Remaining intubated post op

[PainDrain]

Case scenario as follows: 70 yo M with hx of DM and HTN who has a left hip replacement at an outside hospital three weeks prior presents with neck pain, inability to ambulate, fever and lethargy. Work up shows a large cervical epidural abscess, new hip is aspirated and shows pus and he reports several joints that are tender. The neurosurgeon books a multilevel posterior decompression, washout and fusion to start at 11pm. The patient arrives in the PACU AOx1, somnolent and febrile. You start the case and it goes fairly smoothly, guy requires a neo infusion throughout the case and into the PACU and ABGs drawn off the blood gas show metabolic acidosis. At the end of the case the surgeon is really pushing to extubate because “he doesn’t need to be kept intubated for no reason.” I fought him saying he has a fresh cervical fusion, poor mental status, multiple sites of infection and has the potential to become floridly septic. I get “sepsis isn’t a reason to keep someone intubated” from the surgeon. WTF

Am I being unreasonable and is there some new approach here? I have been out of training for a bit but I was always taught to keep certain patients intubated post op; sepsis, poor mental status, large volume resuscitation, and those requiring large amounts of hemodynamic support keep the tube until proving they no longer need it.

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[repititionition]

“Out of training for a bit” = still understands critical illness. You did the right thing.

 

[DocMcCoy]

Case scenario as follows: 70 yo M with hx of DM and HTN who has a left hip replacement at an outside hospital three weeks prior presents with neck pain, inability to ambulate, fever and lethargy. Work up shows a large cervical epidural abscess, new hip is aspirated and shows pus and he reports several joints that are tender. The neurosurgeon books a multilevel posterior decompression, washout and fusion to start at 11pm. The patient arrives in the PACU AOx1, somnolent and febrile. You start the case and it goes fairly smoothly, guy requires a neo infusion throughout the case and into the PACU and ABGs drawn off the blood gas show metabolic acidosis. At the end of the case the surgeon is really pushing to extubate because “he doesn’t need to be kept intubated for no reason.” I fought him saying he has a fresh cervical fusion, poor mental status, multiple sites of infection and has the potential to become floridly septic. I get “sepsis isn’t a reason to keep someone intubated” from the surgeon. WTF

Am I being unreasonable and is there some new approach here? I have been out of training for a bit but I was always taught to keep certain patients intubated post op; sepsis, poor mental status, large volume resuscitation, and those requiring large amounts of hemodynamic support keep the tube until proving they no longer need it.

I would have kept him intubated. F that guy. Just tell him you can’t get him off the vent and go to icu. Multi level cervical fusion, acidosis, sepsis, poor mentation at baseline, large volume resuscitation, pressors collectively is an easy sell to keep intubated

 

[coffeebythelake]

"he doesn’t need to be kept intubated for no reason"... but there are multiple reasons.

The surgeon is a putz. Agree with your plan.

 

[Southpaw]

fusion? he put new hardware in this guy who’s obviously infected everywhere? what’s ortho think about that hip hardware? doesn’t it need to come out, patient made non weight bearing, and antibiotics for 6 weeks or so?

if I’m reading the story correctly I’m not making a call on whether or not you should’ve kept the guy intubated, but I know spine guy doesn’t routinely manage critically ill patients. He can stay in his lane and work on his own judgment.

 

[Arch Guillotti]

Forget all the fancy reasoning. Just tell the surgeon the guy is “too sick” and leave him intubated. Move on.

 

[IMGASMD]

Don’t wanna be the one getting call for “possible” difficult intubation because of “cervical precaution” in the middle of a Friday/Saturday night…. On second thought, any f-ing night.
Extubation criteria not met. (Ask the putz what’s HIS extubation criterias….) Pt can wake up tomorrow when he’s more awake….

 

[coffeebythelake]

Forget all the fancy reasoning. Just tell the surgeon the guy is “too sick” and leave him intubated. Move on.

Sometimes we gotta dumb it down in a way thr surgeon can understand...

 

[kidthor]

Sometimes we gotta dumb it down in a way thr surgeon can understand...

yes, just like the ortho reps do.

 

[AKMD_1984]

please tell me you didn’t extubatne him?

 

[Radetzky]

There’s no right answer. Depends on length of operation, neo dose, overall gestalt, etc. But it’s your call not his

More interested in his decision to put metalware into an actively infected patient

 

[Urzuz]

There’s no right answer. Depends on length of operation, neo dose, overall gestalt, etc. But it’s your call not his

More interested in his decision to put metalware into an actively infected patient

I have a gue$$ as to what hi$ rea$oning wa$

 

[T-burglar]

No benefit all risk. leave intubated and see his clinical trajectory before pulling it

 

[coffeebythelake]

Some surgeons like to talk **** about the ICU team saying they are not aggressive enough in their extubations and that their patients linger for days or weeks with a tube and have a terrible postop course. I think that is clearly an example of selection bias.

 

[Beeftenderloin]

Baseline altered mental status, still metabolizing their anesthetic, middle of the night, septic, acidotic, with a freshly immobilized c-spine for when he aspirates and needs to be re-intubated at 3am? Hard pass. I’ll always entertain a thoughtful discussion about post-op expectations with my surgical colleagues but ultimately, whether the patient leaves the OR w/ or w/o a tube is 100% my call 100% of the time. If my explanation isn’t adequate I just kinda nod while they get out of their system whatever they needed to say, reiterate the tube is staying in, then move on.

Also, I’m not taking any advice from someone with poor enough judgment to put hardware in someone actively/acutely infected.

 

[PpfSuxTube]

"Stay in your lane."

"****"

 

[Caninehalitosis]

You made the smart choice. I recently reviewed similar case. Late night/sick patient/abdominal surg/obese/difficult airway who was extubated late nite/early am after surgery. Pt required reintubation which went poorly. Pt ultimately died and Anesthesiologist ended up with 2 years of med staff misery.

 

[Simba1711]

If in doubt just leave it in. I’ve never regretted leaving a patient intubated. Sort of funny that the ortho surgeon is giving you advice. They have the least medical knowledge of all the specialties.

 

[Dr. Rude]

This isn’t even a close call.

 

[IMGASMD]

If in doubt just leave it in. I’ve never regretted leaving a patient intubated. Sort of funny that the ortho surgeon is giving you advice. They have the least medical knowledge of all the specialties.

They invented bro juice, and wanted me to give that to every patient before tourniquet is up… you’re telling me that they don’t know medicine?!

 

[zizzer]

The patient was somnolent before anesthesia then had a metabolic acidosis. Proper respiratory compensation via mechanical ventilation is enough of a reason in itself, let alone all the other reasons people noted. And this is coming from somebody who thinks we leave too many patients intubated in general.

For trainees, this is why practicing for oral boards is actually very useful. Even when you know you're right, it's imperitive to be able to succinctly state your reasoning.