Oral airways as bite blocks in OR

[Planktonmd]

You mean like





Sure, can't argue with that. You have to work with the limitations of the people around you.



All the tools in the world can't turn a sloppy anesthetic into something elegant.

In my experience the great majority of patients - even the obese OSA'ers - don't need an airway device at all if they're extubated at the right time after a well-designed anesthetic.

For that subset of patients who I think will need an airway adjunct after extubation, ie when they're awake, I prefer nasal trumpets. A little Afrin, some lube +/- phenylephrine, an appropriate size, the discretion to not keep jamming away causing trauma if it doesn't go in easy ... I just don't have problems with bloody noses. So much nicer and better tolerated than an oral airway.

When I see patients arrive in PACU with oral airways, they're obtunded enough to tolerate them, and it always strikes me as, well, sub-optimal.

You are confusing 2 different things: What should be the ideal anesthetic in competent hands and what should be the defensive technique to prevent a CRNA from killing a patient... 2 different things buddy!

---

Members don't see this ad.

 

[pgg]

There's nothing wrong and no one is "a *****" or "need to evaluate career choices" for emerging a patient with an oral airway to help with airway patency, especially if you're waking people up deep.

It was "life choices" not "career choices" and it probably deserved a smiley if the tongue-in-cheekness of it was that non-obvious.

Of course there are a million safe ways to perform an anesthetic.

Deep extubations are another issue entirely, and I wouldn't think anyone doing deep extubations would think they needed a bite block. Although, since you brought it up maybe someone who needs an airway adjunct isn't the best candidate for a deep extubation.

 

[Planktonmd]

It was "life choices" not "career choices" and it probably deserved a smiley if the tongue-in-cheekness of it was that non-obvious.

Of course there are a million safe ways to perform an anesthetic.

Deep extubations are another issue entirely, and I wouldn't think anyone doing deep extubations would think they needed a bite block. Although, since you brought it up maybe someone who needs an airway adjunct isn't the best candidate for a deep extubation.

You can extubate deep more people by pulling the tube and replacing it with an oral airway!

 

[narcusprince]

I am a bit confused about the oral airway causing patients to gag with an ET tube in place. In my opinion the ET tube with a cuff is stimulating more nerves then the oral airway. I agree that long term use of a rigid hard oral airway may cause some pressure related ischemia on the palate. But a soft gel like oral airway I have not seen it cause any oral ischemia related injury. I dont see how using one = hack anesthesiologist. Their are multiple ways to skin a cat in our field. Whats safe is a confluence of your practice and mine that keeps our names out of the national practicioner database.

 

[criticalelement]

The goal is extubate after AWAKE right? Awake patients don t need nasal or oral airways.

 

[jwk]

Either you haven't done enough cases or you have a different patient population, but it doesn't take a large percentage to have one case of a patient biting down and resulting in NPPE. An ounce of prevention, with a simple soft bite block may have prevented the young healthy patient from a complication.

I typically use a soft bite block, but if I anticipate the need to assist in ventilation upon extubation, I will use an OPA. I wouldn't leave the hard airway in place during the case but place it when I am ready to emerge the patient.

Knock on wood - 35 years and I've never had a case of NPPE. Most important key is avoiding it in the first place - and if you head towards trouble, sux is still your friend. I was raised in a time when sux and pavulon was all we had. I respect sux, but I'm not afraid to use it, and sometimes it's the best thing in the world to keep you out of trouble. 10mg can fix any number of evils, and usually they don't quit breathing.

 

[europeman]

So anyone have a suggestion for my ICU? I'm thinking of just asking the anesthesiologists to remove their oral airway bite block when they drop the patient off in the ICU.

Remember, these patients are intimated and are woken up in the ICU (sometimes as soon as paralytic a wear off and sometimes the following morning)

 

[Wiscoblue]

Really? You're 'yelling' about presence of an oral airway in an intubated patient? Is it causing that much harm to warrant so much emotion?

I've been doing cardio thoracic anesthesia for 33 years. I rarely ever leave an airway in when dropping off my patient in the icu. I've never handed off the patient personally to an icu doc. It's usually to a nurse because the icu doc is either busy someplace else or in bed.

But I've seen NPPE at least a couple of times. I use the rolled up gauze between the molars for most of my non cardiac cases. The roll is sticking out quite a bit out of the mouth and usually taped to the LMA or et tube. That way they come out together.

I wouldn't call anyone a hack for using an OPA or a nasal trumpet. To each their own. But I've seen torrential bleeding from a nasal temperature probe. I usually avoid the nose for anything that I can place through the mouth.


Sent from my iPad using Tapatalk

 

[pgg]

So anyone have a suggestion for my ICU? I'm thinking of just asking the anesthesiologists to remove their oral airway bite block when they drop the patient off in the ICU.

