Question about desaturation during induction

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Specializes in LTAC, OR.

Hi everyone, I'm a ciculator in the OR and I was hoping to run a situation I had recently past some anesthesia professionals. I was doing a case on a 3 or 4 kilo NICU kid with some chronic lung issues with an anesthesiologist who is fresh out of fellowship. She pushes the drugs, masks the kid with an oral and nasal airway in (he doesn't look like the easiest mask ever, but he's ventilating ok), and intubates. There's a little CO2 on the capnography and minimal chest rise. The kid's sat starts dropping quickly, and pretty soon he's down to 27. The anesthesia provider is ventilating and listening for lung sounds and his sat isn't coming up AT ALL. She stands there going, "I know I'm in, the tube is foggy....maybe I should try a bigger tube..." all while she continues to listen to his chest. I know you risk trauma to the airway with reintubating and all, but I was really starting to sweat. This tiny kid hovered around 27% for at least 45 seconds. I've assisted in dozens of high-risk pediatric inductions and I've never seen a seasoned anesthesia provider let a kid stay hypoxic that long. I realize that this doc has lots of training that I don't and I should probably give her the benefit of a doubt, but I feel like I need to advocate for my patient if a newbie is in over his or her head!

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Specializes in CRNA.

A baby that size desats quick, so the baby could just desat due to a brief period of apnea but if it was down for 45 seconds that is quite a while. She could have missed the tube, mainstemed, or bronchspasmed. The rule is, if sats drop after putting the tube in, take it out and mask ventilate (you have to remember that the sat monitor lag time is arouond 60 seconds). If the HR starts to drop, you need to fix things now because the next thing-in about 15 seconds-will be a cardiac arrest. But I'm dying to know, what happened?

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Me too, what happened?????

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Specializes in LTAC, OR.

I called into a room I had just been in where I knew there was a peds high risk anesthesiologist and asked if she could please come in and make sure things where ok. I felt bad asking her to leave the patient in there, but they were in the middle of a long case and that kid was stable. By the time she came in, my anesthesiologist had re-intubated (without any bag-mask ventilation, mind you) with the next size tube and the sat was 30. The doc that came in checked tube placement and made a couple adjustments on the anesthesia machine (I don't remember if it was gas, pressure, or what), and the kiddo starting coming back up. I asked her later if I had done the right thing by calling in some back-up and explained that I really just wanted to avoid a code situation. She said, "yeah...in another couple of minutes you might have been coding him." She said that I did the right thing but next time could I please find someone in a closer room. Chances are that things would have turned out fine if I hadn't called in back-up, but my gut was saying that things weren't quite right, and I made a split-second decision. Luckily all was well in the end. :-) I sure was shaking for a few minutes after that, though...

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It's possible that the new doc saw the child's color improving and therefore knew that the sat's had already improved despite the monitor, hence no extubation

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Specializes in CRNA.

Was she using uncuffed ETs? if it had a big leak and the babies lungs are stiff she might not have been able to generate enough title volume to adequately ventilate. Sounds like the anesthesiologist responded well to you taking the iniative, and even if she hadn't I wouldn't worry too much about it. Having someone else come in when things don't look right can never be bad. The only thing is it wouldn't be good to leave just when you need to help with something.

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Specializes in LTAC, OR.

Yeah, it was an uncuffed ET and the kid had some lung problems and had come down on bi-pap. I guess I was just uncomfortable because a lot of the other staff aren't confident in this particular provider and I wasn't sure how long a baby could tolerate having a really low O2 sat.

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Specializes in Anesthesia.
Yeah, it was an uncuffed ET and the kid had some lung problems and had come down on bi-pap. I guess I was just uncomfortable because a lot of the other staff aren't confident in this particular provider and I wasn't sure how long a baby could tolerate having a really low O2 sat.

Just a thought, the patient could have derecruited all those alveoli that had been opened by the use of continuous positive pressure ventilation when they were taken off the bipap for the intubation. Then it took awhile for the alveoli to open back up and proper ventilation to resume/pulmonary shunting to stop.

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Specializes in Anesthesia; Trauma ICU.
Just a thought, the patient could have derecruited all those alveoli that had been opened by the use of continuous positive pressure ventilation when they were taken off the bipap for the intubation. Then it took awhile for the alveoli to open back up and proper ventilation to resume/pulmonary shunting to stop.

Couldn't have said it better!

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Specializes in LTAC, OR.
Just a thought, the patient could have derecruited all those alveoli that had been opened by the use of continuous positive pressure ventilation when they were taken off the bipap for the intubation. Then it took awhile for the alveoli to open back up and proper ventilation to resume/pulmonary shunting to stop.

Makes sense!

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You did the right thing, is always better to call in help and not need it. Plus you are right about being a patient advocate. I know you are used to assisting, but it is always better to have a second anesthesia provider in that situation. Just a fogging tube doesn't mean its in the lungs. I have seen a tube fog in the esophagus from insuflating the stomach. Was there etCO2? Also at the very least could have taken another laryngoscopy to visualize the tube in the cords.

Regardless, you did the right thing. I am curious, I have never worked somewhere where anesthesiologists do cases by themselves. Do you find that they are reluctant to call in help when they need it?

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Specializes in LTAC, OR.
You did the right thing, is always better to call in help and not need it. Plus you are right about being a patient advocate. I know you are used to assisting, but it is always better to have a second anesthesia provider in that situation. Just a fogging tube doesn't mean its in the lungs. I have seen a tube fog in the esophagus from insuflating the stomach. Was there etCO2? Also at the very least could have taken another laryngoscopy to visualize the tube in the cords.

Regardless, you did the right thing. I am curious, I have never worked somewhere where anesthesiologists do cases by themselves. Do you find that they are reluctant to call in help when they need it?

It's been a while now, but I'm pretty sure there was no end title CO2.

As far as anesthesiologists doing cases by themselves goes, we have a couple "cowboys" but most of them are really good about asking for help when things start to get hairy (usually when they've tried a couple blades and the bougie didn't work either). Sometimes they'll have another anesthesiologist in the room before induction if they anticipate a difficult intubation. Also a lot of times there are MD/CRNA pairings in rooms so they're doubled up anyway.

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