available in the US.
I was not eager to use Neosynephrine in this situation since it increases intrauterine artery resistance and therefore decreases blood flow to the placenta. The acetylcholinsterase inhibitors weren't an option to me for obvious reasons.
Open for all comments or suggestions.
Sensory block was T4. Initial pressure was 130's.
Can anyone come up with a good idea not to use Esmolol?
Pt in her early 20s had a history of "fast heart rates", not formally diagnosed by a physician. Becomes mildly symptomatic when it occurs at home... sits down until it goes away.
During c-section with SAB becomes tachycardic with HRs in the 180s. BP stable in the 110s to 120s, but pt states she is becoming dizzy and short of breath.
In my anesthesia drawer I have Esmolol, Metoprolol, and Verapamil. I also have Edrophomium and Neostigmine for those who favor a less traditional (or perhaps more traditional) approach.
Which of the afore mentioned medications would be my best bet for treating the patients tachycardia assuming vagal maneuvers had failed and why?
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