Anesthesia at a new facility, what to watch out

[deleted682700]

A new surgery center is wanting me to give sedation for MAC cases for podiatry. These are the things that I Checked out.

Iv start kits
Medications, versed, fent,propofol, epi, glycopyrollate, cagluconate, that are available. Succinylcholine not available.
Anesthesia machine, monitors Oxygen tank available, no pipeline oxygen
Ambubag available.

Worried about laryngospasm. I know laryngospasm has been dealt with at length here. Ability to positive pressure ventilation.
Worried about the skills of the nurses.
Any other potential things that I need to watch for

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[aneftp]

A new surgery center is wanting me to give sedation for MAC cases for podiatry. These are the things that I Checked out.

Iv start kits
Medications, versed, fent,propofol, epi, glycopyrollate, cagluconate, that are available. Succinylcholine not available.
Anesthesia machine, monitors Oxygen tank available, no pipeline oxygen
Ambubag available.

Worried about laryngospasm. I know laryngospasm has been dealt with at length here. Ability to positive pressure ventilation.
Worried about the skills of the nurses.
Any other potential things that I need to watch for

Seems like amsurg own facility with no sux.

Cost to maintain dantrolene before it expires is around 12-15 months. At a cost of around $3000/year.

While largyospasm would be extremely rare. Ask the Joan Rivers Gi center who didn't stock sux for the same exact reason: they didn't want to pay for MH cart /carry sux ($3000 dantrolene meds)

 

[deleted682700]

How about glycopyrollate to dry secretions
Lidocaine Iv 1-2 mg/kg
Magnesium 15 mg/kg

What is the incidence of laryngospasm in MAC cases?

 

[deleted59964]

How about glycopyrollate to dry secretions
Lidocaine Iv 1-2 mg/kg
Magnesium 15 mg/kg

What is the incidence of laryngospasm in MAC cases?

Wtf ... it's >0

 

[Mman]

they should probably have some intralipid around since podiatrists tend to use a lot of local anesthetic, especially in a setting where you can't ever convert to general anesthesia.

 

[propadope]

Narcan and Flumazenil. Other emergency meds eg. Ventolin, ASA, Beta Blocker, Vasopressor, Benadryl, Nitroglycerin SL, Atropine.

Face masks of all necessary sizes. Oral airways, nasal airways, LMAs or King LTs. Yankauer and suction tubing. AED would be nice too.

Does the monitor have ETCO2?

 

[WholeLottaGame7]

What's the point of the anesthesia machine if you're not going to be doing GAs, don't have wall O2, and are not going to be carrying muscle relaxant or dantrolene?

 

[aneftp]

What's the point of the anesthesia machine if you're not going to be doing GAs, don't have wall O2, and are not going to be carrying muscle relaxant or dantrolene?

It's not the anesthesia machine.

It's the purposely not carry any MH trigger agents (sux) so as not to have to stock dantrolen in order to save $3000 on dantrolene meds each year.

I'm just shocked the Joan Rivers case didn't expose the center didn't have sux available for a largyospasm. Lots of things the media does report.

I'm also annoyed the Asa didn't pound this to the media relations as well.

It's because GI anesthesia is still a cash cow and the Asa leaders have other agenda to pursue rather than throw an anesthesiologist under the bus for working in a place that didn't stock sux. (Center carry roc as a CYA)

Trust me. Highly paid lawyers with health care background have consulted with these centers saying they can legally defend any potential largyospasm death by having a "quick acting" muscle relaxant available.

 

[deleted162650]

I'd be ok with Roc and Sugga instead of sux.

 

[wickedskillz]

I'd be ok with Roc and Sugga instead of sux.

changin the game

 

[aneftp]

I'd be ok with Roc and Sugga instead of sux.

U'd be surprised how these centers operate. Costs matter to them. Even the $100 sugga may be too expensive. But you may be right. That's a very good option if you needed to reverse. Though reversing sugga with zero twitches may end costing the center around 8 vial (200mg/ per vial at cost $100) at 16mg/kg equals $800 if 100kg person.

 

[Ronin786]

Carry a syringe of sux in your pocket if they won't buy it. Chances of laryngospasm are much higher than MH.

 

[fakin' the funk]

A new surgery center is wanting me to give sedation for MAC cases for podiatry. These are the things that I Checked out.

