stylet?

[dilaudid]

Do you guys use a stylet while intubating routinely for your cases? Just curious what folks are doing in the real world...

---

Members don't see this ad.

 

[Bertelman]

Nah.

 

[sevoflurane]

I try to limit my DLs. Most patients I don't need a stylet. On some I'll load it from the beginning cuz I don't want to come back out load a stylet, and then DL for a second time.

Under 4.5 ETTs, I always place a stylet.

 

[rsgillmd]

Do you guys use a stylet while intubating routinely for your cases? Just curious what folks are doing in the real world...

I do. It's easy to pull if you don't need it, and it saves me a DL if I find I do need it.

The main downside to the stylet is because the stiffness increases the risk of tracheal perforation if you are not gentle, or more importantly if there is abnormal tracheal anatomy. That is why I pull it once the tip of the tube is between the cords.

 

[dhb]

No, need it rarely enough to not bother with it, plus it requires an extra set of hands to pull it out.

 

[deleted126335]

I do. It's easy to pull if you don't need it, and it saves me a DL if I find I do need it.

The main downside to the stylet is because the stiffness increases the risk of tracheal perforation if you are not gentle, or more importantly if there is abnormal tracheal anatomy. That is why I pull it once the tip of the tube is between the cords.

 

[BLADEMDA]

I do. It's easy to pull if you don't need it, and it saves me a DL if I find I do need it.

The main downside to the stylet is because the stiffness increases the risk of tracheal perforation if you are not gentle, or more importantly if there is abnormal tracheal anatomy. That is why I pull it once the tip of the tube is between the cords.

On a big dude/gal there is nothing wrong with having a stylet. It doesn't mean you are "weak" because there is stylet loaded inside your ETT. I can't count the number of times per week a CRNA tries 3 laryngosocopies only to stop and then load a stylet in his/her ETT.
This is extra trauma to the patient. My advice to most people is load a stylet in your ETT if the airway is anything but Class1 or edentulous. That said, 90% of the CRNAs in my practice do not load a stylet in their ETT in advance; this is a mistake in my opinion.

The other common error is intubating the patient completely with the stylet in place. This makes me cringe every time I see it. I instruct the CRNA to stop once the ETT is just past the glottic opening so I can pull out the stylet. Sadly, many times the CRNA just rams the tube down the throat with the stylet in place.

I realize many super stars on SDN don't need a stylet until the laryngoscopy shows they need it. I'd rather start with a stylet in place and remove it (save it for another patient) then have to stop and place one. Of course, this is personal preference but I've seen several bloody airways per month which could be prevented just from a pre-loaded stylet.

 

[Monty Python]

Do you guys use a stylet while intubating routinely for your cases? Just curious what folks are doing in the real world...

Not all the time. I will load one if I have any concerns about a possible difficult intubation.

If not using a stylette I'll form the ETT in a circle while setting up my room, inserting the Murphy eye end into the circuit adapter end, and leave it like that in the wrapper while I go get the patient. After detaching the two ends the ETT will maintain a slight fishhook appearance for a few minutes.

 

[BLADEMDA]

Not all the time. I will load one if I have any concerns about a possible difficult intubation.

If not using a stylette I'll form the ETT in a circle while setting up my room, inserting the Murphy eye end into the circuit adapter end, and leave it like that in the wrapper while I go get the patient. After detaching the two ends the ETT will maintain a slight fishhook appearance for a few minutes.

Exactly as done in my practice by 90% of CRNAs. The result being as described in my previous post. Of course, your results may be fine as this technique is based on the skill of the individual CRNA.

 

[Idiopathic]

I do. It's easy to pull if you don't need it, and it saves me a DL if I find I do need it.

