Less than optimum anesthesia?

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Here's a scenario that took place recently in the unit I work in....

Patient "X" has a condition that requires daily debridements in the OR. X goes to the OR for a debridement and wound vac placement. Surgery goes fine but my question is with the anesthesia. Patient was on morphine and versed drips prior to surgery and said drips were shut off just prior to rolling out to surgery. Patient is easily roused and responds appropriately on these drips, just enough to keep X comfortable. X is 38 years old with near normal liver function, diabetic and has renal impairment. If it matters X is also grossly obese.

In surgery Sev is started at 1.5% initially, patient is also given 10mg of Vec. about 15 minutes later Sev is decreased to 1.2 and another 10mg of Vec is given. Approximately 15 minutes later Sev is decreased to 1.0 and remains at 1.0 until finishing. According to the flowsheet at the about the same time the Sev was turned down to 1.0 the patient's heart rate increased by about 20 beats per minute and his blood pressure sharply trended up and when we received X back in our unit his heart rate was about 110, up from 80's, BP 220's/110's, his norm being 140's/70's. He received not one drop of narcotic nor any sedative/hypnotic of any kind during surgery. After we received X we promptly restared the drips and he received a 10mg bolus of Morphine and he eventually returned to baseline after about 30 minutes.

I got this in report, all second hand from the previous shift, and was quite disturbed by the whole scenario. I ended up filing an incident report after talking to my charge nurse, nursing supervisor and our trauma resident who were also disturbed by the situation.

Did we blow this out of proportion? Did we miss something in regards to anesthesia?

Any feedback and education would be appreciated.

Donn C.

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I am looking at this from strictly a nursing process point-of-view. My only question is, did the patient say anything about the situation or was the amn. effect of versed effective regarding the incident. If you had to go solely by the vitals and flow sheets, I probably would have come up with the same conclusion as you did.

I don't know where I would go with it, though.

I'm interested to hear the CRNAs' thoughts here.

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I'm wondering what Sev & Vec are. Maybe they're drugs known to me by another name.

Questions... 1) Was an anesthesia service utilized or was this a "conscious sedation" anesthesia? 2) What patient position was required for exposure of the debrided tissue? 3) What did the physician's post-op note say regarding possible causes of VS changes? 4) Was X in PACU post-op or returned to room from OR?

There are a few blanks to consider for an OR nurse to comment regarding your scenario.

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Sev= Sevoflurane - Inhalation anesthetic

Vec= Vecuronium - non-depolarizing neuromuscular blocking agent.

It sounds like the patient may have been a little "light" but there are other things that can cause changes in V/S during surgery (catecholamines etc).

Also, was N20 also running with the sevo? There is an additive effect when N2O is added to the other inhalation agents. You also mention no sedative/hypnotic but that's what inhalation anesthetics are! Patients getting gas do not always need a benzo and many do not get any. Sounds like the patient should have had some Fentanyl and I am surprised that none was given.

That said, I will defer to more exerienced providers for a more in-depth and knowledgable response.

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I'm wondering how long the Surgery/ Wound Debriedment was?

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Was this patient all ready intubated in ICU? Look at the half lives of versed and morphine, especially in drip form. The patient also has renal impairment.

I wouldn't think a sedative hypnotic is necessary if the patient was all ready on a versed drip in the ICU.

Yes, I think the patient could have been returned in a better fashion. If I remember correctly, the vital signs were still high normal in the OR. Only when the patient was brought back to the ICU did the vitals go up. Just moving a big person to the OR table to the patients bed can cause a sympathetic response. Most diabetics have autonomic dysfunction, so HR and BP can be very unpredictable.

Maybe the anesthesia provider figured that the pt. all ready had a narcotic and hypnotic on board via the drips in ICU, and felt a muscle relaxant(no movement) and a volatile agent to keep them unconscious was all that was needed. A less is more approach, since the patient is not exactly doing very well. A nice bolus of fentanyl could have probably smoothed things out.

jim, CRNA

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My first comment is--I am so happy that I don't work in a situation where incident reports are used. Particularly incident reports on clinical issues where the party completing it has little knowledge of anesthesia.

That being said, there are several factors that could have been in play here. Obesity, daily anesthetics, what other agents were used--eg. nitrous oxide, local anesthetics, other narcotics. In anesthesia, most of us like to titrate our own drugs according to the patient's response to surgery. This is different than what is done in the ICU. Maybe some recent ICU nurses who are now in anesthesia can elaborate further on this.

I am going to assume your question is based upon your concern for the patient, but I must caution you from second guessing the anesthetist. I have reviewed many anesthesia lawsuits and can tell you that there is more to an anesthetic than what is on the record.

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Don't know nuthin' about the anesthesia, but am curious about what condition requires daily debridement in the OR. An infected wound, or something more exotic?

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Specializes in CRNA, ICU,ER,Cathlab, PACU.

interesting about the morphine gtt in a renal impaired patient. active metabolite of ms...morphine6glucuronide can accumulate in renal impairment. maybe the anesthesia provider thought they had more time since he was loaded up already in the unit. it sounds to me like the incident was handled well...based on the assessment of the patient on arrival to you...just be leary with the ms..especially in gtt form on renal patients.

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My first comment is--I am so happy that I don't work in a situation where incident reports are used. Particularly incident reports on clinical issues where the party completing it has little knowledge of anesthesia.

Amen.

The incident report in this case was inappropriate. If it stated anything besides the facts (opinions for example, which I would suspect it did) then it was even more inappropriate. And the only facts are 1) a change in vital signs and 2) that the drips were stopped for the procedure. Anything other than that is speculation and opinion, which have no place in an incident report.

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I got this in report, all second hand from the previous shift, and was quite disturbed by the whole scenario. I ended up filing an incident report after talking to my charge nurse, nursing supervisor and our trauma resident who were also disturbed by the situation.

why are you filing an incident report based all on second hand info and your perception of what you think happened. grossly inappropriate.

the first order of business would be to find the anesthetist and discuss the case management.

1 you might learn something

2 extenuating circumstances your not aware of may be revealed.

3 you only mentioned vec and sevo. were any other meds given? pressors, beta blockers.

4 any intraoperative complications.

5 any transport issues.

6 what was being debrided.

there are too many holes in your description to even try to begin a discussion. while not trying to cover the anesthetists orifice, your argument is lacking alot of information.

d

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the increase in BP and HR could have been due to the anticholinesterase and anticholinergic cocktail given for reversal and may in fact have nothing to do with the patients comfort level....

from what you said it looks like the versed/morphine gtt was d/ced "just prior to goint to the OR..." in this case only a low MAC of sevo would be needed and perhaps the anesthesia provider was better informed about the side effects of a morphine gtt in a renal impaired patient and thus decided not to further worsen the renal issue.

another valid point would be...you said the patient was "obese"...as an anesthesia student and possible even when i am a provider...i would carefully use these meds in an obese person who more than likely has sleep apnea and is more than likely difficult to ventilate and intubate ....

if the patient has no specific "recall" i don't see what your complaint is...many become tachy and hypertensive just from emergence alone - it is a tramatic thing for the body and a predictable response...i am sure if the pressure in the OR was 220/110 as it was in your unit the patient would have received a bblocker...but that isn't the case...the patient didn't have these dramatic changes until he/she hit YOUR unit...that my friend is not anesthesia's fault.

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