A clinical case from a learner's perspective.

[CodeBlu]

The case is paeds, but the principles can apply to adults and difficult airways, and prone surgery.

Adolescent child with cerebral palsy and a bunch of other comorbidities associated with that. You review the previous anesthetic record... Noted to be a difficult intubation on a previous surgery.

Proposed procedure is a prone spine case. What are the considerations for prone surgery, especially neurospine...? Induction? Emergence? How will you secure your tube?

The old anesthetic record noted they used a MAC #3, and an armoured tube. C-Mac STORZ in the room, and a lightwand just incase. DL produces grade 4 view... grade 3 with BURP. Used a bougie and intubated over that.

So, why re-invent the wheel? We did the exact same thing... Tube went in no problem. 5 hours into the case... we needed higher pressures to ventilate... something was off. Low tidal volumes. Turned the pressure up... was fine for a bit. Mind you the surgeons are being quite aggressive with the spine and moving things around. Then, the capnograph goes flat... You stop the surgeons and you place the patient supine. You've got every airway adjunct known to mankind available. Tube has fallen out.

You attempt DL... and there's so much edema. It's physically impossible to see anything...

What would be your initial sequence of management events/steps? (Yes, securing the airway is obvious... but how?

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[Planktonmd]

LMA... you probably could have done that without turning him supine.

 

[Noyac]

Sure you could try an LMA but your screwed if it doesn't work. I would have done what you did by turning the pt supine. Then depending on the severity of the edema either would have gone straight to cric/Trach or proceeded down the difficult airway algorithm.

For cases where I did not want any chance of the tube moving I have sewn the tube in place to the pts lip.

 

[somedumbDO]

Sure you could try an LMA but your screwed if it doesn't work. I would have done what you did by turning the pt supine. Then depending on the severity of the edema either would have gone straight to cric/Trach or proceeded down the difficult airway algorithm.

For cases where I did not want any chance of the tube moving I have sewn the tube in place to the pts lip.

I agree. Mask ventilate yes or no? Better w an lma?, no? quick dl and nada cut the throat. If one can ventilate, then use whatever trick you want. Where I trained we did a ton of pedi spine and peds craniofacial. I wouldn't do a whole spine case w lma especially since it's prob neurogenic scoliosis w sig resp imparment. I know we joke about retrograde on this forum but with a n=10 on craniofacial kids it works remarkably well.

 

[Urzuz]

Putting in an LMA is a temporizing measure at this point until you get an ETT in again, nothing more. It is not an appropriate airway device in a long spine case in a patient with a known challenging airway.

Turning him supine was the right call. As indicated above, and as is clear from the difficult airway algorithm, the critical question is can you mask ventilate.

I think this is just one of those bizarre complications/situations in anesthesia where you did not do anything wrong, should not have / could not have done anything differently (unless the tube was poorly secured from the get-go), and the spotlight is on you to act appropriately at a moments notice and show why we get paid what we get paid and why we are critical to a patient's care.

 

[urge]

Mind you the surgeons are being quite aggressive with the spine and moving things around. Then, the capnograph goes flat... You stop the surgeons and you place the patient supine. You've got every airway adjunct known to mankind available. Tube has fallen out.

Is that an attempt at blaming the surgeons for the tube coming out? I find it hard to believe.

Probably a lot of saliva and an average tape job, would be my guess.

I would get ready right away for a surgical airway.

 

[propadope]

The case is paeds, but the principles can apply to adults and difficult airways, and prone surgery.

Adolescent child with cerebral palsy and a bunch of other comorbidities associated with that. You review the previous anesthetic record... Noted to be a difficult intubation on a previous surgery.

Proposed procedure is a prone spine case. What are the considerations for prone surgery, especially neurospine...? Induction? Emergence? How will you secure your tube?

The old anesthetic record noted they used a MAC #3, and an armoured tube. C-Mac STORZ in the room, and a lightwand just incase. DL produces grade 4 view... grade 3 with BURP. Used a bougie and intubated over that.