Iv start kits
Medications, versed, fent,propofol, epi, glycopyrollate, cagluconate, that are available. Succinylcholine not available.
Anesthesia machine, monitors Oxygen tank available, no pipeline oxygen
Ambubag available.

Worried about laryngospasm. I know laryngospasm has been dealt with at length here. Ability to positive pressure ventilation.
Worried about the skills of the nurses.
Any other potential things that I need to watch for

This whole thing stinks. What's the point of the anesthesia machine if there's no volatile agents, pipeline oxygen, or airway equipment?

 

[deleted162650]

This whole thing stinks. What's the point of the anesthesia machine if there's no volatile agents, pipeline oxygen, or airway equipment?

It's strictly for decoration.

 

[deleted162650]

U'd be surprised how these centers operate. Costs matter to them. Even the $100 sugga may be too expensive. But you may be right. That's a very good option if you needed to reverse. Though reversing sugga with zero twitches may end costing the center around 8 vial (200mg/ per vial at cost $100) at 16mg/kg equals $800 if 100kg person.

Well it's not like I'm gonna give an RSI dose of Roc to break a L-spasm. Just a lil bit to soften 'em up, so I don't see needing to give a 16mg/kg dose of Sug (you don't give a full dose of sux to break a spasm right).

Anyways, I'd leave it up to the GI center to run the numbers and decide roc + sugga or sux + dantrolene. If they decide neither, then they can find someone else to provide anesthesia there.

 

[Dejavu]

An anesthesia machine gives you suction, end-tidal CO2, and a ventilator, if you get that deep in the woods.

Also gives you the ability to say you had one when the plaintiff's attorney asks you in front of the jury.

 

[Libertas]

I haven't checked the ASA standards regarding dantrolene recently....but....

Are you really so worried to give an emergency dose of sux without dantrolene? I mean, we're talking about a rare event (laryngospasm requiring sux in outpatient centers), coupled with an extremely rare event (MH), and you're probably not even using inhaled anesthetic. The probability of triggering MH in this situation is astonishingly small, yes? Also, the patient isn't going to go from life threatening hypoxia to rigors and 104 degrees in the next breath....if they start looking unwell, transfer to a real hospital.

Just curious. An often discussed scenario on this board.....

 

[pgg]

I would think any sane person would rather give succ to treat laryngospasm and accept the vanishingly small chance of MH, than not give it and accept the lack of ventilation and hypoxia happening right now.

If I worked in a place too cheap to stock succ and a MH cart I would just quietly have a vial of it with me. Same way I carried syringes with pressors during ICU rotations even though the RNs wrote me up for it when they found out. Concealed means concealed ...

 

[WholeLottaGame7]

An anesthesia machine gives you suction, end-tidal CO2, and a ventilator, if you get that deep in the woods.

Also gives you the ability to say you had one when the plaintiff's attorney asks you in front of the jury.

What advantage does an anesthesia machine have over having wall suction, O2 tank, Ambu bag, and monitor with EtCO2? Clearly it's not like they're prepared to run a prolonged GA there.

And you can't tell me a jury is going to buy that you were "just being prepared" by having an anesthesia machine, but not having the meds you need to break laryngospasm.

 

[aneftp]

This example of not wanting to pay $3000 for dantrolen meds and avoiding "MH triggering agents" like life saving sux. This is what's wrong with healthcare.

JAHCO and AAAHC will give big red flags to a facility that carries a known triggering MH agent (inhalation anesthetics/sux) without proper emergency drugs (aka dantrolene)

 

[twoliter]

I haven't checked the ASA standards regarding dantrolene recently....but....

Are you really so worried to give an emergency dose of sux without dantrolene? I mean, we're talking about a rare event (laryngospasm requiring sux in outpatient centers), coupled with an extremely rare event (MH), and you're probably not even using inhaled anesthetic. The probability of triggering MH in this situation is astonishingly small, yes? Also, the patient isn't going to go from life threatening hypoxia to rigors and 104 degrees in the next breath....if they start looking unwell, transfer to a real hospital.

Just curious. An often discussed scenario on this board.....

