Couldn’t intubate - when was your last one?

[vector2]

The dude had 20 + yrs experience and I had worked with him for several years. He was quite capable. I saw no need for continued airway manipulation if he could not visualize the larynx. I don't consider a trainee with a couple yrs of experience to be more skillful at laryngoscopy than he was. No disrespect intended.

I've only been out 5-6 yrs so a 20 yr CRNA has certainly done more successful 1st attempt DLs than me throughout their career.

But I would bet that I've done many, many more successful 2nds and 3rds.

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[DazedWanderer]

The dude had 20 + yrs experience and I had worked with him for several years. He was quite capable. I saw no need for continued airway manipulation if he could not visualize the larynx. I don't consider a trainee with a couple yrs of experience to be more skillful at laryngoscopy than he was. No disrespect intended.

I tend to agree. The main difference in value between an anesthesiologist and a CRNA is that the MD has a much broader knowledge of perioperative medicine and how to manage complex patients. There's really no reason to believe a fellow with 3.5 years of anesthesia experience would be more skilled at DL'ing than a CRNA with 20+ years experience who has probably done ten thousand intubations. Same goes for stuff like putting in IVs or a-lines, these are not overly advanced or complicated procedures. Anyone who has been putting in the reps will get very slick at it, including mid-levels. Having an MD doesn't magically give you better hand eye co-ordination or procedural skills, practicing that procedure over and over again gets you the skill. The MD will dance circles around the CRNA knowledge wise, but I'd wager a competent veteran CRNA may often be more skilled than a resident/fellow at DL simply because they've done orders of magnitude more intubations than them.

 

[T-burglar]

I’ve seen some physicians that are absolute trash at intubation

 

[nimbus]

I’ve seen some physicians that are absolute trash at intubation

Rheumatologists? ID?

 

[DrN2O]

Aintree over scope, 6.0 MLT over scope, use another ETT as a “pusher”. Never really understood cutting the scope. I don’t want to thread a tube over something without structural rigidity.

Aintree through LMA. This is the way.

 

[Maz777]

I tend to agree. The main difference in value between an anesthesiologist and a CRNA is that the MD has a much broader knowledge of perioperative medicine and how to manage complex patients. There's really no reason to believe a fellow with 3.5 years of anesthesia experience would be more skilled at DL'ing than a CRNA with 20+ years experience who has probably done ten thousand intubations. Same goes for stuff like putting in IVs or a-lines, these are not overly advanced or complicated procedures. Anyone who has been putting in the reps will get very slick at it, including mid-levels. Having an MD doesn't magically give you better hand eye co-ordination or procedural skills, practicing that procedure over and over again gets you the skill. The MD will dance circles around the CRNA knowledge wise, but I'd wager a competent veteran CRNA may often be more skilled than a resident/fellow at DL simply because they've done orders of magnitude more intubations than them.

We must work with vastly different CRNAs with different mentalities. If our CRNAs can’t intubate, it’s no sweat off their back. They just acquiesce to us for the 2nd attempt and we take of it. It’s rarely a truly difficult airway under those circumstances. More than 50% of the time, it’s a grade 1 DL.

 

[narcusprince]

The McGrath definitely takes some attempts to get comfortable with. However once facile its a cheaper alternative to glidescope. Our AAs and CRNAs are excellent at intubating rarely do we have issues that a bougie and a VL can’t solve.

 

[Angus Avagadro]

I've only been out 5-6 yrs so a 20 yr CRNA has certainly done more successful 1st attempt DLs than me throughout their career.

But I would bet that I've done many, many more successful 2nds and 3rds.

Absolutely agree. Paralyzed pt with complete airway obstruction, I made the call to trach.

 

[coffeebythelake]

We must work with vastly different CRNAs with different mentalities. If our CRNAs can’t intubate, it’s no sweat off their back. They just acquiesce to us for the 2nd attempt and we take of it. It’s rarely a truly difficult airway under those circumstances. More than 50% of the time, it’s a grade 1 DL.

I dont think he is twiddling his thumbs while the experienced crna is performing thr attempt at intubation. He is probably coordinating additional tools and calling for more backup to tackle thr issue. I think that is sound anesthetic planning.

 

[anbuitachi]

Ludwig angina
Awake fiberoptic, through the cords and see the carina 1 shot no problem
prop and roc, hook up the ventilator, no end tidal
DL, can't see anything. VL can't see anything and now there is blood and pus everywhere. No end tidal. Bag the patient. TVs 50s-100s. Try LMA, still 50s-100s. Call for ENT in the room with trach kit. Trach goes in as soon as the patient starts to desat.

Change pants and undies

this before suggamadex?

 

[Sriddymopboi]

Had a posterior tongue cancer for peg. First DL looked like yellow food, mass. Got him deeper looked again and already blood everywhere. Luckily no paralytic, bagged a bit and canceled. Next time awake foi.