Remember, these patients are intimated and are woken up in the ICU (sometimes as soon as paralytic a wear off and sometimes the following morning)

The ICU extubation has a different risk profile.

The kind of patient who goes to the ICU is not, in general, the young strong muscular dude who's at high risk of NPPE from biting the tube at emergence.

More importantly, there's no volatile anesthetic stage 2 emergence for an ICU wakeup. Waking from ICU sedation with propofol or other IV agents is less abrupt.

If you're going to use a bite block, use a soft one. Rolled up gauze is great.

 

[europeman]

Wiscoblue - I'm not yelling. I realize it's use (oral airway as bite block) is based on individual preference and clinical circumstance/practice.

I just want suggestions of how I can assure this device is removed expeditiously once the patient is in the ICU. Like I said, simply instructing my nurses/RT to do is problematic given the characteristics of my Hospital (RT rarely available - over worked and under staffed. RN reluctant to take out something placed by physician - though this culture/practice I am working on).

In short I'm going to ask anesthesia to remove it once they drop the patient off in the ICU, and based on individual circumstance if they are uncomfortable with totally removing a bite block, to instead replace it with a rolled up gauze and/or tongue depressor with gauze. anything but an oral airway basically....

Would you guys/gals think this is reasonable?

Pgg, i'm in a trauma/SICu - so many of our patients actually are young and male. So, from an anesthesiologist perspective, I totally get how our patients actually are high risk.


lemma know your thoughts

 

[NICMAN]

Rolled up gauze taped with wet-resistant or silk tape with a long tail. I always use bite blocks for prone cases in such a way to prevent the tongue from dropping forward between the incisors and swelling up. I typically place a bite block out of habit, not because I'm sloppy with my anesthetic, but I tend to think a single unintended hospital admission from that 1-2 second NPPE event is not worth ditching the habit of using a bite block.

 

[rakotomazoto]

I had one case in ECT where patient chipped a tooth on oral airway bite block, multiple attendings have mentioned having a similar experience at some point in their practice. Gauze to create a soft bite block is a much safer alternative, no one wants to see their dentist because they had anesthesia.

I do agree that poor dentition increases risk of having dental damage, but why go there in the first place?

 

[drmwvr]

Good grief...its an oral airway not a chain saw.

 

[vector2]

I used an OPA as a wakeup bite block for 90+% of my general cases throughout residency (institutional culture) and never had a case where someone broke their tooth. If you're waking up people so abruptly and uncomfortably that they're biting hard enough to break teeth, it's not the OPA that's your problem.

 

[Hoya11]

Wiscoblue - I'm not yelling. I realize it's use (oral airway as bite block) is based on individual preference and clinical circumstance/practice.

I just want suggestions of how I can assure this device is removed expeditiously once the patient is in the ICU. Like I said, simply instructing my nurses/RT to do is problematic given the characteristics of my Hospital (RT rarely available - over worked and under staffed. RN reluctant to take out something placed by physician - though this culture/practice I am working on).

In short I'm going to ask anesthesia to remove it once they drop the patient off in the ICU, and based on individual circumstance if they are uncomfortable with totally removing a bite block, to instead replace it with a rolled up gauze and/or tongue depressor with gauze. anything but an oral airway basically....

Would you guys/gals think this is reasonable?

Pgg, i'm in a trauma/SICu - so many of our patients actually are young and male. So, from an anesthesiologist perspective, I totally get how our patients actually are high risk.


lemma know your thoughts

I would personally give you the eye roll if you ask me to remove the oral airway that I have been using as a bite block in an intubated patient or as an actual airway in a sedated patient non-intubated.

In a non-intubated patient, if they tolerate the oral airway, leave it in until they take it out themselves. If they tolerate it in their mouth it means they probably still need it.

To your original question, in an intubated patient, when they come to your unit they are now yours. Meaning you have to have either yourself or some of your minions remove it, if you for some reason want it removed. Asking anesthesia to remove it is akin to saying, hey we don't like neo drips in the ICU can you switch to levophed before you leave? Can you hook up our CVP so we can monitor the inane wave form please? If your going to make these particular requests you are going to have to find some able body capable of physically removing the airway. An ICU RN being unable to remove an oral airway is not acceptable IMO and is your primary problem here. You are not the task master of the anesthesiologist. Hey can you put a central line in this septic guy prior to coming to the unit please? That is a reasonable request. There are many reasonable requests we would be happy to accommodate. Find a way to remove the airway without hassling anesthesia.

 

[ranvier]

And don't show up without a NGT...

 

[skypilot]

I have been using oral airways almost on every case for many many years and I never had one complication attributed the use of the airway!
There are people here who are still green and already think their way is the only way... very amusing actually!

There are many ways to skin a cat. And there are lots of times I am glad I have an airway in place after the patient wakes up. Airway, airway, airway.