So, why re-invent the wheel? We did the exact same thing... Tube went in no problem. 5 hours into the case... we needed higher pressures to ventilate... something was off. Low tidal volumes. Turned the pressure up... was fine for a bit. Mind you the surgeons are being quite aggressive with the spine and moving things around. Then, the capnograph goes flat... You stop the surgeons and you place the patient supine. You've got every airway adjunct known to mankind available. Tube has fallen out.

You attempt DL... and there's so much edema. It's physically impossible to see anything...

What would be your initial sequence of management events/steps? (Yes, securing the airway is obvious... but how?

As an aside and obviously nothing to do with the management of the crisis but why wouldn't they try a video laryngoscope right of the bat? I realize the bougie and BURP was effective but a grade 3 view is still not ideal. Still potentially more traumatic no? Unless it was a teaching point to do it old school? Sorry for the digression

 

[Planktonmd]

Actually an LMA is the most appropriate next step, and could allow you to avoid flipping the patient over and reprepping everything, So it's undoubtedly worth trying.
It sounds that this case was close to be done, so I wouldn't hesitate putting an LMA in and if it works I would finish the case this way.
I have done that twice during my career, where the ETT was not secured properly and got pulled due to some stupid mistake and in both cases we placed an LMA and in both these cases it worked perfectly.

 

[Urzuz]

Just my opinion as follows, for whoever wants to read it.

Actually an LMA is the most appropriate next step, and could allow you to avoid flipping the patient over and reprepping everything

I can agree that placing an LMA as a temporizing measure may be the most appropriate next step, either in the position the patient is in or after having flipped.

By far, having the nurses reprep everything is the least of my concerns. Flipping a patient with an open wound onto a non-sterile sheet would be a concern for postoperative infection, but the things you can do in this situation are 1) pick up the kid (since it is a child) and throw a sterile drape over the bed and flip him onto this back, 2) Ioban the wound and flip (+/- sterile sheet), or 3) in urgent but non-emergent situation (eg: the situation the OP was originally in where something seemed off with increasing pressures but he hadn't lost all ability to ventilate), have the surgeon do a half-assed closure/staple the wound and then flip (+/- sterile sheet).

It sounds that this case was close to be done,

What makes you say that?

so I wouldn't hesitate putting an LMA in and if it works I would finish the case this way. I have done that twice during my career, where the ETT was not secured properly and got pulled due to some stupid mistake and in both cases we placed an LMA and in both these cases it worked perfectly.

Not saying that it can't be done, but doing it in a kid with a known challenging airway doesn't seem to be prudent in my opinion. We have no idea how many more hours this case is going to be going on for. If they were about to start closing, I can maybe see someone justifying finishing the case with an LMA. But anything short of the surgeon having the closing sutures in his hand, I am putting an ETT back in. The LMA is allowing you to delay the inevitable loss of the ability to ventilate the patient. Look at what the OP said about his laryngoscopy -- severe edema, impossible to see anything. You are comfortable using positive pressure ventilation through an LMA in a prone patient in this situation? I sure as hell am not...

 

[deleted171991]

Intubating LMA?

 

[teeva]

When you initially started having difficulty, I would have suspected ETT migration (in addition to other things) and used a fiber optic scope to confirm placement and advance the tube. If it happened suddenly, then I would leave the tube in its position and still try to advance it, otherwise if that failed flip the pt and attempt to advance tube through the scope or bougie while trying to keep the pt in reverse T position to decrease cephalad edema . If that failed, then mask or LMA and go thru airway algorithm.

IME it only takes a few mins in head up position for cephalad edema to decrease during emergence and extubation for prone peds spine cases, though thankfully I've never had to reassess the airway after extubating.

 

[Planktonmd]

Just my opinion as follows, for whoever wants to read it.



I can agree that placing an LMA as a temporizing measure may be the most appropriate next step, either in the position the patient is in or after having flipped.

