Antacids

stevierae · Oct 24, 2003

Originally posted by Diprivan/Vented
To whomever uses Reglan: In my experience it's use almost always leads to bowl movements. Do you hate your bedside nurses?

Oh, so THAT'S the reason for so many "code browns" as the patient is waking up--always happens in the OR as we are moving patient from OR table to gurney--too bad they never wait until they get to PACU:roll

stevierae · Oct 25, 2003

Originally posted by Diprivan/Vented

About aspiration pneumonia:
Aspiration of foreign material (often the stomach contents) into the lung can be a result of disorders that affect normal swallowing, disorders of the esophagus (esophageal stricture, gastroesophageal reflux), or decreased or absent gag reflex (in unconscious, or semi-conscious individuals). Old age, dental problems, use of sedative drugs, anesthesia, coma, and excessive alcohol consumption are also causal or contributing factors. The response of the lungs depends upon the characteristics and amount of the aspirated substance. The more acidic the material, the greater the degree of lung injury, although this may not necessary lead to pneumonia.

Is the CRNA responsible for the aspiration pneumonia if the pt aspirates? I know CRNA's are responsible for the first 24 hrs, but are we responsible for treating the aspiration pneumonia? I've seen Vanc 1gm x1 ordered by MD's before along with sputum cultures x1.

The American Thoracic Society has guidelines for treatment of hospital acquired pneumoina, including aspiration pneumonia. Makes sense that aspiration pneumonia would be treated as a bacterial pneumonia. I have seen it treated with Zosyn pending cultures; Vanco instead of or along with if the hospital populatin has a high incidence or history of MRSA.

Seems to me that aspiration pneumonia in the operating room (at least during induction) is highly preventable, if cricoid pressure and other rapid-sequence precautions are followed.

I have seen it maybe only once or twice (that is, during induction; have seen a few more instances upon extubation and subsequent bronchospasm, often requiring reintubation) happen in an OR setting, and that's over 22 years of OR nursing. MUCH more common in nursing homes, either from NG aspirate or old food retained in patient's mouths.

Can't help but wonder if better oral hygiene--that is, meticulous mouth care provided by nursing staff (or CNAs) in people who cannot do their own (most of the nursing home population) would play a large part in preventing this nosocomial pneumonia.

Here's a bit of a blurb I remember pulling off the American Thoracic Society guidelines a while back while doing some research:

"Patients with hospital-acquired aspiration pneumonia may be treated with cefepime hydrochloride (Maxipime) or ceftazidime plus clindamycin or metronidazole; a beta-lactam and beta-lactamase inhibitor combination such as ampicillin and sulbactam, piperacillin sodium and tazobactam sodium (Zosyn), or ticarcillin and clavulanate potassium (Timentin); or a newer fluoroquinolone.

For patients who are allergic to penicillin, a newer fluoroquinolone or a combination of clindamycin plus aztreonam may be considered (17). Antistaphylococcal coverage should be added for patients known to have nasopharyngeal colonization with staphylococci and patients with other active staphylococcal infections.

Review of a sputum Gram stain, if available, for the presence of gram-positive cocci in clusters is helpful. Vancomycin (Vancocin, Vancoled) should be used initially for antistaphylococcal coverage in hospitals where methicillin-resistant S aureus is a concern. The American Thoracic Society guidelines on treatment of hospital-acquired pneumonia in adults (17) provide useful guidance for physicians in selecting appropriate initial antibiotic regimens. "

Ok, this is a bit off the subject, but I have always wondered: Why do we persist in using the term "MRSA?" Methcillin has not been available in the United States in at least a decade--maybe two--yet people seem to believe that "MRSA" is an infection that has been found to be resistant to Methcillin.

Why don't we use the more accurate term--"ORSA--" that is, "Oxacillin Resistant Staph Aureus?"

Maybe some hospitals do use the more accurate term--anybody? Does yours? In every facility in which I have worked as a traveler, they still use the term "MRSA."

I am willing to bet there are experienced staff--nurses and docs--who believe there is a drug out there called Methcillin, readily available should they care to prescribe it.

