TILIR #22 & 23: Gotta walk before you can... RUN! NOW!

Last Monday, I started a new block. I am trading in my collared shirt and khakis for some comfy scrubs and heading into the basement of the hospital to hang out with the sedation folks. Sedation is a weird place. It's a very pediatric specific concept where an entire department is created to provide a space for children to have minor procedures and time-intensive imaging. Most adults can handle a lumbar puncture with only local anesthetic or sitting through an MRI with, at most, a little anti-anxiety medication.

Kids, on the other hand often don't understand why they need a procedure, can't sit still enough for a scan, and have a very low pain tolerance. So most pediatric hospitals have a sedation department to help get kids through these little experiences that cause them big anxiety.

MondayIL: The Mallampati score is a way to estimate ease of intubation prior to a sedation procedure. Basically, a score of I says that you can see the back of the throat easily through the mouth. II and III indicate that you can see either most of or just the base of the uvula (the dangly thingy in the back of your throat) respectively. IV means the patient's mouth shape and tongue size make seeing the throat very difficult, and accordingly, they would be a more difficult intubation.

Another metric we use is the ASA (American Society of Anesthesiology) scale, which categorizes patients by how generally healthy or sick they are:

• ASA I - Healthy
• ASA II - Mild sytemic disease or major disease under good control (mild asthma, cancer in remission, etc.)
• ASA III - Major disease/illness, not controlled (influenza, cancer not in remission, etc.)
• ASA IV - Major disease/illness that is a constant threat to life (ICU patients)
• ASA V - Unstable patients that will die without the procedure
• ASA VI - Brain-dead patient awaiting organ donation

Well that escalated quickly, huh?

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On Tuesday I got to experience a bit of the sink-or-swim method of teaching. The physicians that administer monitored anesthesia care (MAC) (formerly known as conscious sedation) in my hospital are all pediatric intensivists (ICU doctors). As this level of sedation is by far the most common in the sedation unit, it's most of what I get to see. After one day observing various intensivists administer sedatives, generally in the form of Propofol +/- Fentanyl, I was getting somewhat comfortable with the procedure of "pushing meds," as they call it.

On day two, I was rushing out of one procedure and into another for which sedation was being provided by an attending I had yet to work with. I walk into the room, apologize for not being there at the start, and am immediately beckoned over to the head of the bed. 

"This is what, your second day?" asks the intensivist. 

"Yep!" I assured him. 

"And you've been pushing meds, right?" 

"Nope! Not yet!" I reply nervously. 

"Well, there's no better time to start!" he says without missing a beat, and hands me the syringe of death milk (it's white and opaque, much like milk, actually for the same reason as milk (it's a colloidal suspension)).

While this may seem horrifyingly reckless, it's a good bet that a nervous resident is going to err far on the side of pushing too little anesthesia than too much. And in fact, that first time, I didn't push a single milliliter of sedative without the attending telling me to.

TuesdayIL: If a patient's oxygen saturation starts plummeting during a procedure, there are several things that can be going on. First, check that the pulse ox sensor is actually still on their finger. Of course they'll have a low reading if the little red light isn't shining through their finger/toe/earlobe/etc.

But say it's real. The patient's oxygen saturation actually is plummeting. What's happening and what do you do? The two most likely answers to what's going on are that:

a) you pushed too much medication and now they aren't breathing, or
b) something irritated the middle part of the throat (larynx) and the patient is trying to breath, but can't because the airway is spasming closed.

So, what do you do? Actually the exact opposite thing. In the first case stop pushing sedatives. You also may need to put a mask on them and bag a few breaths until they start breathing on their own again.

In the second case, it's far easier. Push more sedative medication, and quickly. This will relax those spasming muscles and allow air to pass again.