I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!
Lately, I’ve been annoyed by the things going on at work. I’m not even sure why I’m annoyed. Here’s an email conversation (in order from top to bottom) of a recent annoyance (names have obviously been changed)….things noted in italics are particularly annoying to me:
Dr. QA: “Hello esteemed colleagues, I received a QA regarding a patient of Surgeon for thoracotomy who became unresponsive and required reintubation. Please provide me with any details you may have regarding the incident. Thank, QA”
Attending: “Hi Team, Do you what to explain to Dr. QA what happened. He is on our side. I would also stress that Resident is the one who discovered the patent and initiated the treatment. Please Cc me on the e-mail. Thanks, Attending”
Attending to Dr. QA: “Hi QA, I have asked our fellow and RESIDENT to write you a detailed summary of what happened, as fellow was there during extubation and resident was there during re-intubation. Instead of he said, she said its best to hear it from them. We had a debriefing about the incident and we feel it was a combination of several factors. I fully support their summary. Thanks,”
My account: “Hi Attending and RESIDENT, I’m going to cover the elements of induction, intraop events, and extubation. RESIDENT, would you mind discussing the details of finding the patient “obtunded” and the re-intubation?
I met with Dr. Surgeon in the pre-op area prior to surgery to discuss R VATs and likelihood for converting to an open thoracotomy. He was pretty adament that the surgical procedure could proceed as a VATs with very low likelihood for conversion. I asked if he would like for the patient to have an epidural just in case the case converted, however, he declined an epidural for her at that time. Therefore, we opted NOT to proceed with a thoracic epidural for post-op pain. Prior to induction, the patient was quite hypertensive (SBP ranging 170s-200s, preop SBP 155). Intraoperatively, she received roughly 250mcg fentanyl on induction. She had a history of a L paralyzed vocal cord, however I believe the vocal cords were open bilaterally according to the resident on direct laryngoscopy. A 35Fr L DLT was placed without noticeable trauma or difficulty. The DLT placement was confirmed with fiberoptic bronchoscopy and OLV was provided for the least time possible that was needed by the surgeon (bronchial cuff was deflated as soon as was deemed possible for surgical visualization). 3mg morphine was given at the beginning of the case. Throughout the case, she was given a couple of extra boluses of fentanyl and morphine (please see anesthesia record for exact amounts). At the end of the case, I spoke with Dr. Surgeon and he agreed to place intercostal nerve blocks for the open thoracotomy incision. The patient was breathing spontaneously through her DLT at skin closure (she had 4 full twitches and was given half dose reversal of glyco/neostigmine). As I recall, her tidal volumes through the DLT were in the 300s at PS 12 and RR 16-23 on 100%FiO2 with a SaO2 100%. At this time, I felt that she was adequately ventilating through a 35 L DLT, and she was grimacing from pain. We suctioned her oropharynx prior to extubating her to a FM 10L O2, and she remained stable in her breathing pattern. She was able to follow commands and generate some mild coughing. She was not stridorous or having any increased work of breathing. She had good chest excursion during spontaneous respiration. I believe she did receive some narcotic at this time while still in the OR. Additionally, we felt that she had adequate narcotics for her pain even though she was hypertensive (SBP 170s-190s similar to pre-induction)..therefore, we treated her hypertension with boluses of labetalol that improved her SPB to 150s (pre-op level). We were there roughly 5-10 minutes after the narcotic as we needed to transition the patient from the OR bed to the PACU bed. She was still following commands and breathing adequately on FM. We arrived to the PACU and checked in with the PACU nurse. She appeared to grimace still from discomfort, and I believe the resident administered some fentanyl (again, please see anesthesia record for details). At this time, I walked to the anesthesia workroom to grab an epidural kit for post-op pain and walked back to the PACU (roughly 5-10min). When I got back to the PACU, the patient appeared comfortable and had a RR of 8 on monitor). She did arouse to name and gentle push. I asked the PACU nurse if he was comfortable caring for her and we let her know that she did have a paralyzed vocal cord, therefore her airway may need closer attention. At that time, I felt her BP and pain control were under better control and she was arousable by name and gentle nudging. Dr. RESIDENT will be able to give his account as he found her in the PACU.”