I don't think the ASA has a stance on it (but this suggests they recommend it), but MHAUS does and recommends dantrolene is stocked any place that would possibly administer a triggering agent. Not only that, but the mortality rate for an MH event in an ambulatory setting is 3x that of an event as an inpatient. I imagine that mortality difference is even higher if no dantrolene is available as early detection and treatment are the key to survival. I understand now we're comparing inpatients (many of which will get a triggering agent) versus an outpatient setting (with no volatile anesthetic, hopefully no reason for RSI, etc.), but I think requiring dantrolene to provide anesthesia is a reasonable stance. You could compare it to a defibrillator. I imagine most people would want one of those where they are anesthetizing (even healthy) patients.

 

[Ronin786]

Well it's not like I'm gonna give an RSI dose of Roc to break a L-spasm. Just a lil bit to soften 'em up, so I don't see needing to give a 16mg/kg dose of Sug (you don't give a full dose of sux to break a spasm right).

Anyways, I'd leave it up to the GI center to run the numbers and decide roc + sugga or sux + dantrolene. If they decide neither, then they can find someone else to provide anesthesia there.

There's a difference in the onset of action though for 20mg of succinylcholine vs 20mg of rocuronium. Especially in the setting of hypoxia and laryngospasm.

 

[deleted59964]

There's a difference in the onset of action though for 20mg of succinylcholine vs 20mg of rocuronium. Especially in the setting of hypoxia and laryngospasm.

i imagine you're right, but i'm not aware of any data.
i know sux works, i can't imagine the stress of treating laryngospasm with a small dose of roc and hoping it's fast enough...
not worth it to save a bit of coin

I wouldn't much care about the availability of sugammadex (and I love the stuff). if I have to treat laryngospasm with roc in a centre with no sux ... i'm gonna use that time to change my underwear

 

[deleted682700]

To my luck I found out that they do carry succinylcholine kept cold in the refrigerator. I have to check for dantrolene. Thanks for the advice

 

[deleted162650]

There's a difference in the onset of action though for 20mg of succinylcholine vs 20mg of rocuronium. Especially in the setting of hypoxia and laryngospasm.

Sure, but again, you don't need intubating conditions. Just enough to soften things up. I routinely give low dose (25-30mg) roc for induction, and you can feel the difference in ease of ventilation pretty quick.

I'm not really scared of L-spasm in an adult. Worst case scenario just put a damn tube back in - you don't need to give any relaxant for that. Ya, may not be the most elegant solution but a 7.0 piece of PVC will coax those VC's apart. I'm more scared about concomitant biting/jaw clenching which would prevent me from getting anything in the mouth. That's why I want relaxant around.

 

[aneftp]

Sure, but again, you don't need intubating conditions. Just enough to soften things up. I routinely give low dose (25-30mg) roc for induction, and you can feel the difference in ease of ventilation pretty quick.

I'm not really scared of L-spasm in an adult. Worst case scenario just put a damn tube back in - you don't need to give any relaxant for that. Ya, may not be the most elegant solution but a 7.0 piece of PVC will coax those VC's apart. I'm more scared about concomitant biting/jaw clenching which would prevent me from getting anything in the mouth. That's why I want relaxant around.

We hate to play Monday morning quarterback. But the Joan Rivers Anesthesiologist. Hard to stimulate real life events as they happen in real time.

I'm just wondering what the situation looked like as Joan Rivers was destaturating. No sux available. I means she's like 110 pounds max. I have never had trouble mask ventilating a person that skinny. Even ones with big tongue and sleep apnea who were small like Joan Rivers.

We will never know since case was settled quickly. I don't know how long it's been since the doc did real cases. That could have played a factor. You push propofol for years and years. Your skills will erode. While many Crna's push propofol. The vast marjoity who work at gi center primarily (that I know) have other side jobs are real hospitals doing real cases.

 

[pgg]

Sure, but again, you don't need intubating conditions. Just enough to soften things up. I routinely give low dose (25-30mg) roc for induction, and you can feel the difference in ease of ventilation pretty quick.

+1

Muscle relaxants are way overdosed in general. The ED95 of rocuronium is only 0.3 mg/kg. The only reason 0.6 mg/kg is the "standard" intubating dose is the faster onset time to ideal conditions.

That said, while 20 mg of succinylcholine will break laryngospasm quick enough, I'm not sure 20 mg of roc will. If I had a laryngospasming patient and roc was all I had on hand, I'd probably give all of it. Even if sugammadex wasn't available.

