From anonymous responding to Calling for Help – A sign of STRENGTH, not weakness!
I have spent the last 2 weeks reviewing this article (Charles et al. Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms. Pediatr Anaesth. 2023; 33(6), pp.454-9. PMID: 36932923) along with a few others, as I prepare my M&M presentation for my very first (and hopefully, last) intraoperative cardiac arrest (CA). Fortunately, as a junior-ish attending in a new institution (I changed jobs this past April to a standalone children’s hospital) I had absolutely no hesitation calling for help immediately when the event occurred in the early evening. An anesthesiologist’s greatest fear— “train track” vital signs followed by immediate hypotension and complete loss of end tidal in a prone patient. After a prolonged resuscitation, I dropped the patient off in the PICU and I couldn’t help but contemplate all of the things I should have thought about or done better, despite having help from some of the most experienced anesthesiologists at my institution. As this article states, an MET is not automatically deployed to our OR CA; however, after my experience, we identified that an area of improvement at our institution would be activating a pharmacist to automatically respond to future intraoperative CA to help facilitate medication dilution, drips, etc. specifically in the off hours with less help around. To further this point, another article was recently published by Wake Up Safe that confirmed that CA in off hours was associated with worse outcomes, so optimizing resources should become the standard of care, egos aside.
From Jay Deshpande MD and Wendy Binstock MD
Another 4th of July, another spate of mass shootings. As you and the readers of the PAAD may recall I (WB) was a bystander and an on the scene citizen first responder at last year’s Highland Park parade mass shooting. I am attaching an interview with a local news channel which commemorated the event…
https://abc7chicago.com/highland-park-mass-shooting-parade-anniversary/13438061/
PS from Myron: As discussed in several previous PAADs these mass shooting events are becoming the norm and all of us as citizens need to be prepared to act on the scene and outside of our in-hospital comfort zones….so this is as good a time as any to buy a combat tourniquet to keep on your person at all times. And while you’re at it get intranasal naloxone as well!
From Dr. Greg Hammer Stanford University commenting on the Leak Test
1. The real benefit of the leak test is immediately following intubation in order to ascertain whether the ETT size is appropriate. The patient needs to be deeply anesthetized or paralyzed for the test to be accurate. I think we would all agree that if there is a leak at an inflating pressure below 10 cmH2O with an uncuffed ETT, a larger or cuffed ETT needs to be placed (yes, still useful to place an uncuffed ETT in selected cases wherein the largest appropriate ETT is a 2.5, 3.0, or 3.5 mmID). If there is a leak with a cuff inflated to a reasonable volume the same applies.
2. If there is no leak auscultated at a pressure of 30-35 cmH2O with an uncuffed ETT or with the cuff deflated a smaller ETT should be placed IF this affects management. If the case is a short operation and the provider will leave the ETT in place even if there is no leak then it is obviously pointless to do the high-pressure test. In that case we may as well rely on our fingertips with ETT passage, though this is unreliable - though if there is palpable resistance one should back out and place a smaller ETT. If the intubation is in the ICU or if the ETT will remain in place post-op the test should be done following intubation and the ETT down-sized if there is no leak to a pressure of 30-35 cmH2O.
3.Doing a leak test in the ICU prior to extubation is rather pointless. First, the patient is often moving, coughing, etc, and the test is invalid. Even if the patient is quiet during the test my feeling is, “so what?” If there is no leak the appropriate action is to extubate expectantly, treat stridor with racemic epi and be prepared to reintubate with a smaller ETT. What I find to be unfounded (I am being kind here) and common among non-anesthesia trained ICU docs is the practice of leaving the ETT in place when there is no leak and praying that corticosteroids will come to the rescue. I find it highly unlikely that, even if steroids DO reduce tracheal mucosal swelling, they will do so when the problem is that the ETT is causing mucosal ischemia by virtue of compression of venous drainage +/- arterial occlusion.
From Alexander Rodarte, M.D. retired Rady Children’s Hospital San Deigo on green house gasses and nitrous oxide
Although my days of being an attending are over, there may be times when I can contribute my skills on a trip with Mercy Outreach Surgical Teams once again. We often travel with adult anesthesiologists who need a hand at starting IVs or visualizing a pediatric airway. Keeping up to date with your fun publication is a way to feel more secure in my ability to contribute on a trip. Throughout my active clinical years, volunteering to provide anesthesia in various countries not only offered me great experiences but also presented me with the opportunity to learn to adapt my practice due to limited resources while we were on a trip. One significant adjustment was using oxygen and Sevoflurane without the assistance of nitrous oxide, and using low flows. We would set up multiple stations in the same room, but only split the O2. Low flow helped keep the room from achieving an anesthetizing level of gas since scavenging was quite limited. The days of halothane were horrible and often left people with a headache. Thankfully Sevoflurane was more forgiving of leaks in the system or poor scavenging.
After many years of utilizing Sevoflurane for rapid induction without nitrous oxide while on trips and returning to the OR at Children's, I realized that the addition of nitrous made little difference in expediting the induction process. Consequently, I made the decision to discontinue the use of nitrous oxide. Initially my reason was to decrease the exposure of pregnant or possibly pregnant nurses to nitrous since increased incidence of miscarriage and low birthweight had been associated with it. In 2007, I began distributing the paper on nitrous oxide to justify my campaign against nitrous because of its effect on the environment. Interestingly, when I challenged the residents to differentiate between patients who underwent Sevoflurane induction with nitrous oxide and those who received Sevoflurane alone, they were unable to identify any differences (I know, not a very scientific approach).
In addition, while training at Stanford in the late seventies, Chuck Witcher, a strong advocate of low flow anesthesia, had introduced me to the advantages of employing a closed circuit or low flow system. At Children's San Diego, John Holl also championed this approach. Although I never fully embraced the complete closed system that John favored due to concerns about periodically refilling it with oxygen, using less than a liter proved to be satisfactory for me. In 2011, I started sharing references to the Special Article in A&A, which highlighted the halogenated agents we commonly employ. I used these resources to support my practice of avoiding nitrous oxide at all costs and advocating for low flow whenever feasible. While it may be too late to prevent many of the effects of climate change, I firmly believed that any amount of conservation was worthwhile.
It's great that someone has taken the initiative to quantify the consequences of our misuse of these greenhouse gases.