need attending/senior resident opinions please

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Jeff05

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case i had today.

59 male (70kg/6foot) no PMH for hemicolectomy. easy airway, no sux (roc).
position: supine. maintain: iso-air-o2, roc, fentanyl. surgery time: 3.5 hrs. I/O: 5L LR/EBL 500/Urine 400.

towards the end switch to n20. RR 14/TV 400s. suction pharynx. lots of fentanyl on board. full reversal given after 1/4 TOF. n20 off, iso still around (0.15), opens eyes, protrudes tongue on command. i pull tube. oral airway already in place.

immediately notice loud inspiratory stridor. mask on - he's moving some air. give couple of breaths, no improvement. patient awake following commands, but can barely keep his eyes open, seems weak. insert nasal airway. continue positive pressure ventilation. attending walks in..."he looks weak" he gives another mg of neo. stridor loud. attending suggests racemic epi...ok...slap neb on and stridor disappears within 30 seconds. sats stable. pt breathing unassisted.

start moving patient to stretcher and all of a sudden stridor is back. and it's loud. and then, it's completely quiet and pt is bucking holding his neck. slap mask on can't ventilate. oral airway in, two hands on mask, attending squeezing bag - nothing going in. sats dropping. prop and tube. on DL: grade I view normal anatomy, no secretions or blood, abducted cords - nothing strange.

my impression: partial laryngospasm following extubation. resolved. repeat partial spasm progressed to complete when moving to stretcher.

has anyone seen recurrent laryngospasm in a middle age pt who is completely awake? or is something else going on?
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I think he was obstructed from being weak. Doubt it was a laryngospasm. Vocal cords are very sensitive to muscle relaxants. Thus, I don't think he could spasm. And if it were it should have been very easy to break with positive pressure. Why did you guys give racemic epi? Did you actually think his stridor was from airway edema? Be careful reversing with one or two twitches.
 
s h it happens....you won't always know why....you just have to deal with it.
 
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On a 70kg patient, what's your definition of "full reversal"? How long since the last dose of NMB? How much total NMB given? You also don't specify if you checked TOF/tet after you reversed your NMB. Did you ask him to hold his head up?

Opening their eyes and sticking out their tongue doesn't excite me much.
 
The picture he is describing: "Patient bucking but unable to move air" is more compatible with laryngospasm than muscle weakness, and the existence of stridor prior to that also makes laryngospasm more likely (obstruction because of soft tissue collapse due to muscle weakness will not give you stridor).
It happens.
Did he have a recent cold or some other URI?
 
urge said:
I disagree. Any upper airway obstruction causing turbulent flow will give you stridor.
Click to expand...
Soft tissue obstruction does not cause stridor it causes snoring and whistling.
Think about people with sleep apnea, they don't have stridor every time they fall asleep do they?
Many people confuse stridor with other upper airway noises.
 
Agreed, bronchospasm or laryngospasm is most likely. I have seen similar situations in those who had a recent URI or some form of RAD. Luckily, nothing more than PPV was needed.
 
pmichaelmd said:
Agreed, bronchospasm or laryngospasm is most likely. I have seen similar situations in those who had a recent URI or some form of RAD. Luckily, nothing more than PPV was needed.
Click to expand...

If it is truly stridor it is from upper airway obstruction and would either be the vocal cords or soft tissue just above. Bronchospasm wouldn't cause stridor.
 
I know exactly what this is:

Click here and drag


it is

Mental Masturbation


down here.
 
Planktonmd said:
Soft tissue obstruction does not cause stridor it causes snoring and whistling.
Think about people with sleep apnea, they don't have stridor every time they fall asleep do they?
Many people confuse stridor with other upper airway noises.
Click to expand...

The ENTs would call this stertor.
 
From the description, it sounds like laryngospasm. Did you give this guy some CPAP and a good sturdy jaw lift? Patients also sometimes will obstruct after extubation despite following commands while the tube is still in - though usually what I see in this case is chest movement with no air movement. And a good sturdy jaw lift fixes that too.
 
