When to Contact Anesthesia

[Sirrahsim]

I am an ICU nurse who left the world of ICU and started in the PACU recently. The training was very much focused on unit specific charting and did not cover when I should report abnormal findings to anesthesia. Recently one of the anesthesiologists was laughing about a nurse (not knowing it was me) who had contacted anesthesia repeatedly related to a prolonged and continuous respiratory rate of 5 and 6. They stated "that's what PACU is for"

That brings me to the question. What parameters are appropriate to contact anesthesia for?

In the ICU I would absolutely report respiratory depression, especially if persistent and with no way to monitor ETCO2. In this case the patient was extremely somnolent and would only respond for a few seconds to physical stimuli. I contacted anesthesia 3 times at 30 minute intervals to request a small dose of narcan and was told to just keep watching because "giving narcan is so mean" 

This same provider has also ridiculed me for contacting them after a patient with a baseline heart rate of 70 suddenly started dropping down to a heart rate of 40 after being stable for an hour after reversal with neostigmine/glycopyrolate. 

Are these things normal findings in PACU that I just need to monitor as they suggest? Its unfathomable to me to think of NOT reporting these findings. 

 

[offlabel]

15 hours ago, Sirrahsim said:

That brings me to the question. What parameters are appropriate to contact anesthesia for?

For what surgery? What co-morbidities? What age? What anesthesia type? When did the surgery end?  Getting the point? For a general rule of thumb, if hemodynamically stable with an O2 sat > 92 on less than 3 lpm and you're feeling edgy about what's going on, run it by your charge nurse before calling. Wooden adherence to hard and fast parameters out of the context of the particular patient is what gets people frustrated. Sounds like you just need to gain experience and learn from others expertise. 

[NRSKarenRN, BSN, RN]

Check to see if unit policy on when to contact anesthesia exists --- trust your gut too.  Run past a charge nurse for advice: Better to call than being called on the carpet for not reporting and adverse outcome.  Fully remember 2 personal PACU experiences that nurses saved me from harm. 

Best wishes growing into this specialty. 

[subee, MSN, CRNA]

On 9/30/2022 at 12:01 AM, Sirrahsim said:

I am an ICU nurse who left the world of ICU and started in the PACU recently. The training was very much focused on unit specific charting and did not cover when I should report abnormal findings to anesthsia. Recently one of the anesthesiologists was laughing about a nurse (not knowing it was me) who had contacted anesthesia repeatedly related to a prolonged and continuous respiratory rate of 5 and 6. They stated "that's what PACU is for"

That brings me to the question. What parameters are appropriate to contact anesthesia for?

In the ICU I would absolutely report respiratory depression, especially if persistent and with no way to monitor ETCO2. In this case the patient was extremely somnolent and would only respond for a few seconds to physical stimuli. I contacted anesthesia 3 times at 30 minute intervals to request a small dose of narcan and was told to just keep watching because "giving narcan is so mean" 

This same provider has also ridiculed me for contacting them after a patient with a baseline heart rate of 70 suddenly started dropping down to a heart rate of 40 after being stable for an hour after reversal with neostigmine/glycopyrolate. 

Are these things normal findings in PACU that I just need to monitor as they suggest? Its unfathomable to me to think of NOT reporting these findings.  After ab hour and a half in PACU, most patients should be in their room or getting ready for discharge.  This person sounds like a nut and we sure attract our share of them:)(

 

That person from anesthesia is way to casual.  Maybe they don't know about "baby" narcan doses where one gives the patient a pediatric ampule of Narcan and titrate to a respiratory rate of 12.  

[offlabel]

1 hour ago, subee said:

That person from anesthesia is way to casual.  Maybe they don't know about "baby" narcan doses where one gives the patient a pediatric ampule of Narcan and titrate to a respiratory rate of 12.  

Why is 12 an important number? This is my point. Lot's of patients do just fine right out of surgery with a rate of 6-8 and will gradually come around over time without intervention. Sure, the 80 year old with CAD is not the 24 year old skier, but that is the distinction that the PACU nurses need to make.

[Sirrahsim]

How long would you let them sit that low? Even a healthy person can retain CO2 if they are hypoventilating. 

[offlabel]

1 hour ago, Sirrahsim said:

How long would you let them sit that low? Even a healthy person can retain CO2 if they are hypoventilating. 

To a healthy, non co-morbid patient, hypercarbia is harmless. It passes without any issues unless a sleepy patient in the PACU is an issue.  Pulmonary hypertension? COPD? Different story. Which ones are we talking about?

[subee, MSN, CRNA]

1 hour ago, offlabel said:

Why is 12 an important number? This is my point. Lot's of patients do just fine right out of surgery with a rate of 6-8 and will gradually come around over time without intervention. Sure, the 80 year old with CAD is not the 24 year old skier, but that is the distinction that the PACU nurses need to make.

We know the patient was  overly sedated for 90 minutes.  That's too long and would look negligent in a lawsuit.  It's sloppy practice.

[offlabel]

6 minutes ago, subee said:

We know the patient was  overly sedated for 90 minutes.  That's too long and would look negligent in a lawsuit.  It's sloppy practice.

Quite a determination for not knowing the age of the patient, the surgery, patient history, intraoperative course... But by all means, if flip chart nursing is what works, have at it...

[Sirrahsim]

 This patient with their health history and the procedure performed should have been in and out of PACU in under an hour. The patient received doses of narcotics intraop that were generous but not usually considered excessive.

[subee, MSN, CRNA]

14 hours ago, offlabel said:

Quite a determination for not knowing the age of the patient, the surgery, patient history, intraoperative course... But by all means, if flip chart nursing is what works, have at it...

It's a PACU, not an ICU or CTICU.  Whether the patient was 94 or 24, healthy or not, this is too long to have a patient this somnulent for at least the 90 minutes that we know of.

[offlabel]

19 hours ago, Sirrahsim said:

 This patient with their health history and the procedure performed should have been in and out of PACU in under an hour. The patient received doses of narcotics intraop that were generous but not usually considered excessive.

So we're back to running it by the charge nurse. From there it's a medical judgment call. Giving Narcan to a breathing patient with normal oxygenation and an open airway or not is a call the anesthesia provider gets to make, and that's OK. Doesn't mean something is wrong or someone is making a mistake. There is a lot to be said for not introducing another level of complexity by adding an intervention when all you need to do is wait. The idea that something is wrong with having a very sleepy patient in PACU occasionally is false. 

Narcan may just trade one 'problem' for another. If the patient is safe and stable, most prudent anesthesia providers will 'let sleeping dogs lie'. It was wrong and unprofessional of this person to belittle you and says a lot about the kind of person he or she is but what they decide is based on training and experience, which isn't unsubstantial.

You didn't mention the end of the story...how did it all end up?