The main downside to the stylet is because the stiffness increases the risk of tracheal perforation if you are not gentle, or more importantly if there is abnormal tracheal anatomy. That is why I pull it once the tip of the tube is between the cords.

is there data on this? i always have one in. it does not take an extra person to pull it out .

i find that a lot of the trainees I work with have gotten used to bending a sharp angle in their ETT/stylet combos (see bottom example - even worse sometimes!) which is totally unnecessary (and possibly dangerous) for all but the most anterior airways. I put the tiniest little bend in it but I typically want it fairly straight.

 

[PMPMD]

is there data on this? i always have one in. it does not take an extra person to pull it out .

i find that a lot of the trainees I work with have gotten used to bending a sharp angle in their ETT/stylet combos (see bottom example - even worse sometimes!) which is totally unnecessary (and possibly dangerous) for all but the most anterior airways. I put the tiniest little bend in it but I typically want it fairly straight.

I always pull my own stylet. I hold the ETT back by the 11mm adaptor and retract the stylet with my thumb after the ETT tip is between the cords. I would rather control it myself - I'm an only child after all and don't like to share.

 

[sevoflurane]

I really don't like those green rusch slick stylets that have the adapter that fit to the proximal end of the ETT (which you shouldn't use, cuz it's hard to unhook sometimes).

My stylet of choice are these satin-slip stylets.

If you take a good look, the distal end of the stylet is a flexible piece of plastic that would cause very little damage if the the stylet managed to make it out of the ETT. Additionally, it is very easy to remove.

 

[Bertelman]

is there data on this? i always have one in. it does not take an extra person to pull it out .

i find that a lot of the trainees I work with have gotten used to bending a sharp angle in their ETT/stylet combos (see bottom example - even worse sometimes!) which is totally unnecessary (and possibly dangerous) for all but the most anterior airways. I put the tiniest little bend in it but I typically want it fairly straight.

1) You need to update your avatar. There is no stylet.

2) I'm not sure what advantage there is to placing a stylet into a tube that basically mimics the curvature of the native tube.

 

[BLADEMDA]

1) You need to update your avatar. There is no stylet.

2) I'm not sure what advantage there is to placing a stylet into a tube that basically mimics the curvature of the native tube.

I've got no issues for those who choose to not use a stylet routinely; but, I've had airways were a stylet was crucial to a successful intubation. At least several times a week I load up a stylet for a CRNA who couldn't pass the ETT without one.

Any antincipated difficult airway should have a stylet in the ETT; some say even the routine airway in non edentulous patients should get a styleted ETT. Why subject the patint to more trauma than needed with multiple larygoscopies? Again, I'm always happy to remove a stylet (satin slip) and save it for another patient. Of course, I've had CRNAs ask me to remove the stylet only to then request I put it back when they fail to pass the ETT on the first attempt.

 

[IlDestriero]

I stylet all the RSIs, morbidly obese, anyone who looks challenging, the little guys (<3kg), and the other little guys (dwarves). Better safe than sorry, and I just want to get the tube in and get going. I haven't borrowed ortho's protractor, but my angle is probably just shy of 45°.

 

[Bertelman]

I've got no issues for those who choose to not use a stylet routinely; but, I've had airways were a stylet was crucial to a successful intubation. At least several times a week I load up a stylet for a CRNA who couldn't pass the ETT without one.

Any antincipated difficult airway should have a stylet in the ETT; some say even the routine airway in non edentulous patients should get a styleted ETT. Why subject the patint to more trauma than needed with multiple larygoscopies? Again, I'm always happy to remove a stylet (satin slip) and save it for another patient. Of course, I've had CRNAs ask me to remove the stylet only to then request I put it back when they fail to pass the ETT on the first attempt.

I agree. I stylet every RSI, without question. And I stylet most that I think will be difficult, or at least have it on the gas machine.

