The 10 most stressful situations in anesthesiology from an anesthesiologist’s perspective

These aren’t my own thought, however, I can easily agree with the list below.  One of the things that was left off this list was pediatric hearts.  I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience.  Teeny tiny babies.  Itty bity tubes and IVs.  The heart plumbing/circuitry was anything but normal.  I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.

Taken and shared from The Anesthesia Consultant Blog:

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

  1. Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
  1. Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
  1. An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
  1. Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
  1. Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
  1. Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
  1. Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
  1. An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
  1. Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
  1. The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.

Mr. Chill – #cardiac

CPR training
Image via Wikipedia

Today was an ordinary day.  Come in for a minimally invasive aortic valve and call it a day.  However, that case was cancelled secondary to UTI.  So, I opted to get involved in a different case…. an epicardial lead placement.  This was a gentleman I’ll refer to as Mr. Chill.  He was getting an epicardial lead placement b/c he was in heart failure and was going to undergo CRT.  He already had RA/RV leads and AICD.  He was a rather obese gentleman (280lb, 5’6″).  He had a history of amphetamine induced cardiomyopathy with an EF of 18%, inferior wall infarct and ant-sept wall infart, LV dilatation.  There was noted coronary sinus stenosis hence the need to abandon a coronary sinus lead and just go for the epicardial lead that would be placed via thoracotomy.  Aside from his heart history, he also had DM, HTN, AFib, sleep apnea (not using CPAP).  He’s on a whole host of meds… preop echo showed EF20%, severely decreased LV systolic function, hypokinesis of LV/RV, mild MR/TR, mod pulm HTN.

I met Mr. Chill in the pre-op holding area while a resident and CRNA were attempting to place PIV.  I took a look and you really can’t see anything.  So, while they were bringing the U/S, I was able to get a 22G PIV — not worthy of cardiac surgery…but worthy for induction.  A right radial a-line was placed with some difficulty (imagine poor EF…difficult to feel pulsatility anywhere).  The AICD rep was supposed to be available, but was running late so we were given the green light to go back to the OR.  The reason he earned the name Mr. Chill was b/c he was very relaxed and very interactive with us during PIV and a-line.  Every now and then he’d doze off, but then we’d say his name and he’d wake back up and interact with us.  I’m thinking that’s probably a combo of his OSA and his low flow state.

We brought him back to the OR, placed monitors on him.  The EKG appeared to be a wide complex regular sinus rhythm…someone who appeared to have a LBBB.  His a-line was reading 110-110SBP.  We were pre-oxygenating him for awhile.  Induction: lido 100mg, fentanyl 150mcg, etomidate 20mg, roc 70mg…after induction he stayed in the SBP90s.  Slowly, he started to drift down while taking over mask ventilation.  Luckily, he was an easy mask.  Now his SBP 80s, we intubate with a L DLT.  Confirmed with ETCO2.  SBP hanging in the 70s…multiple boluses of phenylephrine (total 600mcg), ephedrine (30mg), epi (100mcg) the SBP would go up to low 80s, but come back down to 70s.  We checked the DLT via FOI…it seemed a bit deep, therefore we pulled it back.  Still, we weren’t happy with it and his SBP was sagging, therefore, we took out the DLT and reintubated with an 8.0ETT.  Pt was oxygenating well as the SpO2 read 96-98%.  Then, his radial aline went to 60s. We cycled NIBP that showed 50s/20s.  Then the art line went flat.  We started CPR, 1mg EPI followed by atropine.  With CPR, the arterial trace looked good reading a pressure in the 80s.  PEA was suspect…we ran serial ABG, got femoral access.  We came out of it.  First ABG showed CO2 70s…ETCO2 was in the 40s.  We hyperventilated him and started him on an epi infusion.  The AICD rep interrogated his AICD…and we found out that the patient had 4 episodes of VT that was treated by overpacing from the AICD (not shocks).  This occurred in the pre-op area prior to going back to the OR and lasted for 35 seconds total.

We cancelled the case and took the patient to the SICU.

Things I took away from this case:

1) Always have the AICD rep interrogate prior to going to OR.  Period.  It doesn’t matter if everyone in the OR wants you to go… it’s worth waiting.  Obviously, Mr. Chill didn’t show any signs of VT to us b/c we were with him in the pre-op area.  There were no shocks delivered from the AICD.  Had I known he had 4 consecutive VT episodes that were worthy of AICD treatment via pacing, I’d have cancelled the case prior to going back to the OR.  Done!

2)  With an EF hanging around 10%, this guy is probably living off his sympathetic tone.  Do NOT give fentanyl, even if you think he may get tachycardic from the intubation.  Give it as it’s needed…even though it’s “cardiac stable”.  No one is stable with an EF10%.  The last thing I want to do is decrease any tone that may be supporting him. (Sure, maybe it’s a placebo for me… so be it!)

3) This guy’s PEA was most likely caused by hypercarbia.  He had a history of OSA and would intermittently fall asleep in the pre-op holding area… he may have been hypoventilating.  We didn’t see it on the ETCO2 trace while masking him b/c he probably has a large A-a gradient (ETCO2 registered on our monitors was 45).  His lungs are getting well ventilated…but his circulation time is so slow that he’s underperfused.  Dead space… and a lot of it.

4) For a guy like this, make sure surgeon and perfusionist are present in the room on induction.  They were present here…just an FYI.

5) R2 pads are always good to have in place, just in case.  Yes, this guy has an AICD… but at some point the treatment/shock mode will be turned off for the surgery.

6) Go with your gut instinct.  If your gut is telling you that he needs some beta activity to get the heart jumpy enough to tolerate induction… then do it.

7) Be a calm, cool cucumber during the resuscitation.  Our team did a fabulous job of communicating and getting things done… all b/c of clear, concise communication.  It really does make a difference.

8) Debrief.  This helps get everything on the table and brainstorm what could have been done differently or better.  We’re all colleagues; no one has room  to pass judgment.  Ever. (If they do, take’em out back and kick ’em in the shins!)