Airway: Bad outcome

[NomadicMedic]

This article was shared in another group I frequent. http://www.houstonpress.com/news/go...t-leaves-the-room-during-an-operation-7842230

I'm sure @Remi @E tank and @Nova1300 will weigh in on this one. Taking an airway should never be taken lightly.

Of course, the media seems sympathetic to the victims in this story... but if you can get past the bias, it's a good read.

 

[StCEMT]

There are a few things that are expectedly misleading due to a lack of understanding, but curious to see what they have to say about this as well.

 

[EpiEMS]

Of course, the media seems sympathetic to the victims in this story... but if you can get past the bias, it's a good read.

So. Much. Bias. Curious why nobody mentioned "why did nobody drop an SGA" anywhere, or is that too esoteric?

 

[GMCmedic]

So. Much. Bias. Curious why nobody mentioned "why did nobody drop an SGA" anywhere, or is that too esoteric?

Clearly because the Doctor didnt order it cause only a Doctor is capable of doing any of the things mentioned in the article.

Very bias towards anyone but Doctors.

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[VFlutter]

Horrible article title and sounds like something written by the ASA. Things like this happen to every type of anesthesia provider and not because the MDA left the room.

I hated codes in GI/Endo... Always such a cluster. Sounds like a bad laryngospasm.

I mean seriously?
"while others say that the system is inherently flawed since nurses who don’t get the same training as doctors are administering powerful drugs that take a patient to the edge of death without being equipped with the ability to save them"

 

[StCEMT]

So. Much. Bias. Curious why nobody mentioned "why did nobody drop an SGA" anywhere, or is that too esoteric?

Because anyone below a doctor clearly isn't capable of having that kind of problem solving capability.

 

[Summit]

So what was the solution again? I forgot while reading the article about a non-provider specific complication in a case where there was MD management...

Oh right... ban CRNAs and AAs?

Let's cancel 50% of cases in the US!

 

[Carlos Danger]

Ignoring the very strong anti-CRNA bias that seems to be the main point of the article (the author probably doesn't know any different and was clearly spoon fed by highly political anti-CRNA anesthesiologists).......FWIW I actually did 6 EGD's this morning, without an anesthesiologist within 30 miles.....remarkably, everybody survived.

The first case illustrates a couple important things that do relate to prehospital airway management:

1. The hazards of sedation cases. Many people have the attitude that "it's just a sedation case - no big deal - it isn't like you are going all the way to sleep" but a higher rate of anesthesia related complications happen during sedation than during general anesthesia. EGD's can be especially difficult because you often don't have immediate access to the airway, and because the scope can stimulate the lower pharynx (or even the glottis itself, if the endoscopist is sloppy) causing airway irritation leading to laryngospasm and bronchospasm.

2. The challenge of managing morbidly obese patients during anesthesia, especially sedation cases. Everything that makes sedation cases challenging is made several times more challenging when someone is really heavy. Giving a person just enough propofol to keep them from gagging and hacking on the endoscope but still breathing can be tricky in a healthy person, but it is much harder in a really heavy person. Partly because of the way that morbid obesity affects pharmacokinetics, but also because of passive airway obstruction, which I can guarantee was pretty severe in this patient, with a BMI of 52.

There was nothing wrong with the doses of drugs mentioned in the article. Whoever thinks that 100mg of propofol is excessive for an EGD has no business speaking about the topic because they clearly have never done an EGD themselves. Same with the 200mg of sux. Perfect dose when you have to rescue an airway NOW.

It seems unlikely that 4mg of zofran would cause torsades, and if it did, I probably wouldn't expect it to take over 20 minutes to do so. Maybe she got other QT-lengthening drugs that just weren't mentioned in the article. Many drugs have the potential to lengthen the QT.

It sounds like a primary respiratory issue, though. As someone who does a lot of these cases in a part of the country where BMI's (and rates of smoking, and COPD) are much higher than average, my guess would be that the patient's obese airway completely obstructed when the propofol made her relax, and because of her size she had very poor respiratory reserve coupled with a high oxygen demand, so she de-satted quickly. Because of the pathological changes that occur secondary to OSA, it took her longer to recover from the propofol than would a healthier person. She was then hard to ventilate and intubate and even when good air exchange was finally established, atelectasis and greater oxygen demand kept her Sp02 from recovering.

But of course none of that would have happened if an anesthesiologist had been in the room. Just ask Joan Rivers.

 

[BobBarker]

No doubt about the bias in the article. I feel terrible for the family and the medical staff involved.

I'm curious as to why the family didn't know about the CRNA/ anesthesiologist leaving before the operation. Everytime I or my father has had a procedure, the anesthesiologist, doctor and any assistants/nurses would introduce themselves and say what they were doing. Just makes everybody, especially the family who can't be in the operating room, more comfortable. Also, wouldn't the anesthesiologist in this case want to stay with the patient a bit longer after the medication is administered because of the heart condition that was mentioned?

 

[DrParasite]

So is the author saying that if the doctor had never left the room the patient would still be alive? Ok, that's a fair statement to make, because doctors have never had patient's die while under their care.

The patient knew the risks of the surgery. She signed the consent forms, and she shouldn't have signed and agreed to the procedure if she didn't like it's conditions. And I am hoping she actually read all those forms before she signed them.

Hindsight is always 20/20; I'm sure you can find a doctor to say the provider screwed up, especially if the patient died. If the same patient had a successful procedure, would the commenting doctor still say there was a screw up?

It doesn't surprise me that the CRNA didn't say anything to the partner after the surgery; I'm betting she felt horrible, and wanted the doctor to speak to the family. plus, some facilities don't want providers to speak to family after bad events, due to the risk of admitting liability for their actions.

Intubating a skinny person is much easier than a morbidly obese person.

I am curious how everyone missed the prolonged QT syndrome. I would imagine she would have several EKGs taken in her life time prior to having the surgery.

The lawsuit has been filed. I'd be curious to see if the practice settles out of court (highly likely), or if based on all the facts (taking the emotional response that the patient died during a "routine procedure") the case is dismissed or they are found liable and forced to pay punitive damages.

 

[GMCmedic]

We cant say for certain the long QT syndrome was missed. It says the doc acknowledge the patient had a heart condition shown on the EKG, just never says what that condition was.

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