I think comparing your practice with CRNAs to a trained physician asking for their own personal practice is apples to oranges. I also think of stylets like I think of oral airways. Crutches most of the time. I believe residents should begin their training using both, because they need to develop some confidence and basic skills to function somewhat independently. But I can bag-mask 95% of my teeth-wielding patients without an adjunct. And I can intubate 98% of my standard airways without a stylet. I believe both of those devices tend to allow practitioners to forge ahead without optimizing chin lift and mask seal skills, or DL and head positioning skills. A styletted tube can make it into places with Gr 3 views. Without that, I am often forced to optimize my positioning, etc.

 

[sevoflurane]

...and the other little guys (dwarves).

Good one.

 

[BLADEMDA]

I agree. I stylet every RSI, without question. And I stylet most that I think will be difficult, or at least have it on the gas machine.

I think comparing your practice with CRNAs to a trained physician asking for their own personal practice is apples to oranges. I also think of stylets like I think of oral airways. Crutches most of the time. I believe residents should begin their training using both, because they need to develop some confidence and basic skills to function somewhat independently. But I can bag-mask 95% of my teeth-wielding patients without an adjunct. And I can intubate 98% of my standard airways without a stylet. I believe both of those devices tend to allow practitioners to forge ahead without optimizing chin lift and mask seal skills, or DL and head positioning skills. A styletted tube can make it into places with Gr 3 views. Without that, I am often forced to optimize my positioning, etc.

I'm sure they say the same things as you over at Noctor.org; they never need a stylet or an oral airway (oral airways are used primarily in edentulous patients in my practice).
This hasn't been my observation and I bet a study of CA-3 Residents across several thousand intubations would show stylets decrease the number of laryngoscopies required for intubation. As for most things this is user dependent; but, I'd rather have a pre-loaded ETT ready to go then fish around for one when needed.

I at least encourage Residents to make certain there is a stylet ready and available for every intubation. You never know when you are going to need one until you need it.

 

[BLADEMDA]

 

[sevoflurane]

Failing to prepare is preapring to fail.

-UTSW

 

[Bertelman]

I'm sure they say the same things as you over at Noctor.org; they never need a stylet or an oral airway (oral airways are used primarily in edentulous patients in my practice).
This hasn't been my observation and I bet a study of CA-3 Residents across several thousand intubations would show stylets decrease the number of laryngoscopies required for intubation. As for most things this is user dependent; but, I'd rather have a pre-loaded ETT ready to go then fish around for one when needed.

I at least encourage Residents to make certain there is a stylet ready and available for every intubation. You never know when you are going to need one until you need it.

I really could give a **** what they say over there. I don't visit. And I don't compare my intubating skills, or yours, to any of them. Because I am confident I can perform better than them in basically any clinical situation. I'm not the best on the block with everything, but I feel pretty good about my ability to drop a tube into a trachea.

And I really don't care about a study comparing stylet use with a batch of CA-3s. I'm not a CA-3, and I have proven to myself that I possess the skills to intubate these patients without a stylet. Period. I also have stated that I know when a stylet is useful, and I use it appropriately.

And I absolutely 100% agree that every resident, and every practitioner, should make sure there is a stylet available. That should go without saying.

 

[Bertelman]

Failing to prepare is preapring to fail.

-UTSW

Or Ben Franklin

 

[BLADEMDA]

I really could give a **** what they say over there. I don't visit. And I don't compare my intubating skills, or yours, to any of them. Because I am confident I can perform better than them in basically any clinical situation. I'm not the best on the block with everything, but I feel pretty good about my ability to drop a tube into a trachea.

And I really don't care about a study comparing stylet use with a batch of CA-3s. I'm not a CA-3, and I have proven to myself that I possess the skills to intubate these patients without a stylet. Period. I also have stated that I know when a stylet is useful, and I use it appropriately.

And I absolutely 100% agree that every resident, and every practitioner, should make sure there is a stylet available. That should go without saying.

Easy there Bert. The CRNAs I am referencing in my posts have an average experience level of 8 years out of training. They are not newly minted grads. But, I know most of them do compare themselves to Anesthesiologists and follow our examples. Hence, 90% of them don't start with a stylet in the ETT; some don't even bother checking that there is a stylet in the room or another intubating blade which works.

