![]() ![]() At 1040, the patient was extubated uneventfully and placed on a venti-mask. At this time, the patient was responsive to verbal stimuli and was able to maintain head lift for five seconds. The ventilator settings remained unchanged, and at 1030 another blood gas was drawn which showed continued improvement as the COHB level had decreased to 5.3%. At 1000 another blood gas was drawn, and the results were the following: pH 7.56 pCO2 20 mm Hg pO2 482.5 mm Hg HCO3 18.5 MEq/l COHB 12.4%. At 0940 the patient became more reactive, requiring midazolam 1 mg for sedation. The patient arrived in the PACU at 0935 and was noted to be pale and unresponsive to verbal or tactile stimuli. In the PACU, the patient was placed on a ventilator with the same settings as were given in the OR with the addition of 5 cmH20 PEEP. It was decided to leave the patient intubated, on 100% 02, and ventilated in the Post Anesthesia Care Unit, until the level of COHB decreased enough to permit safe extubation. The entire time interval from when the 02Hgb saturation started to decrease to the completion of the surgery was 30 minutes. The surgeon was made aware of the new findings, and the procedure was completed over the next 10 minutes. At this point, the patient’s 02-Hgb saturation remained at 97%. The blood gas report read the following values: pH 7.46 PC02=28 mm Hg P02 467 mm Hg HCO3 20.3 MEq/l COHB 31.5%. The surgeon was made aware of these findings and was asked to complete the procedure as quickly as possible.Īrterial blood gases were sent to check the 02 saturation a COHb level was also requested. This also failed to bring the patient’s O2 saturation above 96%. At this point, the patient was placed on 100% 02 and hand ventilated with up to 40 cmH20 pressure. The endotracheal tube was also checked for its position, and it was noted to still be secured at 20 cm at the lips. Breath sounds remained equal bilaterally, without wheezes, and there was no change in PIP. The pulse oximeter probe was inspected to verify proper placement on the finger. Following induction, the vital signs were: BP 110/60, HR 95, SaO2=100% (FiO2=40%), Temp 36.5 C.Īpproximately 40 minutes into the case, the patient’s 02-Hgb saturation decreased to 96% over a period of 2-3 minutes. ![]() Prior to induction, the patient’s vital signs had been: BP 140/88, Heart Rate 95, SaO2=97% (room air), Temperature 36.5 C. An additional 10 mg of atracurium was given IV to complete the balanced anesthetic technique. The patient was then placed on the ventilator with the settings of TV 600 Rate 10, PIP 20 cmH20. The tube was secured at 20 cm at the lips, breath sounds were equal bilaterally, and EtCO2 was noted on the anesthetic gas monitor. The patient was intubated with a 7.0 cuffed endotracheal tube under direct vision. The patient was pre-oxygenated and general anesthesia was induced with alfentanil 500 mg, lidocaine 70 mg, atracurium 5 mg (defasiculating dose), propofol 100 mg, and succinylcholine 100 mg intravenously. The patient was taken to the operating room where she was placed on the table, positioned, and monitors including NIBP, pulse oximetry, and EKG were placed. The patient then received glycopyrolate 0.2mg IV with midazolam 2mg IV for sedation. While in the holding area, an intravenous line was placed with D5LR infusing at 100cc/hr. Routine pre-op labs were within normal limits, and specific values were: Hgb 14.1, Na 141, K 3.8, Cl 108, C02 23, and Ca 9.6. The patient did, however, admit to being a smoker, with a 20 pack/year smoking history. The patient also denied any prior anesthetics and she was not taking any chronic medications. During her pre-op interview, the patient denied any cardiac or respiratory history. Report of a CaseĪ 46-year-old white female was scheduled as an outpatient for septoplasty, endoscopic bilateral anterior ethmoidal sinus surgery, and excision of a left tonsillar cyst. Reported here is an instance where this appears to be so. As new halogenated anesthetics become available and are used, it remains to be observed whether they too will be associated with this apparent phenomenon. ![]() Previous reports regarding the diagnosis of carbon monoxide exposure from an unknown source have suggested that there is an interaction of the halogenated volatile anesthetics and the carbon dioxide absorbent in the breathing circuit, particularly when an anesthesia machine which delivered volatile anesthetic then sat unused for a period of time.
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