By far, having the nurses reprep everything is the least of my concerns. Flipping a patient with an open wound onto a non-sterile sheet would be a concern for postoperative infection, but the things you can do in this situation are 1) pick up the kid (since it is a child) and throw a sterile drape over the bed and flip him onto this back, 2) Ioban the wound and flip (+/- sterile sheet), or 3) in urgent but non-emergent situation (eg: the situation the OP was originally in where something seemed off with increasing pressures but he hadn't lost all ability to ventilate), have the surgeon do a half-assed closure/staple the wound and then flip (+/- sterile sheet).




What makes you say that?



Not saying that it can't be done, but doing it in a kid with a known challenging airway doesn't seem to be prudent in my opinion. We have no idea how many more hours this case is going to be going on for. If they were about to start closing, I can maybe see someone justifying finishing the case with an LMA. But anything short of the surgeon having the closing sutures in his hand, I am putting an ETT back in. The LMA is allowing you to delay the inevitable loss of the ability to ventilate the patient. Look at what the OP said about his laryngoscopy -- severe edema, impossible to see anything. You are comfortable using positive pressure ventilation through an LMA in a prone patient in this situation? I sure as hell am not...

The airway edema as you probably know could mean many things and could mean that it is what happened after multiple direct laryngoscopy attempts after they flipped the patient.
In this business the best solution is usually the simplest solution and if you place an LMA, get a good seal and are able to ventilate, then you are golden!
If the case is expected to take hours then with your LMA you can give the surgeon a chance to stabilize the spine at least and cover the wound properly and at that point you can flip and do what you need to do to intubate under controlled conditions.

 

[Ronin786]

Does it make a difference if this is a cervical vs lumbar spine case? At times during the middle of their decompression, those pins are the only thing holding the entire neck in place.

 

[IlDestriero]

I think this is just one of those bizarre complications/situations in anesthesia where you did not do anything wrong, should not have / could not have done anything differently (unless the tube was poorly secured from the get-go), and the spotlight is on you to act appropriately at a moments notice and show why we get paid what we get paid and why we are critical to a patient's care.

I'll reserve any other comments to allow for residents to comment as this is the kind of case I do regularly, however barring the surgeon working on the face/airway, it's not a bizarre situation that couldn't be avoided, it's you not securing and or supporting the tube and vent tubing properly. A tube should not dislodge itself, ever.
As an aside, I've never sutured a tube in, but I've had the OMFS guys wire it to a tooth. And I had a surgeon suture in a couple of emergent cricothyrotomy tubes in trauma patients. They can do it much faster and probably better and more secure. That's not a tube I want to slip. Those days are probably over for me now though.

 

[fakin' the funk]

Tube fell out? C'mon, man.

The only ETT / LMA I've ever had dislodged went like this. Placed an untaped armored tube and then turned 180 for a facial plastics surgeon who likes it that way. Been turned 180 about 30 seconds, barely put the vent back on and haven't even had time to put the zigzag "kinks" in the long circuit that help anchor the tube, before the circulator goes to put on the SECOND safety strap (yes, two straps) and snags the circuit so hard the tube just straight up flies out the mouth. Facepalm.

 

[deleted59964]

Does it make a difference if this is a cervical vs lumbar spine case? At times during the middle of their decompression, those pins are the only thing holding the entire neck in place.

Cervical case neck often flexed in pins ... Makes opening mouth very difficult and prone lma placement an unlikely option

 

[Urzuz]

I'll reserve any other comments to allow for residents to comment as this is the kind of case I do regularly, however barring the surgeon working on the face/airway, it's not a bizarre situation that couldn't be avoided, it's you not securing and or supporting the tube and vent tubing properly. A tube should not dislodge itself, ever.
As an aside, I've never sutured a tube in, but I've had the OMFS guys wire it to a tooth. And I had a surgeon suture in a couple of emergent cricothyrotomy tubes in trauma patients. They can do it much faster and probably better and more secure. That's not a tube I want to slip. Those days are probably over for me now though.