I see the
beatpq2.gif
continues.
 
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ok, here's a non-masturbatory question

nobody in my program pulls the tube and subsequntly/simultaneously leaves an oral airway in....somwtimes, they'll put in a nasal airway..my sense is this is from concern for the oral airway being poorly tolerated....can oral airways lead to laryngospasm? (I think i've seen this when I rotated at the childrens hospital...)
 
joshmir said:
ok, here's a non-masturbatory question

nobody in my program pulls the tube and subsequntly/simultaneously leaves an oral airway in....somwtimes, they'll put in a nasal airway..my sense is this is from concern for the oral airway being poorly tolerated....can oral airways lead to laryngospasm? (I think i've seen this when I rotated at the childrens hospital...)
Click to expand...

At CHOP ....all peds cases leave the OR with an oral a/w in place..ie placed before extubation.
 
Yes oral airways can cause spasm, it is important to properly select the size of the OAW. Physically place one next to patient's mouth/neck and see where the tip will ride to. Don't go by weight. If the tip would be clearly seated in the neck past the vocal cords, that would be a bad choice. Likewise with nasal airways. Just quickly place one on the side of the patient and see where the tip would lie.

Almost all of my patients leave with an OAW or NAW and that allows me to keep the OR turnover time to a minimum while still safely recovering the patient.
 
joshmir said:
ok, here's a non-masturbatory question

nobody in my program pulls the tube and subsequntly/simultaneously leaves an oral airway in....somwtimes, they'll put in a nasal airway..my sense is this is from concern for the oral airway being poorly tolerated....can oral airways lead to laryngospasm? (I think i've seen this when I rotated at the childrens hospital...)
Click to expand...
I am a strong believer in oral airways, I think every patient that gets intubated should have one in during the case and keep it after extubation unless they are able to take it out themselves.
They prevent tube biting (during the case or at emergence)) which could be really ugly, and after extubation they minimize the likelihood of soft tissue collapse and allow you to suction if you need to.
Sure you can do without it but that requires extra vigilance and more skill which can not be guaranteed if you are not in the room at all times (supervising).
 
we've had 5 dental injuries at my practice in the last 3 years.

4 of them were oral airway related.
 
militarymd said:
we've had 5 dental injuries at my practice in the last 3 years.

4 of them were oral airway related.
Click to expand...
If the oral airway causes dental injury it means it did it's job and prevented the patient from biting the tube or biting the tongue, so these 4 dental injuries would have been 4 negative pressure pulmonary edema or tongue lacerations, I prefer dental injury.
 
Planktonmd said:
If the oral airway causes dental injury it means it did it's job and prevented the patient from biting the tube or biting the tongue, so these 4 dental injuries would have been 4 negative pressure pulmonary edema or tongue lacerations, I prefer dental injury.
Click to expand...

I'm not sure what your patient population is like, but the patients we anesthetize are able to move air through clenched teeth......

I suppose you could live somewhere where once you close your mouth, it becomes a hermetic seal....AND ALL of them are obligate mouth breathers because the nasal passages are sealed due to genetic anomalies....

Where do you practice??? Could it be Mississippi?
 
and the sword-fighting begins.
 
We had a case where a patient had a crainiotomy and had an oral airway for the case. When the patient woke up after surgery, he had medial necrosis of his tongue, right where the airway was. ENT resected the middle third of his tongue. Patient did well. No speech impediment, but a little Gene Simmons action.

Me personally, I only put in an airway if I need to. Dental claims are like a giant hemorrhoid you can't scratch.
 
numbmd said:
We had a case where a patient had a crainiotomy and had an oral airway for the case. When the patient woke up after surgery, he had medial necrosis of his tongue, right where the airway was. ENT resected the middle third of his tongue. Patient did well. No speech impediment, but a little Gene Simmons action.

