The meds don't work
July 10, 2023 2:31 PM Subscribe
A few weeks ago I had a revision surgery to implant a CRT-D. Despite me telling them I need more lidocaine than the average bear, I didn't get enough. And the fentanyl and versed barely touched me. Why? (More details inside.)
So, regarding the lidocaine, they gave me some, but I could still feel them cutting and fussing in my chest. What can I say or do next time to make them understand I need more? Is there an alternative?
The fentanyl and versed worked at first, but I kept waking up groaning "I need more sedative." Apparently they gave me 8 "units" of versed, plus fentanyl, and then I maxed out. They couldn't give me any more despite me being conscious, having a panic attack, and annoying the doctor with all my talking and commentary (which I do understand). Eventually they gave me benadryl which made me very sleepy, but by then the surgery was almost over.
Why might these drugs not have worked on me? They did 6 years ago.
Doc said next time or for other procedure to ask for general anesthesia, but that seems like overkill for colonoscopies or when they have to change my battery out in a few years. Plus, since I am super fat and have a Mallampati score of 3/4 I am just generally afraid of general anesthesia. What are some other twilight/moderate sedation things I could ask for?
If your response is "this is a question for your doctor" please move on. They have fucked up my STD paperwork, don't answer the phone or portal messages, did not schedule the required wound check appointment, and have spent <10 minutes total helping me, outside of the operating room.
So, regarding the lidocaine, they gave me some, but I could still feel them cutting and fussing in my chest. What can I say or do next time to make them understand I need more? Is there an alternative?
The fentanyl and versed worked at first, but I kept waking up groaning "I need more sedative." Apparently they gave me 8 "units" of versed, plus fentanyl, and then I maxed out. They couldn't give me any more despite me being conscious, having a panic attack, and annoying the doctor with all my talking and commentary (which I do understand). Eventually they gave me benadryl which made me very sleepy, but by then the surgery was almost over.
Why might these drugs not have worked on me? They did 6 years ago.
Doc said next time or for other procedure to ask for general anesthesia, but that seems like overkill for colonoscopies or when they have to change my battery out in a few years. Plus, since I am super fat and have a Mallampati score of 3/4 I am just generally afraid of general anesthesia. What are some other twilight/moderate sedation things I could ask for?
If your response is "this is a question for your doctor" please move on. They have fucked up my STD paperwork, don't answer the phone or portal messages, did not schedule the required wound check appointment, and have spent <10 minutes total helping me, outside of the operating room.
I'm so sorry, this must be really frustrating and scary.
Have you gained substantial weight in the last 6 years? These drugs work based on body weight so you may be above the weight now where the max dose is effective.
I have a genetic condition that makes opiates not work great for me, but I found Dilaudid did actually work, although at a very high dose. Maybe you could try that? And maybe nitrous for the panic attack? I'm not sure how much that is used in surgery in the US tho.
I hope you find a solution!
posted by ananci at 2:48 PM on July 10, 2023
Have you gained substantial weight in the last 6 years? These drugs work based on body weight so you may be above the weight now where the max dose is effective.
I have a genetic condition that makes opiates not work great for me, but I found Dilaudid did actually work, although at a very high dose. Maybe you could try that? And maybe nitrous for the panic attack? I'm not sure how much that is used in surgery in the US tho.
I hope you find a solution!
posted by ananci at 2:48 PM on July 10, 2023
Is propofol an option for you? I find the fentanyl + propofol combo works well for me. I know less about the lidocaine question, but I recall seeing a number of other -caines (I think bupivacaine was one) on my surgical paperwork so it sounds like there are other options. No idea if they will be more effective for you, though.
posted by wheatlets at 2:58 PM on July 10, 2023 [2 favorites]
posted by wheatlets at 2:58 PM on July 10, 2023 [2 favorites]
There are also links between having red hair and anesthesia issues.
posted by Chrysopoeia at 3:20 PM on July 10, 2023 [4 favorites]
posted by Chrysopoeia at 3:20 PM on July 10, 2023 [4 favorites]
Not fully an answer to your question, but worth sharing I think. Lidocaine doesn't really work for me. I didn't know when you were "numb" you aren't supposed to feel anything. I thought it was more like, just dampened sensation. I had a biopsy and told the doctor I could feel what he was doing. He didn't believe me, but then he hit some piece of tissue the resisted and l gasped at the pain. He went a bit pale, froze, and said "oh, you ARE feeling that!"