When I read threads like these it reminds why I'm glad the ASA sets standards in practice. From U/S to Pulse Oximetry the ASA has enhanced patient safety (IMHO).
If it was up to individual practitioners too many things would not be routinely used in practice and many patients across the USA would suffer as a result.

 

[BLADEMDA]

 

[Bertelman]

Easy there Bert. The CRNAs I am referencing in my posts have an average experience level of 8 years out of training. They are not newly minted grads. But, I know most of them do compare themselves to Anesthesiologists and follow our examples. Hence, 90% of them don't start with a stylet in the ETT; some don't even bother checking that there is a stylet in the room or another intubating blade which works.

When I read threads like these it reminds why I'm glad the ASA sets standards in practice. From U/S to Pulse Oximetry the ASA has enhanced patient safety (IMHO).
If it was up to individual practitioners too many things would not be routinely used in practice and many patients across the USA would suffer as a result.

Is there a standard stating I must have a stylet in my tube?

I know it's great to think there is some ideal way to practice, which, if we all followed it, there would be no adverse events. That's not reality. Every patient is different, every practitioner is different.

If you are trying to dictate my choice of stylet, what next? Tell me I should be using a Mac blade on every patient?

 

[BLADEMDA]

Is there a standard stating I must have a stylet in my tube?

I know it's great to think there is some ideal way to practice, which, if we all followed it, there would be no adverse events. That's not reality. Every patient is different, every practitioner is different.

If you are trying to dictate my choice of stylet, what next? Tell me I should be using a Mac blade on every patient?

Easy there again Bert. I don't think a discussion about stylets warrants such heated debate. I was making a bigger point about safety and standards in practice. The fact that a patient gets 2-3 laryngoscopies because a provider's ego gets in the way doesn't rise to that level.

There is no standard for stylets or type of intubating blade for routine cases requiring General endotracheal intubation.

I'm still glad the ASA does set standards on major issues like pulse oximetry, EKG, ETCo2, etc. or we would be debating those as well.

 

[Bertelman]

And I'll settle down when you stop comparing me to your CRNAs.

 

[Bertelman]

Easy there again Bert. I don't think a discussion about stylets warrants such heated debate. I was making a bigger point about safety and standards in practice. The fact that a patient gets 2-3 laryngoscopies because a provider's ego gets in the way doesn't rise to that level.

There is no standard for stylets or type of intubating blade for routine cases requiring General endotracheal intubation.

I'm still glad the ASA does set standards on major issues like pulse oximetry, EKG, ETCo2, etc. or we would be debating those as well.

I can tell you that if any of my patients were getting multiple DLs because of my technique, I would most assuredly change my technique. Until then, I'm gonna keep doing what I'm doing.

 

[BLADEMDA]

And I'll settle down when you stop comparing me to your CRNAs.

My intent was not to compare you to my CRNAs. They like to compare themselves to you. Do you see the difference there? Since you don't use or need a stylet in the ETT then they believe (erroneously I might add) they don't need one either.

You set the standard and they follow.

 

[Bertelman]

My intent was not to compare you to my CRNAs. They like to compare themselves to you. Do you see the difference there? Since you don't use or need a stylet in the ETT then they believe (erroneously I might add) they don't need one either.

You set the standard and they follow.

Fair enough.

 

[periopdoc]

This may surprise some folks, but I stylet every tube with a fairly steep bend. My average time from entering the the OR to having the airway secured is just under five minutes. Sometimes three and rarely do I go over 5 minutes. I can't afford to waste an attempt because I needed a stylet and didn't have it. I have the luxury of having a circulator assigned to assist me until the airway is secure so removal is not an issue. Induce, DL, place the tip through the cords and ask the circulator to remove the stylet. Advance tube and reconfirm correct position. Remove laryngoscope.

