Patient won't wake up after surgery

Carlos Danger

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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?
 

NomadicMedic

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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

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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

Carlos Danger

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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

Carlos Danger

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He remains intubated and breathing sevoflurane for sedation.

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

ERDoc

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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

Carlos Danger

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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.
 

PotatoMedic

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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

Carlos Danger

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Nerve stimulation results in 4 weak twitches
 

chaz90

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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.
 

ERDoc

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

triemal04

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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.
 

Akulahawk

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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

Carlos Danger

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What is the most reliable early sign of MH?

(It wasn't present in this patient)
 
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Carlos Danger

Carlos Danger

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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.
 

NomadicMedic

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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?)
 

Akulahawk

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chaz90

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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?
 

chaz90

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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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