Once upon a time that really happened, the patient was not waking up the way they should. All the anesthesia gases were off, the reversal agent given at least 10 minutes, but they were not opening their eyes or making any effort to, you know, breathe. Time ticks by, first five minutes, and then 10, and then 15 minutes. The anesthesiologist has been called to the room.
While anesthesia is trying to wake the patient up, you drag the workstation on wheels to the patient’s bedside so you can be an active part of the extubation, but also able to read the chart looking for clues.
There are none.
Time for a group think.
You ask about family history that isn’t in the chart. You remember that there is an enzyme deficiency that delays the clearance of anesthesia. You remember because one of your med-surg patients had it and would call for a certain medication whenever she woke up from anesthesia. You remember her telling you that she had a liver problem in the beginning of this conversation. And not only did she have it but so did her youngest daughter. And the last time there was a very long delay in waking up from anesthesia on one of the cases you’ve worked, it was also an enzyme deficiency. The same one the med-surg patient had.
The anesthesiologist goes out to the surgical waiting room to ask about family history of slow wake ups. This was covered in the pre-op consultation at bedside but this is a check in that what the patient and family said pre-op is correct. This is where they remember that grandfather would talk about the time that it took so long for him to wake up after surgery that when he finally did it was the next day and he was in ICU. But no one else has had a long wake-up. Not that many of them had ever had surgery other than babies.
There is such an enzyme deficiency that causes this. It is called pseudocholinesterase deficiency. This is an enzyme that breaks down anesthetic medications, such as succinylcholine. This is the medication that is often used to paralyze the patient prior to intubation.
Unknown to any of us, and the patient, and the family, this patient had a pseudocholinesterase deficiency. Their liver wasn’t metabolizing the paralytic, which kept them unable to breath on their own.
This is a quandary. There are two paths. The first is to keep the patient intubated in the operating room until enough time has passed to allow them to breath on their own. This is costly as an OR minute is expensive and who knows how long it will take before the patient wakes up. And also it effectively ties up the anesthesia team and leaves OB especially vulnerable in case there is a stat section. The second path is to keep the patient intubated, call for a ventilator to be brought to the PACU, and admit them to the ICU. Not long, just long enough for them to start breathing on their own. This can be anywhere from 2 hours to 12 hours.
The decision is made to move the patient to PACU and the waiting ventilator. If they are not extubatable at 2 hours, then PACU would move the patient to the ICU. Because call back time for the PACU nurse is expensive.
The first thing to do as the OR call nurse is to check the hospital census. This is a picture of what rooms are available. The second thing is to call the supervisor and tell them about the situation and the steps that might need to happen going forward. They promise to save an ICU bed.
The patient is moved to PACU, and attached to the ventilator and the monitors.
The waiting begins.
After the patient is settled in PACU, on a ventilator, you call the surgeon, who has been long gone, to tell them of the situation. Regardless of the working theory it is pseudocholinesterase deficiency, the surgeon still needs to be informed of what is going on. You tell the surgeon of the plan to wait in PACU for 2 hours and then the admission to the ICU if the patient is not yet awake.
You check in the PACU nurses and tell them that you’ve called the surgeon and gotten them up to speed on the situation. If there is nothing else, you will be heading home because OR call back time is expensive and being in the PACU when there are 2 recovery room nurses is expensive.
You remind them that the nursing supervisor is aware, there is a bed being held and the surgeon is aware. They run through the plan again with you of 2 hours intubated in the PACU and then, if not awake enough to extubate, admission to the ICU. They tell you to go home.
On your way out of the PACU you pass the anesthesiologist who is writing a letter to the patient advising them to be tested for pseudocholinesterase deficiency and advising them of the importance of having the family tested to. Because this is a genetic deficiency and is passed down. Like the patient’s grandfather likely passed it down to the rest of the family.
Luckily there is a test for that.
You tell the anesthesiologist that the PACU nurses know the plan and ask if they’ve spoken to the family again. If they have, you are going home.
The anesthesiologist assures you that the family has been spoken to and are waiting to see which path is to be taken.
You head home.
In a rare follow-up, you learn that the patient was able to breath in the PACU after an hour. They were extubated and sent home with family. The entire family was aware that they had to be tested or tell the next hospital and operating room they found themselves at.
This was the best case scenario. If the patient hadn’t been a young, health individual with a possible family history of pseudocholinesterase deficiency, more steps would have been taken in case it was something else. A head CT would have been the next stop to check for a stroke, and labs would have been drawn.
But not this patient. They were able to be extubated and go home with their family. With a heck of a story to tell and homework to do.
Dispatches from the Evening Shift 