I've since had marcaine and chloroprocaine for subsequent biopsies and they worked like a charm. I felt nothing. I kept poking the area and going, "whoa, Is that what numb feels like?!" Lol. I realized all my dental work was worse than necessary.
Now I just let doctors know lidocaine doesn't work for me and make sure they have one of the others on hand.
I also have almost no effect from morphine either and oxycodone mostly makes me sick and disorientation but doesnt help pain. No advice on these, just different bodies are different and sometimes things don't work they way they do for most people.
posted by CleverClover at 6:03 PM on July 10, 2023 [5 favorites]
I've since had marcaine and chloroprocaine for subsequent biopsies and they worked like a charm. I felt nothing. I kept poking the area and going, "whoa, Is that what numb feels like?!" Lol. I realized all my dental work was worse than necessary.
Now I just let doctors know lidocaine doesn't work for me and make sure they have one of the others on hand.
I also have almost no effect from morphine either and oxycodone mostly makes me sick and disorientation but doesnt help pain. No advice on these, just different bodies are different and sometimes things don't work they way they do for most people.
posted by CleverClover at 6:03 PM on July 10, 2023 [5 favorites]
I know it won't help you, but I'm the same way -- my dentist has been polite enough to triple my novocaine (which works, and she's the best injection person I've ever had for any injection ever), while other specialists routinely fail to give me sufficient drugs despite my warning them in advance. The normal doses of Versed, Phenobarbital and Sodium Pentathol don't work well enough to stop me from waking during surgical procedures, which is profoundly non-fun, remarkably dangerous, and very hard for any medical person to believe until they see it happening in front of them and then they freak out (which is also not-fun). I'm even mildly resistant to fentanyl (takes roughly 30% more to see the expected effect, from what they told me).
I'm not a redhead either, but there's definitely something going on with all of us and it would be just swell if docs could actually listen to their patients when we warn them if they use the usual dose we're gonna either A) not go down or B) wake up in the middle of it.
...which, I guess, I mainly mention to encourage you to keep fighting!
posted by aramaic at 6:30 PM on July 10, 2023 [1 favorite]
I'm not a redhead either, but there's definitely something going on with all of us and it would be just swell if docs could actually listen to their patients when we warn them if they use the usual dose we're gonna either A) not go down or B) wake up in the middle of it.
...which, I guess, I mainly mention to encourage you to keep fighting!
posted by aramaic at 6:30 PM on July 10, 2023 [1 favorite]
> What are some other twilight/moderate sedation things I could ask for?
No experience, but I'd get the relevant records and a note from your anesthesiologist to show to future anesthesiologists, so that you aren't just trying to communicate with future anesthesiologists verbally, but rather you actually have a hardcopy to go over with them in the pre-surgery stage.
posted by sebastienbailard at 6:42 PM on July 10, 2023 [13 favorites]
No experience, but I'd get the relevant records and a note from your anesthesiologist to show to future anesthesiologists, so that you aren't just trying to communicate with future anesthesiologists verbally, but rather you actually have a hardcopy to go over with them in the pre-surgery stage.
posted by sebastienbailard at 6:42 PM on July 10, 2023 [13 favorites]
Best answer: Unfortunately these procedures when not performed under general anesthesia are typically performed with the cardiologist dictating the moderate sedation while a regular nurse (not a nurse anesthetist) administers the medications. Consequently, they tend to be very cautious and conservative with dosages, usually adhering to a strict numerical limit rather than titrating to effect. For most patients this is not an issue, but if you happen to be an outlier in terms of what you require for adequate sedation, you'll unfortunately run into trouble.
