I'm a brand new CRNA (one week out) and I'm slowly finding that the beginning of my nurse anesthetist career is going just like the beginning of my nursing career. Everything was smooth sailing as a student and now that I'm on my own the sh#% has hit the fan! Ok maybe I'm being a little over dramatic, the majority of my cases have gone well but I had one the other day that really scared me to death.

In GI lab for an ERCP on a 57 yr old man in with obstructive jaundice and no previous medical history. I notice him coughing up some thick secretions prior to starting the case and he reports that he has had a bit of a cold. No matter to the MDA, were continuing the case...

In my facility, the standard anesthetic for our GI procedures is Propofol and a little lido--nothing else. I begin the case and patient does fine for the next 45 minutes right up 'til the end. Suddenly he goes into a coughing fit and in response I give a few cc's (maybe 3-5) of Propofol. This alleviates some of the coughing but then he begins this asynchronous abdominal breathing pattern. His Vt/RR appeared to be adequate from my standpoint so I thought maybe he was just a little light so I gave another 3ml of Propofol. Asynchronous breathing continues and SpO2 begins to drop. I turn up my O2 flow and perform a jaw thrust. Pt continues to make respiratory effort but strange breathing pattern continues and SpO2 decreases further (maybe around 85 by this time).

I tell the doc to remove the scope so I can apply O2 via FM and while I'm waiting give some blow-by with the mask hovering over the patient's face while nasal cannula flows continue at 8ml/min now. Doc says he's only a few seconds from finishing and doesn't want to come out. I tell him he needs to pt sats are too low (maybe 75 now). He argues more and finally removes scope after a few more seconds. SpO2 in high 60s now. I flip pt on his back quickly suction him with the yankeuer and perform bag-mask ventilation with oral airway. SpO2 dropped to high 40s or low 50s before they started coming up. Gradually I get him back to mid 90s and he recovers back to baseline.

Just curious what any of you think might have happened or what I could have done differently. I spoke to 2 CRNA friends of mine and my MDA about it and they all had the same response: sh#$ happens! While I know sometimes that's the case I can't help but feel that the situation could have somehow been avoided. It also bothers me that I'm not sure what caused it in the first place? Was the patient too light/deep? Did he have a laryngospasm or bronchospasm? I got a scant amount of secretions with the yankeuer and never heard any wheezing or stridor. Should I have avoided giving the Propofol?

Also I'm curious to know how some of you perform these type of cases yourself. EGDs and ERCPs always make me uneasy. As a student I tended to keep patient's too light and they'd always start coughing so then I started trying to "stay ahead" and continue giving Propofol based on their RR/SpO2/HR more like it's on a gtt than just boluses every few minutes. I'd really appreciate any advice and/or insight that any of you (who have made it through all my rambling) might be able to offer. Thanks!!!