While I agree with your general sentiment that an ETT falling out is suboptimal, using absolute words like "never" and "always" in medicine is dangerous, and you will be proven wrong by case reports, anecdotal experiences, and as I like to call them, "bizarre" situations. In my original post, I purposefully said that the OP could not have done anything differently, unless the tube was improperly secured from the start. Then, obviously, there was a goof up that could have easily been prevented. However, since we haven't heard anything else from him regarding tube security, I will continue to give him the benefit of the doubt.

And to be clear, I've done thousands of spines and prone cases through my residency and career, have never sutured a tube in, and have never had one dislodge or fall out. That being said, weird **** happens in medicine. I HAVE seen a piece of a rod being cut by a spine surgeon fly across the room and hit the instrument rep in the room, and he then had to go to the ED. That's probably something that should "never" happen either...

 

[IlDestriero]

A tube should never dislodge itself during a case. That's a fair never. It's may happen, but it's unacceptable. It's reportable in our CQI for that reason. And it shouldn't happen barring staff error (pulling it) or anesthesia error (not properly securing it at the start, light anesthesia and tonguing it out, etc. ). Those are not freak unavoidable events like lightning strikes, tornadoes, and getting broadsided by someone running a red light. It's an avoidable event, and things can actively be done to avoid them.
I look forward to seeing a case report where the tube fell out on its own while prone due to no fault of the operative team or anesthesiologist. That would be bizarre indeed.
And I'm not giving the OP the benefit of the doubt because something caused that tube to dislodge. It was either pulled out or it fell out because the tape was slobbered off. It didn't shrink, get cut, or spontaneously decompose.

 

[Hoya11]

I also disagree with the sentiment that "oh how bizarre the tube came out, s** happens in anesthesia" This should be seen as a failure to properly secure and monitor the tube and actions should be taken to ensure it doesnt happen again. I would also flip the kid over and intubate, LMA, or mask in that order. Sterile sheet underneath is a good idea but who cares, secure the airway, deal with the aftermath. LMA prone in this kid who slobbered so much the tube came out is not a good idea IMO

 

[Urzuz]

A tube should never dislodge itself during a case. That's a fair never. It's may happen, but it's unacceptable. It's reportable in our CQI for that reason. And it shouldn't happen barring staff error (pulling it) or anesthesia error (not properly securing it at the start, light anesthesia and tonguing it out, etc. ). Those are not freak unavoidable events like lightning strikes, tornadoes, and getting broadsided by someone running a red light. It's an avoidable event, and things can actively be done to avoid them.
I look forward to seeing a case report where the tube fell out on its own while prone due to no fault of the operative team or anesthesiologist. That would be bizarre indeed.
And I'm not giving the OP the benefit of the doubt because something caused that tube to dislodge. It was either pulled out or it fell out because the tape was slobbered off. It didn't shrink, get cut, or spontaneously decompose.

I also disagree with the sentiment that "oh how bizarre the tube came out, s** happens in anesthesia" This should be seen as a failure to properly secure and monitor the tube and actions should be taken to ensure it doesnt happen again. I would also flip the kid over and intubate, LMA, or mask in that order. Sterile sheet underneath is a good idea but who cares, secure the airway, deal with the aftermath. LMA prone in this kid who slobbered so much the tube came out is not a good idea IMO

I agree that if it was improperly secured, the patient coughed it out, he pulled it out, etc...then it is on him. But he hasn't didn't say anything about how it came out in his original post.

I guess we are all saying the same thing, but approaching it from different angles. I am saying right now "innocent until proven guilty," and we just don't know enough about the circumstances to say who or what was at fault. Maybe the adhesive from the tape was faulty? Maybe the surgeon yanked on the circuit? Or maybe, the tape job was ****.

I didn't mean to become an advocate for the OP. Condemn him all you want, doesn't affect me one bit. I guess I'm just a little more interested in the circumstances.

