Anesthesia for HALO placement.

Tweety, BSN, RN · Sep 2, 2007

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.

Electric · Sep 4, 2007

Had a patient the other day that required a HALO application related to a C2 nondisplaced fracture. The patient was a 16 yr old female. The Neuro Surgeon rounded with his nurse and she was responsible for the conscious sedation. Some dose of morphine and versed was used along with the local injection of Lido with epi.
The patient screamed and writhed in agony. Her heart rate reached 135 and she reported that she remembered the entire procedure. She described the feeling of the pins penetrating her skull.
Is it just me or does this just not sound right to you. I wrote it up.
What are your thoughts?

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 piss people off and make things a bit more difficult for everyone. Unless it is totally warranted of course.

GeminiTwinRN, BSN · Sep 4, 2007

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.

:)

GmanRN · Sep 5, 2007

Thanks for all of the replies. There is new pain literature coming out that includes emotional responses to stimuli as well as physical. I think that if someone is having a horrific experience during a procedure, and we have the abilitiy to make the situation better (which we absolutely do), then we should.

In my facility writing up isnt necessarily a bad thing. Its a way to bring change and to focus on problem areas. It gets many departments involved in looking at a potential or actual event. Its very much a learning and awareness tool and not so much a disciplinary process. Its a way to bring positive change and make procedures better for patients. After all part of my role is to advocate.

I agree that anesthesia should have been used with my patient. I understand that they cant always be readily available. With a little forethought and planning I think we could have done a better job for this girl. Its not a person's fault or wrong doing if they respond to a situation in a way that we dont think is appropriate. Really its the same thing as assessing someones physical pain as something other as they report it.

My two cents.

smileyRn96 · Sep 5, 2007

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

NeuroICURN · Sep 8, 2007

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.

GmanRN · Sep 8, 2007

Ok..im convinced that USUALLY the standard sedation works, but what do we do in those cases when they dont? Im not sure that being complacent when we have an atypical occurrence is the right thing to do. Sort of shrugging it off as being the patients fault or all about the drama doesnt quite seem to be correct. Some people may need a little more. What do you do then? Especially when the Neurosurgeon is in a hurry and just wants to get it done.

paindoc · Sep 9, 2007

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.

foraneman · Sep 17, 2007

...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.

foraneman · Oct 22, 2007

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 · Oct 22, 2007

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??? :bugeyes: