# Patient won't wake up after surgery



## Carlos Danger

You are called to an outpatient surgery center for a post-op patient who needs to go to the hospital.

You arrive, don bunny suits and hats, and are led into one of the OR's. Since there were just a few cases this morning, a sole CRNA is working; there is no anesthesiologist or other anesthetist on site. The CRNA is pretty new and has never seen this before, so she is a little frazzled. 

She tells you that the patient is a healthy male in his mid 40's with no medical problems. He has had several surgeries and no history of problems with anesthesia, other than telling the CRNA that "it takes me a long time to wake up from anesthesia". He just had an uneventful shoulder surgery that took about 90 minutes. Now, he won't wake up and breathe adequately. The CRNA is afraid that whatever is going on is not going to resolve soon, so he needs to go to the hospital.

Here are the meds he's gotten:

Pre-op:
20 mg famotidine PO
250 mg alfentanil 2 mg midazolam IV for brachial plexus block sedation
20cc 0.25% bupivacaine with decadron for interscalene brachial plexus block

The patient tolerated the block sedation well.

About 30 minutes after the block was placed, they went to the OR, where the patient was given:

100 mg lidocaine
100 mcg fentanyl
5 mg rocuronium
300 mg propofol
100 mg succinylcholine 
Patient was intubated easily with an 8.0 ETT

The case started and anesthesia was maintained with 1.8% sevoflurane in 50% oxygen. 

A total of 1500ml of LR was given during the case.

Additional meds given included several boluses of phenylephrine, 2 grams of cefazolin, 4 mg of ondansetron, and 4 mg of dexamethasone.

Now the patient won't wake up or breathe well. When the gas is turned off he breathes very fast and shallow and becomes very hypertensive and won't follow commands, so he is being maintained on a low concentration of sevo and the ventilator. It has been a little over an hour since the surgery ended and wake up was first attempted.

Anything else you might want to know before you begin transport? What might be going on?


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## NomadicMedic

I'm blue skying here, but it would seem that the gas should be fully off and the rock be fully reversed with sugammadex. You say he's not breathing well, but how effective is his ventilation? How long ago was the fent and rock administered? Curiously, was he sitting in the "beach chair" position? (Yeah I did a little Google look at desaturation incidents in shoulder surgery) Was there any instance of desaturation or any other untoward instances during the procedure? I'm assuming he was not extubated...

This is probably beyond the scope of most paramedics. I'd either assume a medication issue or an instance of cerebral hypoxia due to the surgical position. He would be ventilated and transported to the highest level ED.


(By the way, this is a bad day for me to see this scenario, I'm about to take my 40 year old wife to the same day surgery center for ACL repair. I already specified NO STUDENTS on the airway.)


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## Gurby

I'm calling a supervisor pretty much as soon as I walk in the door, and probably giving medical control a call soon after.


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## Carlos Danger

Beach chair position was used, but there were no periods of desaturation or prolonged periods of MAP < 80% of baseline.


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## Carlos Danger

He remains intubated and breathing sevoflurane for sedation. 

Roc and fent were both immediately prior to intubation, and none since.


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## ERDoc

Has she discussed this case with her supervising anesthesiologist, if she is one of the states that requires one?  Has she contacted the receiving facility to discuss this case with them?


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## Carlos Danger

ERDoc said:


> Has she discussed this case with her supervising anesthesiologist, if she is one of the states that requires one?  Has she contacted the receiving facility to discuss this case with them?



For the purposes of this scenario, let's say she consulted with one of the MDA's at the facility who told her to send the patient to the ED, as he was unavailable to come in. She also spoke with the ED attending at the receiving facility.


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## PotatoMedic

No idea what is going on.  Possibly a med reaction.  What did the pt's heart rate do when they tried to wake him up?

My transport decision would be to sedate and paralize and bag the pt to the er and let them try to wake the pt up.


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## Carlos Danger

Nerve stimulation results in 4 weak twitches


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## chaz90

Whew. I'll be the first to admit that I would be in over my head here. 

My first thought though knowing that volatile anesthetics and succs were administered is a high suspicion for malignant hyperthermia. Did the CRNA consider following their MH guidelines and administer any dantrolene yet? What is the patient's core body temp? Honestly, I would imagine the receiving anesthesiologist would like the patient to receive dantrolene from the CRNA prior to transport. I know MH is considered life threatening and dantrolene used to even be given prophylactically, so this would seem a safe bet to me.  

Did the CRNA delve any deeper into his history that it takes him "a long time" to wake up from anesthesia? I'm going to take a wild guess that is significant. 

Transport wise, how can we wean this patient off the sevoflurane and keep him sedated? I'd do this in conjunction with the CRNA and medical control consult immediately, but are IV benzo boluses a viable alternative here? I'd also have the CRNA speaking to the ED doc or potentially anesthesia at the receiving facility if one were available and in a helpful mood. If the CRNA is available to come along on the transport I would actually like that very much. If she wants to bring additional medications that she thinks may be necessary that would be fine with me as I honestly don't know much about caring for a patient like this. 

In any case, continued sedation and maintenance of the airway/ventilator settings seems to be the order of the day along with a high suspicion for MH.


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## ERDoc

Was the train of four with the pt being maintained or when trying to arouse him?


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## triemal04

1.  Cross that surgery center off your list of places to go to.  Ever.  For any reason.
2.  Standard set of current vitals; pulse, BP, rr, SpO2, ETCO2 and waveform, ecg, cbg, temp (core if available). 
2.5  What are these values when the sevo is turned off?
3.  Standard physical exam.
3.5  Any difference from the preop eval?
4.  Turn of the ****ing sevoflurane and *****-slap the CRNA. 
5.  When did the surgery end?
6.  When did she start lowering the flow of sevo to wake the patient?
7.  Soft restraints if there is a concern about their need (shouldn't but why not).
8.  Since the patient just had surgery and has a chunk of plastic in his trachea and it's been >2 hours since the block and >1.5 hours since his last analgesia give 50mcg of fentanyl (yes this is a low dose, but the goal is to extubate this guy...or at least the goal was to extubate him).
9.  Was the statement about "it takes me a long time to wake up" investigated further?  Either by questioning the patient or pulling his previous anesthesia record (if available)?
10.  Were any labs done pre-op?  Probably won't matter but hey, if they're handy...
11.  Liver function?
12.  Ventilator settings?

Lot's and lot's of things that could be going on with this patient, some related to the surgery/anesthesia some not.  In no particular order:

Given that sevoflurane can accumulate in the lungs in prolonged use that might be part of the issue, especially since he is STILL on it, but doubtful it's the only cause.  I believe it can technically cause hypertension but I'd bet that's one of those side effects that is listed but not real.  Especially since it's a potent vasodilatator...

Malignant hyperthermia.  Real risk and there are some real concerns here.  If the above tests paint a clearer picture (elevated core temp, high ETCO2 and at this point the physical) give dantrolene. 

Stroke.  Certainly could happen.  As sevo is a vasodilatator it could mask the associated hypertension while in use though if that is a low dose maybe not as much.

The guy just takes a long time to wake up from anesthesia and due to the lack of current analgesia is in pain.  Also got versed preop (which was a long time ago though) which might make things take a bit longer.

Those would be the my top 4.  But.  With the exception of malignant hyperthermia which should have been recognized and treated long ago and a good PACU the place for this guy to be is not there.  Based on what's been said so far, move to the sedation of your choice, switch him to your ventilator/BVM and go to the appropriate hospital. 

Obviously this can change based on further info.


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## Akulahawk

I admit I'm out of my depth here as well but I wonder about MH as well. Core temp? Also, what does the patient weigh? Unless he's pretty good sized, I wouldn't necessarily expect a propofol dose that large. The last time we gave that stuff in anywhere close to that amount, it was because the patient had meth onboard and was still moving after both Sux and Vec had been given in their usual doses (he was difficult to keep sedated) and the other time that we gave that much, the patient stayed under for quite  a while, but we'd also given that patient a healthy dose of ativan too.


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## Carlos Danger

ERDoc said:


> Was the train of four with the pt being maintained or when trying to arouse him?



At either point.


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## Carlos Danger

What is the most reliable early sign of MH? 

(It wasn't present in this patient)


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## Carlos Danger

Lots of good questions and points here. I'm going to come clean in a few hours when I get home and get to my computer.


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## NomadicMedic

Here's what really shocking... Most of the replies in this thread are from the gunners. How many run of the mill medics would shrug and bag/vent this guy to the local ED. I'd bet you could ask 10 medics and 8 of the 10 would have not heard of MH other tha obliquely, would have no idea what sevo, dantrolene or sugammadex is or where to even start with this patient. (Do same day surgery centers stock dantrolene?)


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## Akulahawk

DEmedic said:


> (Do same day surgery centers stock dantrolene?)


One can only hope... and that they have it reasonably close by.


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## chaz90

Remi said:


> What is the most reliable early sign of MH?
> 
> (It wasn't present in this patient)


Tachycardia and increasing EtCO2? What are the pre-op and current vitals, and what are they when the sevoflurane is turned off?


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## chaz90

I imagine, at least in my ideal world, that any facility administering anesthesia should have dantrolene available. I've been wrong once or twice before though.


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## luke_31

DEmedic said:


> Here's what really shocking... Most of the replies in this thread are from the gunners. How many run of the mill medics would shrug and bag/vent this guy to the local ED. I'd bet you could ask 10 medics and 8 of the 10 would have not heard of MH other tha obliquely, would have no idea what sevo, dantrolene or sugammadex is or where to even start with this patient. (Do same day surgery centers stock dantrolene?)


I got to admit I've never heard of those drugs, but I went and looked them up. Malignant hyperthermia I've heard of before and I already have a protocol to deal with that. I do recognize that the patient not coming out of anesthesia is pretty significant and would start with the ABCs and inform the ED before we even left in case they need more info from the CRNA.


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## Gurby

The thing that gives me pause is that he's stable and maintaining (I assume) while on the sevo, and seems to go downhill once the sevo is stopped.  I have no clue what's going on, I don't know any of these meds, I have never encountered this situation before.  The patient is currently in the care of people with literally a combined 15+ years more education and training than I have (there must be at least 1 MD/DO surgeon around and the CRNA) who are very familiar with the patient and have a lot of tools available to them.

I'm extremely uncomfortable disturbing this seemingly stable situation.  My instinct is that not calling medical control is a big mistake here.


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## ERDoc

Gurby said:


> The thing that gives me pause is that he's stable and maintaining (I assume) while on the sevo, and seems to go downhill once the sevo is stopped.  I have no clue what's going on, I don't know any of these meds, I have never encountered this situation before.  The patient is currently in the care of people with literally a combined 15+ years more education and training than I have (there must be at least 1 MD/DO surgeon around and the CRNA) who are very familiar with the patient and have a lot of tools available to them.
> 
> I'm extremely uncomfortable disturbing this seemingly stable situation.  My instinct is that not calling medical control is a big mistake here.



There are only about 10 states that require CRNAs to have a supervising physician, so there is a good chance that this one is on her own.  You will have a doctor there, the orthopedic surgeon who is doing the case but he probably has less experience with airway/sedation than you do.  He's stable but you have to get him to the hospital and there is no way to keep him on the sevo.  This is definitely a great thinking-outside-the-box case.


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## Carlos Danger

This was my case a few weeks ago. I changed quite a few details (including the fact that I had no help around) just to make it sound a little more prehospital scenario-ish.

The problem was......wait for it........a _cholinesterase deficiency_, and the resulting prolonged neuromuscular blockade from succinylcholine!

Some degree of cholinesterase deficiency or dysfunction is present in around 1% of the general American population (considerably higher or lower in some ethnic groups) but only a few percent of _that_ group has such a degree of dysfunction that it results in clinically significant prolongation of paralysis from succinylcholine. Many anesthetists go their entire career without seeing such a dramatic example as this one.

Most patients who have this do not know it until they undergo anesthesia with succinylcholine. This patient, for instance, had undergone several procedures in the past, but it's likely that he never had sux before. When he said "I wake up slowly from anesthesia" (lots of people say that and it isn't true), I'm very confident this was not what he was talking about. If this had happened before, he would have had it explained to him and been tested before now.

So here's what happened:

Up until the wake-up, this case was very routine - everything from the pre-op to the block to the induction to the surgery itself. All the drugs and doses that I listed are what I actually gave and are my standard for a case like this, and 99% of the time my patients wake up easily and are very comfortable. The only thing slightly remarkable here was that his airway was MP 3 and he had a large neck, so I Glidescope'd him. No problems there.

He never breathed during the case. I usually get them breathing on PSV not too long after induction, but he never did, and that's not a big deal or that unusual, so I thought nothing of it.

After the case ended, when the gas was completely off and he should have been breathing well and responding, he was breathing extremely fast and shallow and was very hypertensive and was not responding at all. This was the first time that I knew something was really wrong, and I started working through differentials in my head. Gas is off - check. Flows are up - check. Narcotized? Nope - all he got was the 100 mcg of fent on induction. Local anesthetic toxicity? No; he got bupivacaine, which tends to case cardiovascular collapse. Worst-case in my mind was an intra-op stroke. He also had twitching movements in his extremities that I was afraid was seizure activity. I treated his hypertension and the twitching movements didn't stop. I considered giving versed but decided against it; his Sp02 was 100 and I figured I'd dose him with propofol in a couple of minutes if it didn't stop. A stroke seemed extremely unlikely, though. MH crossed my mind a couple times, but his Etc02 was normal and his temp was only slightly elevated. I had the OR nurse check his BG - 140. I then called for the i-Stat to check a sodium.

About this time, the charge MDA walked by and poked his head in the door and said "you guys about to come out?" and then when he saw the patient still intubated and I was still assisting his ventilations he said "do you need anything?" I told him to come in and explained the problem. He immediately said "he looks like he's still paralyzed - didn't you reverse him?" I explained that he had never gotten a non-depolarizer - just the tiny defasiculating dose 90 minutes ago at this point. MDA wondered if maybe the 100 of sux I'd given him wasn't actually roc. I didn't in fact draw up the drugs for this case, but the likelihood of that seemed low. Even if that _had_ happened, it should have worn off by now. I hadn't checked his twitches ever, because, again, I'd never given him anything long-acting. Residual paralysis post-op is actually not that uncommon - I'd seen weakness a handful of times, but never like this - but it almost always happens in someone who was inadequately reversed after several doses of a long-acting non-depolarizer. Anyway, I checked his twitches, and he had 4 weak twitches with tetany. MDA wanted to reverse the guy, thinking that he definitely looked partially paralyzed, and knowing that measuring twitches isn't always 100% reliable. I was very reluctant because I was not at all convinced we were on the right track, but at that moment I couldn't think of any reason not to try, so I agreed. Gave the guy a dose of edrephonium and....nothing.

About now, one of the other CRNA's wandered in. "What are you guys screwing up?" he asks. We explained the situation and he says "sounds like a cholinesterase deficiency to me - you didn't reverse him, did you?" Crap. We hadn't thought of that.

Knowing that the other CRNA was probably right about a cholinesterase deficiency - and also knowing that the reversal we just gave would prolong his weakness even more, I turned on the sevo at a low concentration to provide sedation, started the ventilator, and just waited. About 2.5 hours later I tried a 4th time to wake him up, and he was extubated successfully. We then watched him in PACU for several hours. MDA explained everything to the patient in detail, called the guy's primary, and wrote him a letter explaining what happened and strongly recommending that he avoid succinylcholine and get tested for a cholinesterase deficiency.

Two weeks later the guy calls and tells us he got tested.....he had a dibucaine number <30
This was a great learning experience for me as a newer CRNA. I wished I had recognized much quicker that he had residual paralysis, but he just didn't look like the floppy patients I'd seen before. I also wish I'd thought a little harder about what 4 weak twitches meant in someone who'd gotten sux and was still weak a long time later, but like I said, this just wasn't something that you see.....it was one of those things that you have a hard time thinking of because it's so uncommon.....but as soon as someone else mentions it, you want to slap yourself for not thinking of it.

Anyway, I know we don't test twitches in EMS, and I know we don't usually wake people up......but if we are giving sux I think it's important to keep in mind how it works and how it's metabolized and what can go wrong with it. I vaguely remember hearing about cholinesterase deficiency when i first learned about succinylcholine years ago as a new paramedic, and just not worrying about really understanding what it meant, because it just didn't seem relevant.

Hope you guys found this interesting.


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## Akulahawk

Very interesting case and good to know that MH wasn't the issue. Cholinesterase deficiency is something I've never heard of, but makes sense.


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## NomadicMedic

Great case. Thanks for sharing.


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## teedubbyaw

Solid post.


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## ViolynEMT

Makes me want to go on to learn and become more.


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## ERDoc

Awesome scenario, thanks for sharing.  Definitely not on my differential.


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## chaz90

Outstanding scenario, and a true learning opportunity for me! Thanks for posting this and providing follow up.


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## Tigger

Really well done. So as a followup, what would do you think an appropriate EMS treatment plan would be?


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## Carlos Danger

I'm glad you guys liked the scenario. 



Tigger said:


> Really well done. So as a followup, what would do you think an appropriate EMS treatment plan would be?



Good question, Tigger.

Again, this was a really unusual case. But if this patient had to be transported, you would just transport him just like any other intubated patient - provide ventilation and sedation. The anesthesia provider may or may not be able to accompany you, depending on whether they have other patients. At the very least, of course, they should give you a good report and answer all of your questions, and also call the ED to let them know what is going on. If needed, they should be able to give you orders to follow during transport, and you can touch base with your MC before you leave to get their approval for those orders.