And in regards to the sterile sheet idea, usually there is a sterile drape somewhere that would take two seconds to throw onto the gurney. Obviously airway/ventilation takes priority, but I think if it were readily available it could be a good idea if the kid's back is still filleted open.

Edit: And if you both look above, the tube coming out has happened to even experienced people like Plankton. Once again, rather than saying the anesthesiologist ****ed up, it is sometimes better to inquire as to how it happened...

 

[Hoya11]

I agree that if it was improperly secured, the patient coughed it out, he pulled it out, etc...then it is on him. But he hasn't didn't say anything about how it came out in his original post.

I guess we are all saying the same thing, but approaching it from different angles. I am saying right now "innocent until proven guilty," and we just don't know enough about the circumstances to say who or what was at fault. Maybe the adhesive from the tape was faulty? Maybe the surgeon yanked on the circuit? Or maybe, the tape job was ****.

I didn't mean to become an advocate for the OP. Condemn him all you want, doesn't affect me one bit. I guess I'm just a little more interested in the circumstances.

And in regards to the sterile sheet idea, usually there is a sterile drape somewhere that would take two seconds to throw onto the gurney. Obviously airway/ventilation takes priority, but I think if it were readily available it could be a good idea if the kid's back is still filleted open.

Edit: And if you both look above, the tube coming out has happened to even experienced people like Plankton. Once again, rather than saying the anesthesiologist ****ed up, it is sometimes better to inquire as to how it happened...

Dont mean to castrate the OP, we have all had failures of all kinds Im sure with lines and tubes. The key is to do failure analysis and see how you can get it better next time, not to dismiss it as a crazy unforeseable event (which it might indeed be) but best to analyze.

This is a tube that came out gradually, without any sudden movement by anyone else, during a long prone case with a kid, WITH signs of something fishy with the tube just prior.

 

[Urzuz]

This is a tube that came out gradually, without any sudden movement by anyone else, during a long prone case with a kid, WITH signs of something fishy with the tube just prior.

Agree that something does sound fishy!

 

[Planktonmd]

Agree that something does sound fishy!

How does fishy sound???

 

[urge]

How does fishy sound???

Like an air leak perhaps?

 

[urge]

Dont mean to castrate the OP, we have all had failures of all kinds Im sure with lines and tubes. The key is to do failure analysis and see how you can get it better next time, not to dismiss it as a crazy unforeseable event (which it might indeed be) but best to analyze.

This is a tube that came out gradually, without any sudden movement by anyone else, during a long prone case with a kid, WITH signs of something fishy with the tube just prior.

Let's get this thread moving. There really is not much to do other than:

1 attempt facemask ventilation
2 attempt supra glotic mask ventilation
3 attempt intubation (DL, video, retrograde!, fiberoptic if you are crazy)
4 surgical airway ( jet ventilation , cric)

We know DL was attempted and failed.

You can try all the others until something works or the patient dies.

Now, let's go to the relevant points of this case;
1 How was the tube secured?
2 Was the circuit secured close to the patient so that the weight wouldn't pull on the tube all case long?
3 How did you position the head? Prone pillow? Head turned to the side? Horseshoe? Pins?
4 Was your bellows loosing volume and did you have to go up on the flow?
5 When you say the "tube has fallen out", do you mean it was on the floor with all the tape around it and still attached to the circuit?

 

[urge]

Since the OP neglected his thread I have taken the liberty to give it some conclusion.

Here is what I imagine happened:

Mask attempt didn't work. DL showed a grade 4 view, bougie resulted in an esophageal intubation while someone made sure the glidescope worked. By now the sat is in the 20's and the patient is getting bradycardic. Glidescope has an unrecognizable picture. CPR started when the patient goes asystolic. An ENT surgeon walks in and does an emergency trach after about 15 min of cpr. The patient goes to the icu and doesn't really wake up but does not fulfill criteria for brain death.

All due to a botched tape job.