Me personally, I only put in an airway if I need to. Dental claims are like a giant hemorrhoid you can't scratch.
Click to expand...
Do you do your own cases?
 
btw ....even if you go ahead and just pay for dental repairs....that is an action that is reportable to the National Practitioner Database....or so my lawyer tells me...

so I wouldn't offer to pay for broken teeth even if it is your fault...ie you used an Oral airway as a bite block....


which if you look at the package insert ...it is not meant to be a block......the insert specifically says " NOT a bite block " on it.
 
I'm a fan of the soft bite block, ie a bunch of 4x4 gauzes rolled up and taped. Low risk, prevents the tube biting if you're going to pull it awake, and easy to make.
 
militarymd said:
btw ....even if you go ahead and just pay for dental repairs....that is an action that is reportable to the National Practitioner Database....or so my lawyer tells me...

so I wouldn't offer to pay for broken teeth even if it is your fault...ie you used an Oral airway as a bite block....


which if you look at the package insert ...it is not meant to be a block......the insert specifically says " NOT a bite block " on it.
Click to expand...
The masseter muscles are the strongest muscles in the human body and no matter what you put in the mouth, even if you put nothing, if the patient bites hard enough he/she is going to have dental injury.
So if the patient injured his teeth on the oral airway it's not the fault of the airway it's the fault of the anesthesia provider who allowed the patient to emerge in such a brutal way to bite so hard.
Anyone can induce general anesthesia but only few really know how to wake patients up.
Still, if I have a less skilled provider in the room I would rather have dental injury than have negative pressure pulmonary edema or tongue laceration.
But that's my practice and I realize that many people see things differently.
 
Planktonmd said:
The masseter muscles are the strongest muscles in the human body and no matter what you put in the mouth, even if you put nothing, if the patient bites hard enough he/she is going to have dental injury.
So if the patient injured his teeth on the oral airway it's not the fault of the airway it's the fault of the anesthesia provider who allowed the patient to emerge in such a brutal way to bite so hard.
Anyone can induce general anesthesia but only few really know how to wake patients up.
Still, if I have a less skilled provider in the room I would rather have dental injury than have negative pressure pulmonary edema or tongue laceration.
But that's my practice and I realize that many people see things differently.
Click to expand...

so what you're saying is that you INTENTIONALLY use a medical device in a way that it is not supposed to be used.
 
Planktonmd said:
:laugh:
Exactly! it's an off label use!
I am curious though, when did you start worrying about legal and liability issues?
Very out of character for you.
Click to expand...

I'm not. I'm just pointing out that using an oral airway as a bite block is not good practice.
 
Planktonmd said:
Do you do your own cases?
Click to expand...

I do well over 90 % of my own cases. I crack open an oral airway only when it's difficult to ventilate. I'm not trying to be a braggart, but most days I don't open an airway. I'm out 13 years. Can't quite figure out number of cases, but I generate about 16-18 thousand units a year (somewhat over 800 cases a year) and yes we do have residents, but they cover less than 10% of my cases. If I have a hip or bariatric case, the crainy or thoracotomy usually supercedes, and I get jack.

Oral airways are great, I'm just cautioning you on some complications for it's use. If you don't need it, why use it? I don't mind a dental complication with an patient when I have a difficult time ventilation. But getting a complication when I didn't even need an airway is worse.

One other word on Dental issues. I had two since starting training. One as a resident, trying to intubate a hip in bed with the the trapeze still in place. (very stupid) The other on an uncomplicated cysto. I get a call from a patient three weeks after the case stating that his dentist told him to go to me for reimbursement for a 4000 restoration.

I'm in a panic. I look up the chart....... That mother f-er had an LMA! I called him back told him he only had a soft tube in his mouth he should go to the dentist who did the original work, not me.

Then he tells me that it happened 1 week AFTER the procedure. But his dentist tells him that it was most likely anesthesia's fault. Did he use to be a surgeon?
 
numbmd said:
I do well over 90 % of my own cases.
Click to expand...
This is why you can do cases without oral airway since you are the one in the room watching the patient at all times, I don't have that luxury.
I have seen many cases of negative pressure pulmonary edema over the years that made me see things differently.
 