:eek:

Just a little pet peeve of mine.

loisane · Oct 25, 2003

Maybe they don't hammer these numbers into SRNAs heads the way they did when I was in school. If my memory is right, the thresholds numbers are----aspirates greater in volume than 25 ccs, or lower in ph than 2.5, have the greatest chance for doing the most harm if aspirated.

I don't have access to the books right at this moment, so feel free to correct these if my synapes aren't firing like they used to.

On the topic of treatment of aspiration. Pnemonia is not the worst of it for an anesthetic related aspiration. Pnemonia will develop later, after infection has had a chance to set in. The immediate results of a significant aspiration event will be pnemonitis-the inflamatory response to the chemical burn from the low pH. It does tremendous damage to the respiratory membrane, altering gas exchange, and causing poor oxygenation similar to ARDS. So the immediate treatment is intubation and support of ventilation.

This is not a subject I (thankfully) have much experience with, so my comments come strictly from (my memory of) "the book answers". Any other "old timers" are encouraged to chime in. Any SRNAs are encouraged to read, read, READ! Then share with us the current recommendations, this is the kind of stuff they test you on.

loisane crna

Diprivan/Vented · Oct 25, 2003

Originally posted by stevierae
Can't help but wonder if better oral hygiene--that is, meticulous mouth care provided by nursing staff (or CNAs) in people who cannot do their own (most of the nursing home population) would play a large part in preventing this nosocomial pneumonia.

Someone told me about a study in which patients who had meticulous oral care TID had a much lower incidence of pneumonia vs. those that didn't have it performed at all or on a less routine basis. Makes sense. The oral cavity has lots of bacteria, and if the patient is intubated, fluids tend to build up and stagnate. Prime grounds for antimicrobial growth.

As far as treatment (of just about anything), have you guys checked out emedicine.com? It's a great resource. With the appropriate skills of application, you can treat yourself for just about anything. Here's what it says about aspiration pneumonia:

http://www.emedicine.com/EMERG/topic464.htm

I wonder if appropriate body position might help prevent aspiration. Most of the times that I've seen it performed, the anesthetist will have the pt flat to semi-elevated (20), propped the shoulders up (forward) with a couple pillows and hyperextended the neck, you should still get appropriate vision of the laryngeal cords but now you'd have gravity helping to keep the aspirates down in the stomach. Of course, if you're having to do chest compressions, all bets are off.

Diprivan/Vented · Oct 25, 2003

edit: "antimicrobial" to "microbial"

stevierae · Oct 25, 2003

Originally posted by Diprivan/Vented
As far as treatment (of just about anything), have you guys checked out emedicine.com? It's a great resource. With the appropriate skills of application, you can treat yourself for just about anything. Here's what it says about aspiration pneumonia:
http://www.emedicine.com/EMERG/topic464.htm

I LOVE emedicine.com! I use it all the time for research, and recommend it to every LNC or aspiring LNC I know, and to attorneys. The articles are so easy to read and user friendly, and actually INTERESTING, as opposed to some of the really dry, boring stuff you find on medline or cinahl.

ctbsurf · Oct 25, 2003

as far as positioning... t-burg (head down) may facilitate regurgitation but it is the position of choice if vomiting has already occurred. it allows secretions to drain into the oropharynx to allow suctioning and prevent it from draining into the lungs of a patient who has lost their protective reflexes.

it has been demonstrated that approx 1% of total operative pop'ln gastric contents reach airways. this most likely occurs during induction

as already mentioned the morbidity increases if aspirate is >25cc and/or >2.5 pH (mendelson syndrome)

>Barash

g8rlimey · Oct 26, 2003

CTB:

Just to be sure, I believe you meant to write Mendelsohn's syndrome as gatric volume>25cc and pH

g8rlimey · Oct 26, 2003

CTB:

