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

Specialties CRNA

Published

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 ...but my point was made and the scope was withdrawn and the pt was bagged back up.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?????

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Sound totally justified to me! Way to stick up for what is right for your patient's well-being! Especially oxygen, FTLOG! A~B~C, it's easy as...:redpinkhe

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Specializes in Critical Care.

2 minute monitor delay? What is the source of that information? And even if there is a 2 minute delay, then the patient has been severely hypoxic for 2 minutes before the SpO2 even registered in the 40's on the monitor. I think you were appropriately converying the patient's risk of endangerment. The resident was getting snappy because he was probably ******** his pants.

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Specializes in Anesthesia.

Well if the resident pulled the tube out every time the sat started to drop the throat would have started to look like ground beef, and the patient would have probably bought themselves an emergency trach. I think what the resident was referring to is that the cerebral vasculature has a delay before it starts adapting to the low O2 sats. People desat in the OR all the time during intubation (especially those with heart and lung disease) and do just fine. IMHO sitting there calling out the VS repeatedly with several anesthesia residents already probably watching the patient and the monitor would be more than a little distracting and uncalled for, but then again I wasn't there so I don't know the whole story.

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Specializes in ICU, ED,.

Tell the resident to take the probe off his finger and see how long it takes to register. That statement he made was ridiculous. What good would a monitor be if it were two minutes in arrears?

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Specializes in Hospital, med-surg, hospice.

thank you for being there and a pt. advocate!:loveya:

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Specializes in Critical Care.
Well if the resident pulled the tube out every time the sat started to drop the throat would have started to look like ground beef, and the patient would have probably bought themselves an emergency trach. I think what the resident was referring to is that the cerebral vasculature has a delay before it starts adapting to the low O2 sats. People desat in the OR all the time during intubation (especially those with heart and lung disease) and do just fine. IMHO sitting there calling out the VS repeatedly with several anesthesia residents already probably watching the patient and the monitor would be more than a little distracting and uncalled for, but then again I wasn't there so I don't know the whole story.

As a CRNA, your input is definitely super helpful. Definitely agree that the more often you have to go fishing, the more inflammation will occur, not to mention the gastric distension from bagging.

I'm curious to know more about what you mean regarding the response of the cerebral vasc. to low O2. 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?

I can appreciate how VS calling would add to the stress of an already stressful situation- however, how else is the resident going to know how the patient is tolerating/not tolerating the intubation attempt? I have no idea what the other residents hanging out were contributing or not contributing either, but the patient is the nurse's responsibility, and should a bad outcome occur, the tubing resident could have easily turned it around on the RN if s/he did not update him on the pt.'s status. What are your recommendations for effectively supporting the tubing resident and conveying important information?

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Specializes in Anesthesia.
As a CRNA, your input is definitely super helpful. Definitely agree that the more often you have to go fishing, the more inflammation will occur, not to mention the gastric distension from bagging.

I'm curious to know more about what you mean regarding the response of the cerebral vasc. to low O2. 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?

I can appreciate how VS calling would add to the stress of an already stressful situation- however, how else is the resident going to know how the patient is tolerating/not tolerating the intubation attempt? I have no idea what the other residents hanging out were contributing or not contributing either, but the patient is the nurse's responsibility, and should a bad outcome occur, the tubing resident could have easily turned it around on the RN if s/he did not update him on the pt.'s status. What are your recommendations for effectively supporting the tubing resident and conveying important information?

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"

If the anesthesiology residents have taken over the airway then they have essentially taken over patient care at that point. There is very little that the resident(s) could do to blame you for anything.

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Thanks for the replys you guys.

WTBCRNA- Thanks for your input. I totally agree that for the resident intubating it would be rather irritating to hear the RN call out VS, especially in this case since it was a nerve racking case to begin with....I also had not thought about the tracheal irritation that occurs during multiple attempts. However, I was at the foot of the bed watching one resident tend to the video machine, one resident focused on cricoid pressure and the third was intubating. None of which were paying attention to the vitals, so I took that responsibility. Im pretty sure I wouldn't do it any different if I had to do it all over... Nobody in that hospital has my back...except me....and some of you guys! LOL

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Specializes in Critical Care.
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"

If the anesthesiology residents have taken over the airway then they have essentially taken over patient care at that point. There is very little that the resident(s) could do to blame you for anything.

I don't know if this specifically has been argued in court before, but just because the resident(s) are present, I don't think that absolves the RNs legal (or ethical) responsibility to the patient. Particularly if the patient suffers anoxic brain injury and the family sues- the resident could easily say that the RN failed to notify the resident attempting to tube that the patient had vital signs showing he was in extremis for a prolonged period. And if the RN tries to argue that there were other residents present who were fully aware of the VS, they could argue with reason that it is not their job, but the RN to monitor those and keep the tubing resident updated. That's just my line of reasoning for why I do think it is appropriate for the RN to call out VS, even though I can appreciate how it would add to the stress.

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It was standard practice in our ICU for either the nurse or respiratory therapist to announce the O2 Sat if it fell below say 80% and then again around 70, 60, etc. I see nothing wrong with it as long as it's done in a calm, "FYI" tone and not a "you're killing the pt" tone.

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Specializes in Anesthesia.
Thanks for the replys you guys.

WTBCRNA- Thanks for your input. I totally agree that for the resident intubating it would be rather irritating to hear the RN call out VS, especially in this case since it was a nerve racking case to begin with....I also had not thought about the tracheal irritation that occurs during multiple attempts. However, I was at the foot of the bed watching one resident tend to the video machine, one resident focused on cricoid pressure and the third was intubating. None of which were paying attention to the vitals, so I took that responsibility. Im pretty sure I wouldn't do it any different if I had to do it all over... Nobody in that hospital has my back...except me....and some of you guys! LOL

No worries even providers and physicians need to be checked once in awhile.

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