I rarely need it, but when I do, I don't have to withdraw, place stylet and re-DL. I use the satin stylet.

- pod

 

[BLADEMDA]

This may surprise some folks, but I stylet every tube with a fairly steep bend. My average time from entering the the OR to having the airway secured is just under five minutes. Sometimes three and rarely do I go over 5 minutes. I can't afford to waste an attempt because I needed a stylet and didn't have it. I have the luxury of having a circulator assigned to assist me until the airway is secure so removal is not an issue. Induce, DL, place the tip through the cords and ask the circulator to remove the stylet. Advance tube and reconfirm correct position. Remove laryngoscope.

I rarely need it, but when I do, I don't have to withdraw, place stylet and re-DL. I use the satin stylet.

- pod

Simply Bad-Arse and Right on once again.

 

[dhb]

Ok for those who stylet routinely, how often does it happen that you have to DL x2 because the curve on the stylet was not appropriate?
If the patient in in the sniffing position the line from the mouth to the trachea can be very strait thus any curve you would have on your tube would make it hard to intubate.
There are a lot of factors that come into play in how you approach the airway, patient morphology is one of them and varies with where you practice.
As Bert said i know when i need one and when i have a difficult airway i prefer to go strait to the bougie. Overall i need these tools very rarely so i don't feel the need to bother with systematic use.

 

[IlDestriero]

Ok for those who stylet routinely, how often does it happen that you have to DL x2 because the curve on the stylet was not appropriate?
If the patient in in the sniffing position the line from the mouth to the trachea can be very strait thus any curve you would have on your tube would make it hard to intubate.
There are a lot of factors that come into play in how you approach the airway, patient morphology is one of them and varies with where you practice.
As Bert said i know when i need one and when i have a difficult airway i prefer to go strait to the bougie. Overall i need these tools very rarely so i don't feel the need to bother with systematic use.

If you have an easy grade one view, I'm not sure how the 45° angle would keep you from getting the tip in unless you made the bend too long. You could always turn the tube and your hand 90° and go in from the "side".

 

[BLADEMDA]

Ok for those who stylet routinely, how often does it happen that you have to DL x2 because the curve on the stylet was not appropriate?
If the patient in in the sniffing position the line from the mouth to the trachea can be very strait thus any curve you would have on your tube would make it hard to intubate.
There are a lot of factors that come into play in how you approach the airway, patient morphology is one of them and varies with where you practice.
As Bert said i know when i need one and when i have a difficult airway i prefer to go strait to the bougie. Overall i need these tools very rarely so i don't feel the need to bother with systematic use.

The question is how often do you perform a second DL which could be avoided by having a stylet preloaded and do you believe avoiding that second DL warrants the routine use of that stylet.

 

[dhb]

The question is how often do you perform a second DL which could be avoided by having a stylet preloaded and do you believe avoiding that second DL warrants the routine use of that stylet.

Why? If the numbers are the same you have no ground to stand on...
So how often do you do multiple DLs with a stylet?

 

[BLADEMDA]

Why? If the numbers are the same you have no ground to stand on...
So how often do you do multiple DLs with a stylet?

I practice in an ACT with CRNAs. I believe stylets reduce trauma and the number of DLs..

I rarely do multiple DLs with a styleted ETT; I usually intubate more frequently than I would like and use a Miller blade with a styleted ETT.

 

[Bertelman]

I practice in an ACT with CRNAs. I believe stylets reduce trauma and the number of DLs..

I rarely do multiple DLs with a styleted ETT; I usually intubate more frequently than I would like and use a Miller blade with a styleted ETT.

Then we're in the same boat. I rarely do multiple DLs.

And if you are able to rotate the styletted ETT all sorts of ways to make it in the hole, realize you can do the exact same thing with an empty tube.

 

[IlDestriero]

And if you are able to rotate the styletted ETT all sorts of ways to make it in the hole, realize you can do the exact same thing with an empty tube.