Just to be sure, I believe you meant to write Mendelsohn's syndrome as gastric volume >25cc and pH

ctbsurf · Oct 26, 2003

yes that's what I meant, good call

thank you g8r

Tenesma · Oct 29, 2003

this is a good discussion.... a few points

33% of aspirations happen at induction

33% of aspirations happen at emergence (we often forget about that one)

you don't treat aspiration pneumonias with antibiotics.... unless they become symptomatic... there is no evidence to show that prophylactically giving an antibiotic upon aspiration reduces the progression from aspiration event to full blown pneumonia... just talk to any pulmonologist or ID or ICU or Anesthesia attending... or review the literature.. The only exceptions to that rule are alcoholics, HIV, cancer patients or other immunosuppressed patients.

the standard of care upon aspiration is to clinically gauge severity of aspiration: ie, do you need to re-intubate and fiberoptically suction all the segments of the lung clean? or just provide some oxygen for a few hours and watch for a day... Most aspiration events pronounce themselves within 24-48 hours of observation (no antibiotics until they do pronounce themselves), and a decent number of them go home with a slight irritating cough for a few days.

Most aspiration events that progressed to bad pneumonia or ARDS were always in patients with many other bad components

stevierae · Oct 29, 2003

Originally posted by Tenesma
this is a good discussion.... a few points

33% of aspirations happen at induction
33% of aspirations happen at emergence (we often forget about that one)

you don't treat aspiration pneumonias with antibiotics.... unless they become symptomatic... there is no evidence to show that prophylactically giving an antibiotic upon aspiration reduces the progression from aspiration event to full blown pneumonia... just talk to any pulmonologist or ID or ICU or Anesthesia attending... or review the literature.. The only exceptions to that rule are alcoholics, HIV, cancer patients or other immunosuppressed patients.

the standard of care upon aspiration is to clinically gauge severity of aspiration: ie, do you need to re-intubate and fiberoptically suction all the segments of the lung clean? or just provide some oxygen for a few hours and watch for a day... Most aspiration events pronounce themselves within 24-48 hours of observation (no antibiotics until they do pronounce themselves), and a decent number of them go home with a slight irritating cough for a few days.

Most aspiration events that progressed to bad pneumonia or ARDS were always in patients with many other bad components

It is a really good discussion. Your comments are very insightful, Tenesma, as always.

Loisane said earlier that leaving high-risk patients--i.e. morbidly obese, sleep apnea, short neck, or all three-- intubated overnight is not standard practice.

The more I see, both in O.R. nursing practice and in cases I review as an LNC, I am really starting to think it should be.

Why not leave someone intubated overnight if the intubation has been prolonged; if the attempted intubation has proceded to a fiberoptic intubation; (which probably should have been done in the first place and probably been done awake) if the patient's stomach has filled with air because the anesthesia provider thought they had successfully intubated but, upon attempting to ventilate, found they were in the esophagus; if, during the case, the O2 sats were suboptimal, and aspiration was suspected--wouldn't leaving the patient intubated overnight be safer? Wouldn't the advantages outweigh any potential disadvantages?

I know from personal experience of 2 deaths--one on the table, when an obese male in his 20s (not even morbidly obese) with a hx of sleep apnea bronchospasmed upon extubation--the anesthesia provider was unable to reintubate; he went into full blown cardiorespiratory arrest and, despite open chest cardiac massage, died on the table after his elective surgery.

The other patient, young, morbidly obese and with a hx of sleep apnea, had a prolonged intubation; again, after the relatively short elective procedure, upon extubation, bronchospasmed and had to be reintubated; this second intubation was also difficult and prolonged. He never regained consciousness and eventually progressed to ARDS in ICU and died.

Both probably aspirated at some point; unknown as to whether during intubation or extubation--I know on the second patient his O2 sats never reached 100% throughout the case, but hovered around 95-97%--to me, that would have been a red flag, possibly indicating aspiration or improper tube placement-- but I am not an anesthesia provider. What is your opinion?

I just think these 2 deaths could have been prevented had they remained intubated ovenight and perhaps had a chance for some of their airway edema (secondary to the traumatic and prolonged multiple intubation attempts) to decrease.