For sedation in a patient you are trying to wake up, it would be preferable to use drugs that don't have a long duration, so a propofol drip or dexemedetomidine would be much better than large boluses of versed, for instance. But if you don't have the ability to do a propofol drip, whatever you would normally use is fine.  

Pain really isn't usually a big problem in the immediate post-op timeframe, so giving lots of opioid isn't necessary. 

Things I can think of off the top of my head that could potentially cause EMS to have to transport from an outpatient surgery center: severe bleeding that is uncontrollable, intra-op stroke or MI or PE, severe allergic reaction to something, cardiac arrest for whatever reason. These are all really uncommon, of course, in the outpatient setting. But we all know how to manage them if we come across them.

Anything really bad and anesthesia-specific, like MH or LAST (local anesthetic systemic toxicity), or cardiac arrest due to succinylcholine, and an anesthesia provider really should accompany you, but they may not be able to. In that case just follow the anesthesia providers instructions to the extent that your protocols and MC allow.


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## Brandon O

lol at "What are you guys screwing up?" I like that guy. Great case.


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## Brandon O

Dumb question from a non-gaseous fellow like myself: by what mechanism does edrophonium reverse a depolarizing paralytic to begin with? (I was going to ask why giving it would exacerbate the situation above, but that actually makes more sense to me than the basic premise. Reversal agents confuse me.)


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## Carlos Danger

Acetylcholine (Ach) is released from the prejunctional membrane, travels across the junction, and binds with post-junctional receptors, which generates a nerve potential and ultimately muscle movement. Ach is then hydrolyzed by acetylcholinesterase and its components are taken back up by the pre-junctional membrane and recycled.

Neuromuscular blockers work the same way as Ach.....they bind to the postjunctional receptors, but they are incapable of generating a potential (except for sux), so they just block Ach so that it cannot bind and generate a new nerve potential. So you get paralysis. 

The non-depolarizing NMB's are termed _competitive_ ligands because they compete with Ach for the binding sites, in that high enough concentrations of Ach will displace the NMB from the binding site, restoring nerve transmission (sux is different).

So that is how anticholinesterase reversal agents work: they bind to the acetylcholinesterase, which renders the enzyme unable to hydrolyzed Ach, so Ach concentrations increase, and the NMB is displaced from the postjunctional receptor.

Anticholinesterases can't reverse a depolarizing (sux) block, because sux binds more strongly with the post-junctional receptor and can't be knocked off by Ach. A sux block lasts until sux diffuses away from the receptor on its own and is then hydrolyzed by different plasma esterases. 

In fact, an anticholinesterase with prolong a sux block, because the resulting increase in Ach will make it harder for sux to diffuse away from the receptor. Also because the anticholinesterases likely  inhibit the action of the plasma cholinesterases that metabolize sux, to at least some degree.

Sux + an anticholinesterase has actually been used as a poor-mans long-acting paralytic, in fact.


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## Brandon O

I was confused because it seemed like you were giving it to reverse the sux. But now in rereading, it sounds like it was because there was a question that perhaps you'd accidentally used roc instead, so you were empirically reversing that. That makes more sense.


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## NomadicMedic

That Roc was given instead of Sux was my first guess, waaaay back. But that was far to easy and figured it was a false flag. 

I reeeeealy enjoyed this scenario.


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## exodus

DEmedic said:


> Here's what really shocking... Most of the replies in this thread are from the gunners. How many run of the mill medics would shrug and bag/vent this guy to the local ED. I'd bet you could ask 10 medics and 8 of the 10 would have not heard of MH other tha obliquely, would have no idea what sevo, dantrolene or sugammadex is or where to even start with this patient. (Do same day surgery centers stock dantrolene?)



This is actually a (somewhat) fairly common occurrence out here, maybe once a year or two per medic.  The local outpatient surg center transports all patient that wake up outside of reasonably baseline to the receiving facility.  I've personally been on two where they were extubated and still not waking up.  Both were still stable and managing their own airways though.  

Our transport time is about 1 minute code 2 across the campus to the ED


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## Chewy20

I like reading stuff that lets me know, I DON'T KNOW CRAP. Good discussion.


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## Carlos Danger

Glad you guys liked it. 

I almost didn't bother writing it up here because I didn't know if most here would find it relevant. Glad you did.


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## Ensihoitaja

Remi said:


> Glad you guys liked it.
> 
> I almost didn't bother writing it up here because I didn't know if most here would find it relevant. Glad you did.



I don't know jack about anesthesia, but this was an interesting case and I definitely learned some stuff. Thanks for writing it up!


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