 

[propadope]

Sure, but again, you don't need intubating conditions. Just enough to soften things up. I routinely give low dose (25-30mg) roc for induction, and you can feel the difference in ease of ventilation pretty quick.

I'm not really scared of L-spasm in an adult. Worst case scenario just put a damn tube back in - you don't need to give any relaxant for that. Ya, may not be the most elegant solution but a 7.0 piece of PVC will coax those VC's apart. I'm more scared about concomitant biting/jaw clenching which would prevent me from getting anything in the mouth. That's why I want relaxant around.

Worst case scenario you could try jamming the tube in but in a full laryngospasm I'm not sure if you could reliably get through. Has anyone heard of this being successfully done?

 

[deleted682700]

We hate to play Monday morning quarterback. But the Joan Rivers Anesthesiologist. Hard to stimulate real life events as they happen in real time.

I'm just wondering what the situation looked like as Joan Rivers was destaturating. No sux available. I means she's like 110 pounds max. I have never had trouble mask ventilating a person that skinny. Even ones with big tongue and sleep apnea who were small like Joan Rivers.

We will never know since case was settled quickly. I don't know how long it's been since the doc did real cases. That could have played a factor. You push propofol for years and years. Your skills will erode. While many Crna's push propofol. The vast marjoity who work at gi center primarily (that I know) have other side jobs are real hospitals doing real cases.

Joan rivers was only 110 pounds and was 82 years old. A lot of propofol? in that lady might have produced severe cardiovascular depression because of decrease in both preload and after load. She probably was dehydrated from the colon prep. Propofol probably also has a direct myocardial depression effect in susceptible individuals who have compromised ejection fraction.
I have seen anesthesiologists dilute propofol with normal saline before they inject it in elderly.
Sorry Monday morning quarterback

 

[deleted682700]

What happened to 3 mg curare that we used to give to prevent fasciculations. Do you still get that drug?

 

[aneftp]

Joan rivers was only 110 pounds and was 82 years old. A lot of propofol? in that lady might have produced severe cardiovascular depression because of decrease in both preload and after load. She probably was dehydrated from the colon prep. Propofol probably also has a direct myocardial depression effect in susceptible individuals who have compromised ejection fraction.
I have seen anesthesiologists dilute propofol with normal saline before they inject it in elderly.
Sorry Monday morning quarterback

Joan Rivers egd case sounds more like a case of largyospasm rather than circulatory arrest from large dose of propofol

Lots of blame to go around. That's why caSe was settle very quickly.

Most outpatient facilities carry 1-3 million dollar insurance policy in addition to docs carrying their own malpractice policy. They probably settled up to the max at the facility, the docs malpractice policy limit

I'm guess a 3-5 million dollar settlement

 

[Consigliere]

Joan Rivers egd case sounds more like a case of largyospasm rather than circulatory arrest from large dose of propofol

Lots of blame to go around. That's why caSe was settle very quickly.

Most outpatient facilities carry 1-3 million dollar insurance policy in addition to docs carrying their own malpractice policy. They probably settled up to the max at the facility, the docs malpractice policy limit

I'm guess a 3-5 million dollar settlement

I have some "insider information" on this case and your guess is spot on.

 

[Robotic Wis-Hipple]

I haven't checked the ASA standards regarding dantrolene recently....but....

Are you really so worried to give an emergency dose of sux without dantrolene? I mean, we're talking about a rare event (laryngospasm requiring sux in outpatient centers), coupled with an extremely rare event (MH), and you're probably not even using inhaled anesthetic. The probability of triggering MH in this situation is astonishingly small, yes? Also, the patient isn't going to go from life threatening hypoxia to rigors and 104 degrees in the next breath....if they start looking unwell, transfer to a real hospital.

Just curious. An often discussed scenario on this board.....

MH is obviously rare and even more so in the setting of sux as the only triggering agent given. But it happens. I'm not saying that if I worked at a site without Dantrolene I wouldn't give sux if available in the setting of laryngospasm, as I certainly would treat the active life endangering condition and hope the stars hadn't aligned to screw me with MH. But where I have a problem is centers jeopardizing patients and asking me to assume liability so that they can net a few more grand a year. No thanks.

 

[deleted682700]

Watch out for the kissing enlarged tonsils which might increase the risk of laryngospasm?