With regard to lidocaine, even with perfect use it will not prevent you from feeling the procedure - what it does is dull the 'sharp' and 'pain' sensations, but it is perfectly normal to feel pressure and manipulation throughout (not clear from your question if you felt sharp pains or mainly pressure). With a combination of lidocaine and adequate sedation, the sensations of pressure should not be distressing.
The most common reason to require higher than typical doses of opioid and benzodiazepines for conscious sedation is tolerance due to habitual use of related medications. Do you take opioid medicines like oxycodone, or benzodiazepines like Xanax or Ativan? Do you drink alcohol daily or have a very high alcohol tolerance? High body weights can also relatively increase the absolute dose that would be required for effective sedation.
Asking for general anesthesia means that at a minimum you would have an anesthesia specialist (anesthesiologist and/or CRNA) dedicated to your care during future procedures - not necessarily that they would give you general anesthesia, but you would have someone dedicated to assessing you, selecting the most appropriate plan of anesthesia, monitoring you and titrating medication to effect. Because they would not also be focused on performing the procedure (colonoscopy, generator change, etc), they would be better able to provide you with adequate sedation. Given the challenges you experienced this time it doesn't sound like overkill to me.
(IAAD, NYD)
posted by telegraph at 7:25 PM on July 10, 2023 [14 favorites]
With regard to lidocaine, even with perfect use it will not prevent you from feeling the procedure - what it does is dull the 'sharp' and 'pain' sensations, but it is perfectly normal to feel pressure and manipulation throughout (not clear from your question if you felt sharp pains or mainly pressure). With a combination of lidocaine and adequate sedation, the sensations of pressure should not be distressing.
The most common reason to require higher than typical doses of opioid and benzodiazepines for conscious sedation is tolerance due to habitual use of related medications. Do you take opioid medicines like oxycodone, or benzodiazepines like Xanax or Ativan? Do you drink alcohol daily or have a very high alcohol tolerance? High body weights can also relatively increase the absolute dose that would be required for effective sedation.
Asking for general anesthesia means that at a minimum you would have an anesthesia specialist (anesthesiologist and/or CRNA) dedicated to your care during future procedures - not necessarily that they would give you general anesthesia, but you would have someone dedicated to assessing you, selecting the most appropriate plan of anesthesia, monitoring you and titrating medication to effect. Because they would not also be focused on performing the procedure (colonoscopy, generator change, etc), they would be better able to provide you with adequate sedation. Given the challenges you experienced this time it doesn't sound like overkill to me.
(IAAD, NYD)
posted by telegraph at 7:25 PM on July 10, 2023 [14 favorites]
People with Ehlers-Danlos Syndrome are hard to freeze, not that telling healthcare professionals this will make a difference, because they mostly sneer at people who mention EDS, if they even know about it, and will probably still assume you have a drug problem. Just sharing that for your knowledge in case it’s relevant. You now have this unfortunate experience on your file, so the suggestions above should work.
(Takes 3-4 times the normal amount of whatever to freeze me for dental work, my last experience was straight up reportable. Dentist didn’t believe or listen to me - god forbid you tell a HCP anything - then insulted me and continued working anyway, before aggressively jabbing a needle into my jaw which left me with lockjaw for a few months, the assistant was shocked.)
posted by cotton dress sock at 10:04 PM on July 10, 2023 [3 favorites]
(Takes 3-4 times the normal amount of whatever to freeze me for dental work, my last experience was straight up reportable. Dentist didn’t believe or listen to me - god forbid you tell a HCP anything - then insulted me and continued working anyway, before aggressively jabbing a needle into my jaw which left me with lockjaw for a few months, the assistant was shocked.)
posted by cotton dress sock at 10:04 PM on July 10, 2023 [3 favorites]
Best answer: IANYD. This is general commentary about anesthesia.
