So I get a call from our general surgeon on ESS (Emerg Surg Servs) the other night at around 11pm. He wanted to know if I was comfortable or willing to come in for an Appy. Now, keep in mind this was a few days ago in the middle of the night, wasn't planning on posting this, and I'm going off of memory here.
The patient is a 79yo male who was schedule for a lap appy earlier in the day but his INR was 1.6. 5 units of FFP was given and now his 10pm INR was down to 1.3. He has a Hx of CHF, MI x 2 (last one 10 yrs ago), recent AICD/pacer for Afib, lifetime smoker (w/ undiagnosed emphysema). Surgeon said he wanted to do him tonight instead of waiting till tomorrow b/c he didn't want his INR to go back up and that it may be late tomorrow by the time this case gets going. But he wanted me to decide, not knowing if I was comfortable with doing the case and having to put a magnet on the guy's AICD.
So I'm thinking, "well I would really rather sleep BUT if it was me or my family member, I wouldn't want them laying around for 12+ hours with a hot "appendix" so I obliged.
I see the guy on the unit and he looks as though death has swooned over him. He is on NC 5L/min and Sats are 92% at best. His breathing isn't labored but I hear bilateral wheezes. His skin color is rather dusky. He is coherent and aside from his cardiac and pulmonary issues, he has no other significant history.
I explained general anesthesia to him along with the potential complications and told both he and the surgeon that there is a good chance he may not extubate tonight and may need to be on the ventilator until tomorrow. All parties are in agreement that the risks are worth the surgery so to the OR we go.
Case was not that exciting and took less than an hour. Knowing that this surgeon is fairly quick, I abstain from using my usual paralytic of choice Roc and went with Nimbex after a RSI with Succs. I noted that his sat never went above 95% even on 100% O2 throughout the case. We had minimal EBL, 200cc UO via foley, and I gave him a total of 300cc of NS, 100mcg of Fent, and zofran.

So during the middle of this case, I get a call from the house Sup that Dr. Soandso (CV surgeon who normally works in the CV OR) wants to do an emerg embolectomy in the OR. As she didn't have the answers to all of my questions, I call him myself to get the scoop on the patient. Introduced myself as the CRNA on call. He has "a really sick patient" that he has been following for several weeks now who fell and fractured her femur. Had an ORIF, and subsequently threw a bunch of PE's. They discovered that she has a PFO that is allowing clots to travel throughout her system. Just last week, he had to remove a clot from her abdominal aorta and she almost didn't make it off the table." He says she has a brachial thrombus and wants to do an embolectomy under local with very little sedation but doesn't think she can tolerate a general anesthetic. I say OK, sounds doable. It's now 2am and I tell him we are in the middle of a case and could be ready by 4am if he still wants to do his embolectomy. He says ok he'll be there and hangs up.

So back to my old friend with crappy sats. It's been an hour since his last dose of Nimbex, I reversed him with 0.4mg of Robinul and 2mg of Neostigmine even though he has an = double burst on the PNS. He's spontaneously ventilating at a RR of 14, pulling a TV of 300ml, ETCo2 at 40's, and Sat's are 92%. I drop his Fio2 to 50% and Sats are 90%. Well not too far off from where we started considering he just had surgery and a bit of narcotics. Decided to extubate to see if he would breath better knowing he was an easy intubation if I need to put the tube back in. Extubated and placed OPA and maintaining a decent airway. Sats are now 88% on 50% O2. He's a bit confused waking as expected and won't lay flat. I give him multiple puffs of albuterol through the mask with minimal improvements. Well 90% is the best he'll give me with the Albuterol, so I decide to ship him out to PACU so they can watch him there.
So at this point, he's not far off from where he started but I'm just not thrilled about a 90% sat with a face mask at 10L. He's fully awake & coherent in PACU, says pain is a 3/10, breathing is not labored, lungs sound the same (wheezing but not wet). Put him on a non-rebreather to see if his sats will improve. Gave albuturol treatment, ordered a CXR, and decided on 10mg of lasix even though he only got 300cc NS and didn't sound wet. Was thinking it may help him.
It's now 315am, and I wanted to be done with this patient 15min ago since I have a 4am embolectomy with a "really sick" patient and don't want to have to start something and have to call in the backup guy b/c my patient is not fairing well in PACU. So I leave my cell number with the PACU nurse. I figure I'll go check out this other patient upstairs and PACU can call me if they have issues. The patient in PACU is "stable", he's just not ready to go back to the telemetry unit quite yet and not 92% back to his old self just yet. He's putting me on edge.
So off to see my next patient. She is in the CVICU, intubated, dopamine just started at 3mcg, fent gtt, VSS stable at sys BP 120-130, HR 100. Get her ready for transport.
30 minutes has gone by, I call down to PACU and 1st patient is improving. Now 93% on face tent, 300cc UO from lasix, should be ready to go back to tele unit in another 15-20min. Cool....
Transported 2nd patient to OR, and surgeon says to me so who's on tonight? Meaning which MDA is on and who's backing me up? My response, "well I'm on tonight. :nurse:. There are 2 others on back up call but I'm not calling them in unless there are other cases that need to go emergently."
He says "wow, they let you guys do a lot here huh?"
I say, "yeah, the only thing I don't do is open heart. Aside from that there is little I haven't done or can't do". Meanwhile I proceed with getting the patient ready to transfer to the OR table. He doesn't say anything else. He sees me setting up a prop gtt and says, "i'd be real careful with that, she's really sick and just last week when I had to open her up she didn't tolerate her GA, and was sat'ing in the 60's the whole time." :eek5: Again, a little late with the details from the surgeon.
I say, "Don't worry doc, I'll go really gentle with her. Just a touch"
Well I ended up giving her about 5mg versed for a 2 hour case and ran the prop gtt at 25mcg/kg/min. She slept the entire time without gas or dopamine. She kept her pressures above 110 systolic the entire case. She tolerated having the dopamine off and went back to the unit safely.
I signed off to the ICU nurse at 630 am and was glad to be done for the morning.
Had McD's for breakfast, check the forum for updates, and went to bed at 8am. :nurse:
Sorry to be long winded but thought it was worth sharing.