Planktonmd said:
This is why you can do cases without oral airway since you are the one in the room watching the patient at all times, I don't have that luxury.
I have seen many cases of negative pressure pulmonary edema over the years that made me see things differently.
Click to expand...

Good point.
 
jwk said:
On a 70kg patient, what's your definition of "full reversal"? How long since the last dose of NMB? How much total NMB given? You also don't specify if you checked TOF/tet after you reversed your NMB. Did you ask him to hold his head up?

Opening their eyes and sticking out their tongue doesn't excite me much.
Click to expand...

actually tongue protrusion is a better indicator of pharyngeal mx strength than head lift.
 
Point well taken about the oral airways. What I've tried to do after hearing from people about dental injury is use a size 10 o/a instead of the regular size 8.

If you notice the bottom part of the o/a is 'softer'. Therefore, if you use a larger sized o/a the patient will only bite on the soft part and not the hard part that usually pt's bite on to cause dental injx.
 
SleepIsGood said:
Point well taken about the oral airways. What I've tried to do after hearing from people about dental injury is use a size 10 o/a instead of the regular size 8.

If you notice the bottom part of the o/a is 'softer'. Therefore, if you use a larger sized o/a the patient will only bite on the soft part and not the hard part that usually pt's bite on to cause dental injx.
Click to expand...

Using the wrong size is not much help. An 8 works for a small woman. Stick a 10 in her and a good inch of the airway is going to hang out, or it will be tickling her cords.
 
numbmd said:
I do well over 90 % of my own cases. I crack open an oral airway only when it's difficult to ventilate. I'm not trying to be a braggart, but most days I don't open an airway. I'm out 13 years. Can't quite figure out number of cases, but I generate about 16-18 thousand units a year (somewhat over 800 cases a year) and yes we do have residents, but they cover less than 10% of my cases. If I have a hip or bariatric case, the crainy or thoracotomy usually supercedes, and I get jack.

Oral airways are great, I'm just cautioning you on some complications for it's use. If you don't need it, why use it? I don't mind a dental complication with an patient when I have a difficult time ventilation. But getting a complication when I didn't even need an airway is worse.

One other word on Dental issues. I had two since starting training. One as a resident, trying to intubate a hip in bed with the the trapeze still in place. (very stupid) The other on an uncomplicated cysto. I get a call from a patient three weeks after the case stating that his dentist told him to go to me for reimbursement for a 4000 restoration.

I'm in a panic. I look up the chart....... That mother f-er had an LMA! I called him back told him he only had a soft tube in his mouth he should go to the dentist who did the original work, not me.

Then he tells me that it happened 1 week AFTER the procedure. But his dentist tells him that it was most likely anesthesia's fault. Did he use to be a surgeon?
Click to expand...

Un-friggen-believable man. I'd go put sugar in that dentist's gas tank. As for the patient, he's never welcome back.
 
numbmd said:
I'm in a panic. I look up the chart....... That mother f-er had an LMA! I called him back told him he only had a soft tube in his mouth he should go to the dentist who did the original work, not me.

Then he tells me that it happened 1 week AFTER the procedure. But his dentist tells him that it was most likely anesthesia's fault. Did he use to be a surgeon?
Click to expand...

That's right up there with a chiropractor blaming a patient's back pain on their labor epidural a year ago.
 
SleepIsGood said:
actually tongue protrusion is a better indicator of pharyngeal mx strength than head lift.
Click to expand...

OK, I've heard (over the past 15 years) folks state that 5 seconds of head lift is the gold standard, whereas an equal number of folks state that sticking out the tongue is a better measure than head lift.

Comments please. Thanks.
 
actually, pt doing a cartwheel is a better indicator of strength. i just stayed at a holliday inn express. :D
 
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