First, the numbness from local lidocaine infiltration (unlike a nerve block) is usually incomplete and dull sensations remain. When working with pockets like for implanting a cardiac device generator, patients will especially feel pressure transmitted to deeper tissues.
Second, midazolam and fentanyl have a number of factors that modify their effectiveness. With lower cardiac output (which I assume you have getting a CRT-D), midazolam takes longer to work but fentanyl is effectively stronger. Younger people need larger doses. People who take ADHD or narcolepsy medications (read: uppers) or regular cannaboids sometimes need much more. People who consume large amounts of alcohol but don't have cirrhosis are resistant to midazolam. If these medications worked for you in the past, it is unlikely related to genetic variation. Fentanyl requirements go up with body mass, and it dissolves well into fat. Requirements don't quite scale linearly because fat isn't as well supplied with blood flow. Midazolam does not work if the IV isn't working well, either because it isn't in the vessel or because that vein is pinched off based on the arm position. Fentanyl will work even injected subQ, but takes longer. Syringe swaps or other medication admin errors also occur.
8 mg of midazolam is enough to induce general anesthesia in many people; 5 mg will knock many people out cold if not quite able to tolerate putting in a breathing tube. I will often use 10 mg for intubation if that is the only agent I have available (less in sick people), so wanting to stop at 8 for a short procedure is pretty reasonable. Starting over and seeing what's not working would make sense if the procedure wasn't almost over.
There are alternative agents. Dexmedetomidine (precedex) is popular for younger people and alcoholics, but tends to leave one groggy. Ketamine is very effective but causes hallucinations in some people. Propofol almost always works well, but can cause apnea and is only usable by clinicians skilled in its use and airway management (CRNAs, anesthesiologists, ED docs, ICU docs). It is often used for deep sedation (and often indistinguishable from general anesthesia).
Some people don't tolerate mild-moderate sedation well. It's ok.
posted by a robot made out of meat at 2:42 PM on July 11, 2023 [3 favorites]
First, the numbness from local lidocaine infiltration (unlike a nerve block) is usually incomplete and dull sensations remain. When working with pockets like for implanting a cardiac device generator, patients will especially feel pressure transmitted to deeper tissues.
Second, midazolam and fentanyl have a number of factors that modify their effectiveness. With lower cardiac output (which I assume you have getting a CRT-D), midazolam takes longer to work but fentanyl is effectively stronger. Younger people need larger doses. People who take ADHD or narcolepsy medications (read: uppers) or regular cannaboids sometimes need much more. People who consume large amounts of alcohol but don't have cirrhosis are resistant to midazolam. If these medications worked for you in the past, it is unlikely related to genetic variation. Fentanyl requirements go up with body mass, and it dissolves well into fat. Requirements don't quite scale linearly because fat isn't as well supplied with blood flow. Midazolam does not work if the IV isn't working well, either because it isn't in the vessel or because that vein is pinched off based on the arm position. Fentanyl will work even injected subQ, but takes longer. Syringe swaps or other medication admin errors also occur.
8 mg of midazolam is enough to induce general anesthesia in many people; 5 mg will knock many people out cold if not quite able to tolerate putting in a breathing tube. I will often use 10 mg for intubation if that is the only agent I have available (less in sick people), so wanting to stop at 8 for a short procedure is pretty reasonable. Starting over and seeing what's not working would make sense if the procedure wasn't almost over.
There are alternative agents. Dexmedetomidine (precedex) is popular for younger people and alcoholics, but tends to leave one groggy. Ketamine is very effective but causes hallucinations in some people. Propofol almost always works well, but can cause apnea and is only usable by clinicians skilled in its use and airway management (CRNAs, anesthesiologists, ED docs, ICU docs). It is often used for deep sedation (and often indistinguishable from general anesthesia).
Some people don't tolerate mild-moderate sedation well. It's ok.
posted by a robot made out of meat at 2:42 PM on July 11, 2023 [3 favorites]
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posted by damayanti at 2:47 PM on July 10, 2023 [6 favorites]