 

[deleted59964]

seems to me the previous anesthetic was lucky to get a tube in -- grade 4, then 3 with burp and got a tube with a bougie ...
plan to repeat the same was "courageous" IMHO

hardly surprised this resulted in a CICO when the tube was displaced ... it may well have happened with the initial induction.

 

[propadope]

seems to me the previous anesthetic was lucky to get a tube in -- grade 4, then 3 with burp and got a tube with a bougie ...
plan to repeat the same was "courageous" IMHO

hardly surprised this resulted in a CICO when the tube was displaced ... it may well have happened with the initial induction.

My sentiments exactly (See my previous post); whether or not it had anything to do with the crisis.

 

[WholeLottaGame7]

Adolescent child with cerebral palsy and a bunch of other comorbidities associated with that. You review the previous anesthetic record... Noted to be a difficult intubation on a previous surgery.

The old anesthetic record noted they used a MAC #3, and an armoured tube. C-Mac STORZ in the room, and a lightwand just incase. DL produces grade 4 view... grade 3 with BURP. Used a bougie and intubated over that.

So, why re-invent the wheel? We did the exact same thing... Tube went in no problem. 5 hours into the case... we needed higher pressures to ventilate... something was off. Low tidal volumes. Turned the pressure up... was fine for a bit. Mind you the surgeons are being quite aggressive with the spine and moving things around. Then, the capnograph goes flat... You stop the surgeons and you place the patient supine. You've got every airway adjunct known to mankind available. Tube has fallen out.

You attempt DL... and there's so much edema. It's physically impossible to see anything...

What would be your initial sequence of management events/steps? (Yes, securing the airway is obvious... but how?

To echo other people: you re-invent the wheel because a grade 3/4 intubation is a "we got lucky, let's not do that again" intubation that should not lead to a "they got lucky last time, maybe we'll get lucky again" plan for intubation the next time. That's fine to see if maybe the first anesthetist was just a bum with a DL or to see if the VL produces a better view, but there should have been a FO cart in the room.

And I would have taped the ever-lovin-bejeezus out of that tube, plus mastisol with tegaderms. With prone cases and difficult airways, I would almost intentionally mainstem then pull back until you're right above the carina. That way if it comes out a cm or two on flipping, you're still safe. If it goes in a cm or two, you're one-lung ventilating, which is not ideal but still better than no-lung ventilating.

As for your case, in order, I would call for ENT/gen surg stat, go supine, try to place LMA. I doubt there's any point in even trying to DL considering you got lucky twice with intubations under ideal scenarios, and now you're edematous and hypercarbic and hypoxic. Someone's going to have to cut the neck, so if gen surg/ENT aren't around the corner it's going to have to be you.

Who am I kidding? We all know the answer here: retrograde wire.

 

[IlDestriero]

It's a good case for retrograde wire.

 

[WholeLottaGame7]

It's a good case for retrograde wire.

I've never done one, but it does seem like one of the few times I'd even consider trying it. I was only like, 70% joking in the original post. This time.

 

[Libertas]

Would you still attempt retrograde wire even if the patient wasn't able to be ventilated? I know an attending who has done multiple of them for complex ENT cases, but they were always awake, and not done in emergent circumstances.

 

[IlDestriero]

We have a wire kit in the difficult airway cart. I've used it on sim heads. Way back in the day I used to do a transtracheal lido injection. I've done surgical cricothyrotomies in trauma patients. That's all good experience which should make this successful. If this patient was circling the drain, had a good neck, and could not be intubated or ventilated, a retrograde wire is much less traumatic than a cric or slash trach from ENT and can be done quickly. You can always convert it to something more dramatic 30 seconds later if it doesn't work for some reason.
We actually did one on an esophagectomy patient of mine as a resident with a lost airway post procedure, but I didn't place it, the attending did. I used the wire to place the tube though. So I guess I did 1/2 of one. . That patient was in the death spiral and was 30 seconds from an ugly trach by the surgeon. Worked great.
We've used them for impossible airways in EXIT procedures as well. It's a very underrated rescue technique, yet taught in every difficult airway class.