(notice how i didn’t throw resident under the bus?)
RESIDENT’S account: “Hi, The events of the case as described by [fellow] are all accurate. My account will begin with extubation and follow through the PACU course. Just prior to extubation, 3mg Morphine was administerred as RR was in the mid 20’s. After this dose, RR decreased to the range described by [fellow]. As noted below, the pt was extubated in the OR to face mask. At that time she was responsive, and her breathing was un-labored. En-route to PACU, pt began to experience significant pain from the surgical site. Upon arrival in the PACU, 50mcg fentanyl was administerred. She was then connected to all standard PACU monitors, and report was given to the PACU RN. [fellow] got an epidural tray from the work room with plans for a thoracic epidural once the pt was more settled in PACU. Approx 10 minutes had passed, and although the pts pain was improved, she was still experiencing discomfort. At that time, an additional 50mcg fentanyl was administerred. I then proceeded to enter my PACU orders on the computer. After that, I returned to the bedside to check on the pt one last time prior to leaving the PACU. Upon arrival at the bedside, I noticed the pulse-ox alarming and reading a value in the mid 70’s. I called the pts name to which she did not respond. I then proceeded to tap the pt on the shoulder, followed by sternal rub. She did not respond to either stimulus. At this time O2 sat was 70%, and the pt was noted to be cyanotic. I called for an ambu bag which the nurse at the adjascent bed provided very quickly. I initiated bag mask ventilation. I was able to move air, though stridor was noted with each breath. The pt was notably more difficult to mask ventilate than she had been on induction of anesthesia in the OR. An oral airway was placed, and mask ventilation continued, though there continued to be marked stridor. O2 sats had returned to high 90’s-100%. At that time 2 CRNA’s and a CA-1 arrived with the code bag. 2-person mask ventilation was intiated while re-intubation supplies were prepared. 1.5mg Midazolam and 100mg propofol were administerred. No muscle relaxant was given. I performed a DL which yielded a grade 1 view. The vocal cords were noted to be midline and tightly opposed except for a small area inferiorly. At that time I asked for a 6.0 ETT, though I was able to pass the 7.0 ETT which had been prepared without significant difficulty. Shortly after intubation while still ventilating by Mapleson prior to RT arriving with a vent, the pt did begin to resume spontaneous ventilation. After being placed on the Vent. 8mg Decadron was given due to concern for possible airway edema. A propofol gtt was started for sedation. The pt was taken to the ICU where she was maintained on scheduled Decadron. Please refer to the chart for further ICU course details. On POD#1, bronchoscopy was performed, which did not reveal any significant airway edema. After confirming an air-leak around the deflated cuff of the ETT, the pt was extubated.
Please let me know if I can provide any further information. Thanks.”
(why on earth would you stack 100 mcg fentanyl on an 80 year old in the PACU who just had a thoracotomy? Blood pressure was being controlled with labetalol… pain is the 5th vital sign, right? in someone who has a fragile airway, don’t completely eliminate the pain and sacrifice the airway. Loss of the airway will KILL someone…. pain doesn’t KILL.)
ATTENDING email to QA: “Hi Dr. QA, As you can see very detailed information about the case. Fellow and Resident did an outstanding Job taking care of this patient. Given her age, VC paralysis, double lumen tube( 35F) together with narctics might have lead to this incident. The other thing, if it wasn’t for Resident going back to check on patient, we would have been called few minutes later for a full code. I will definitly take this to the PACU nurse manager.
FYI I was present during the start of the case and responded to the PACU page, but by the time I arrived to PACU, Resident already took care of everything.
Thank you CT fellow and Resident!”
Here are my current thoughts: can you believe this? let’s thank the CA-1… who clearly over-narcotized her (let’s not sugar coat it with a L paralyzed vocal cord and a 35Fr L DLT)… who didn’t know how to give naloxone… who subsequently reintubated her… And let’s shift blame to PACU nurse. seriously??
Converting PACU to SICU stay: $1000
Knowing how to use naloxone to reverse narcotized patient: priceless
Some things residency doesn’t teach…