I know this is all in retrospect but a few questions:

1. Did you have any idea about his anatomy beforehand, like any ENT visits describing the mass in the clinic, or CT/MRI imaging?
2. If you didn't have any imaging, then how did you come to the decision to DL first instead of just AFOI in the first place?
3. Why did you cancel? Why didn't you just do an awake fiber right after? In no way am I trying to be accusatory, I'm just a CA-2 and trying to get more nuanced answers on this. My place would have gone straight to AFOI.

 

[ERRES2288]

I know this is all in retrospect but a few questions:

1. Did you have any idea about his anatomy beforehand, like any ENT visits describing the mass in the clinic, or CT/MRI imaging?
2. If you didn't have any imaging, then how did you come to the decision to DL first instead of just AFOI in the first place?
3. Why did you cancel? Why didn't you just do an awake fiber right after? In no way am I trying to be accusatory, I'm just a CA-2 and trying to get more nuanced answers on this. My place would have gone straight to AFOI.

If already blood everywhere it would be tough to do awake fiberoptic right after I would think.

 

[DrOwnage]

I know this is all in retrospect but a few questions:

1. Did you have any idea about his anatomy beforehand, like any ENT visits describing the mass in the clinic, or CT/MRI imaging?
2. If you didn't have any imaging, then how did you come to the decision to DL first instead of just AFOI in the first place?
3. Why did you cancel? Why didn't you just do an awake fiber right after? In no way am I trying to be accusatory, I'm just a CA-2 and trying to get more nuanced answers on this. My place would have gone straight to AFOI.

There are pathways for everything, but you have pick your battles and understand that sometimes the best thing is to abort for another time when one of your colleagues gets to do the case rather than you. All kidding aside, It's not good practice to convert from a general anesthesia dose induction and intubation attempt to an awake unless the case is urgent/emergent. Especially if there are external factors besides the difficult airway itself, i.e. secretions and blood. When doing an AFOI its key to have complete patient cooperation and control of depth of sedation. You don't want anything muddying the picture (i.e. disinhibited patient, possible residual paralysis, higher chance of laryngospasm and reactive airway, swelling from initial attempts, just to name a few). Although some on this forum will claim to be anesthesia jesus and could intubate this patient with their nutsack after the fact.

 

[Anestheezee]

Man I've transitioned to awake glidescope, facing the upright patient, holding the GS "tomahawk" style. Works great when you get used to the video being reversed.

 

[coffeebythelake]

I had to do one asleep. I don’t recommend it and probably a slam dunk malpractice suit if things went south. I had the patient in the or and neck prepped by the general surgeons who are on standby. Tried to do awake but patient started refusing despite me explaining risks beforehand. Decision made to do it asleep.

seems like you've done what you could to protect yourself. The patient, presumably of right mind, refused the safer awake intubation and understood the risks of proceeding with induction. What else were you supposed to do?

Idiot partner that nurse asked to assist me tried to push medications without giving me chance to preoxygenate. Some anesthesiologists are so ******ed.

some people try to be helpful but just make things worse! haha

 

[PpfSuxTube]

Man I've transitioned to awake glidescope, facing the upright patient, holding the GS "tomahawk" style. Works great when you get used to the video being reversed.

Tried it a couple times, couldn't get the hang of it, never again

 

[woopedazz]

Also had an AFOI take a stressful turn after it got coughed out.

Abscess with trismus. I topicalised and did a tracheal puncture for good measure, then took a step back. Trainee scoped all the way down to the Carina with nil issues. Then when railroading tube it got hung up on cartilage/swelling, patient coughed, then tube slid in easy.

They hilted the tube in the nose as withdrawing scope and never really got a good view of the end of the tube despite being so deep until suddenly it popped into view and then trainee just whipped it out as patient was starting to struggle.

Cuff went up and he switched on the vent. Suddenly leak. Panic. Patient did another big cough and the end of the tube popped out the other nostril... Hilarious, bit a bit scary.

 

[ToKingdomCome]

This thread is terrifying lol

 

[DocVapor]

I tend to agree. The main difference in value between an anesthesiologist and a CRNA is that the MD has a much broader knowledge of perioperative medicine and how to manage complex patients. There's really no reason to believe a fellow with 3.5 years of anesthesia experience would be more skilled at DL'ing than a CRNA with 20+ years experience who has probably done ten thousand intubations. Same goes for stuff like putting in IVs or a-lines, these are not overly advanced or complicated procedures. Anyone who has been putting in the reps will get very slick at it, including mid-levels. Having an MD doesn't magically give you better hand eye co-ordination or procedural skills, practicing that procedure over and over again gets you the skill. The MD will dance circles around the CRNA knowledge wise, but I'd wager a competent veteran CRNA may often be more skilled than a resident/fellow at DL simply because they've done orders of magnitude more intubations than them.

This all sounds nice but the reality is that the vast majority of CRNA's only care about getting "good enough" and then stop improving. Putting in reps doesn't make you any good when you start with mediocre technique and never try to improve it.

You're right that having an MD/DO doesn't mean those pesky veins start cooperating for you when they don't others, but it does mean you're more likely to know the buck stops with you, so you don't stop improving. I dance circles around all my CRNAs not just in knowledge but also all of those manual skills you mention even though I've been out 3 years and they've been "experiencing" for decades.

 

[pocafx]

I know this is all in retrospect but a few questions:

1. Did you have any idea about his anatomy beforehand, like any ENT visits describing the mass in the clinic, or CT/MRI imaging?
2. If you didn't have any imaging, then how did you come to the decision to DL first instead of just AFOI in the first place?
3. Why did you cancel? Why didn't you just do an awake fiber right after? In no way am I trying to be accusatory, I'm just a CA-2 and trying to get more nuanced answers on this. My place would have gone straight to AFOI.

1. I had 4 month old CT showing mass that was slightly displacing epiglottis. Small-medium sized mass, open airway
2. As it was a PEG tube, I considered doing a sedation with no airway. But wanted to be more cautious so wanted to intubate and plan was to breathe him down, look, and if bad I could wake up and threw AFOI. The problem was it got bloodly and I couldn’t see ****.
3 . It was bloody. Next time I’ll go straight to AFOI. Live and learn.

 

[coffeebythelake]

I faced a similar problem after ICU freaked about an ETT + igel in situ and wanted me to exchange to a “normal ETT” 😂 - a mere minutes after I was congratulating myself for avoiding a catastrophe.

It’s funny though - I’d never really thought about how to get the igel/lma “out” after a difficult airway scenario before and actually required a bit of thinking. Didn’t have a disposable FOB but if I did I reckon that (cutting it) would be a good way to go.

Tube exchanger and the smallest ett u can railroad through jt

 

[2Fast2Des]

Called to ICU for a 40ish patient who was bleeding from the mouth and gums. Hx of RA and bad rxn to methotrexate, so she was continuous oozing needing constant suctioning from the bleeding raw oral mucosa. Very slim mouth opening, maybe a fingerbreadth at best, even at that the only view was blood. Neutropenic, septic on 3 pressors, and they needed a tube because the bleeding was compromising her airway. My plan was to make this completely awake because of her borderline status, so I had her sitting position, nebulized/atomized the best I could, used soft tip suction to keep the blood mildly at bay. Slid in an Ovassapian airway with the last third sticking out because of the limited mouth opening. Through all this process she was getting tired and complaining she had more trouble breathing, but thankfully the ICU attending was a surgeon, so I had them prep the neck and surgeon gowned/gloved, trach kit at the ready if this didn't work. I slid in the Fiberoptic scope and like a Starfox pro weaved in and around the blood while doing a barrel roll and somehow didn't touch a spec of blood despite the minefield, sprayed some more lido down the scope on the cords and got the tube in. Pt did perfectly despite the situation and didn't buck at all since I wasn't sure how much lido even would have gotten absorbed with all the blood in the mouth coating everything. I basked in my glory and awe of the ICU staff, turned around, dropped the scope and strutted out.

 

[sakata8242]

Morbidly obese parturient, BMI over 60. Urgent D+C for retained POC. I had the dubious honor of taking care of the same patient less than a year ago for her primary c/s. At that time she refused neuraxial up and down - we told her she could die, or worse, and ended up doing a GA with Glide and it went fine. So now she's oozing after her second baby, weighs a little less than a year ago, but unsurprisingly, adamantly refusing neuraxial again. Foolishly, I felt reassured because of her relatively straightforward airway I managed a year ago for her c-section. We did an RSI with Glide and passed the tube through. No end tidal. Double checked the tube, circuit and machine. Still no end tidal. Patient starts desaturating. Suspecting an esophageal intubation, I took another look but at this point was not able to identify any recognizable anatomy. Shoved an LMA in and we were able to squeak some air in and out but not ideal. Woke the patient up and told her she almost died, and that she was getting a spinal for the procedure - I didn't care anymore that she didn't want a needle in her back. Did a CSE (not easy either) but the spinal was good and we didn't have to use the epidural. She did ok.

Another patient - crash c/s - induced GA, couldn't positively identify the glottic opening, couldn't pass the tube with the Glide. Patient desaturates. Shove an LMA in with marginal results. Meanwhile my colleague sneaks in behind me with a 6.0 MLT loaded on a fiberoptic. Slams that tube in through the LMA (no Aintree). The tube is barely long enough to stick far enough out of the iGel LMA so that the circuit can attach. I spend the entire case with my hand on the tube to keep it from moving. He later told me he couldn't really identify anything through the fiber optic either. He saw a hole, guided the fiber in, and shoved the tube in. Patient did ok too.

All of my sphincter tightening airways have always been on ****ing L&D. The stress is even higher because these typically happen at ass-o'clock in the morning, with no other experienced personnel around. OB/GYN is useless and so are the OR nurses (they are just repurposed L&D nurses). ENT is a mile away and if I'm lucky I get a pediatric CRNA from downstairs.