Come on now Bert, it's fine for you to disagree with the routine use of a stylet, but you know that's just not true.

 

[Mman]

This may surprise some folks, but I stylet every tube with a fairly steep bend. My average time from entering the the OR to having the airway secured is just under five minutes. Sometimes three and rarely do I go over 5 minutes. I can't afford to waste an attempt because I needed a stylet and didn't have it. I have the luxury of having a circulator assigned to assist me until the airway is secure so removal is not an issue. Induce, DL, place the tip through the cords and ask the circulator to remove the stylet. Advance tube and reconfirm correct position. Remove laryngoscope.

I rarely need it, but when I do, I don't have to withdraw, place stylet and re-DL. I use the satin stylet.

- pod

that's what we do as well. I understand that many times you don't need a stylet, but I've still never found a situation where I wish I hadn't used a stylet. At worst it's unneeded and occasionally it's required.

 

[sevoflurane]

... and it costs 2 dollars.

But... if its a butter or edentulous aw... I won't use it.

Any questions in my mind... they are getting satin-slipped.

 

[periopdoc]

The prebend of the ETT approximates the curve of the airway when it is not being instrumented. When we do a DL, we need a straight line view, unless you have learned to alter the laws of optical physics, so the airway is straight until you get to the level of the cords or lower. The classic "hockey stick" bend most closely approximates this alignment.

In three plus years of practicing this way, I have never had a problem with "too much of a bend" requiring me to straighten out the stylet.

I have had three airways in the last two years where I needed an increased bend in which I maintained my view, removed the tube, and increased the bend by pushing the tip of the styleted tube down on the bed then re-inserting. A little longer DL than I would like, but still only one DL.

I have required a bougie once because if there is a airway that requires that technique, I just use the styleted tube itself as the bougie.

I have had three airways where I had to completely remove the laryngoscope and modify something. One I rescued with a change from a Miller to a Mac. One required repositioning. One required both repositioning and two changes of blades to get the right combination.

Probably most importantly, I have yet to have a failed intubation with a styleted tube that I subsequently rescued by removing the stylet. So, why not just use the thing?

- pod

 

[Bertelman]

Come on now Bert, it's fine for you to disagree with the routine use of a stylet, but you know that's just not true.

What I am saying is that if you find that the natural curve of the ETT is not aligning well with the cords, you can rotate the tube, bringing the angle down, and slide it in. I am not making this up. Rotating the tube alters the position of the tube tip.

If I find that I need a little more anterior bend, I can push the tube against pharyngeal structures, get a fulcrum to change the tip angle, and advance. I'm not making this **** up, I do it every day.

 

[periopdoc]

I should add that I am not critical of Anesthesiologists that do not use a stylette for every intubation. 50% of my training was at an institution where we didn't use them routinely and 50% at an institution where it was essentially mandatory. The two institutions argued about who was right. Ultimately, you make a judgement call about what is most important to you. Save a little cash or save a little time. If I practiced in an environment where I didn't have a circulator assigned to me while I was securing the airway, I would not use a stylette on every intubation. Every time I intubate, I hear the voice of my airway Jedi Master, Art Lam, saying something along the lines of.

You either know that the tube is in or you don't know, there is no think that it is in. Anesthesiologists get in trouble because they fool themselves and think that the tube is in. Confirm it. Don't remove the laryngoscope immediately upon placing the tube. Place the tube, then take another look. Is the tube still between the cords? Then the rest doesn't matter. Even if they are so bronchospastic that there are no breath sounds and no EtCO2, you KNOW that the tube is in. But be honest with yourself if you don't know for sure, then you need to rely on other methods of confirming tube placement.

- pod

 

[periopdoc]

What I am saying is that if you find that the natural curve of the ETT is not aligning well with the cords, you can rotate the tube, bringing the angle down, and slide it in. I am not making this up. Rotating the tube alters the position of the tube tip.

If I find that I need a little more anterior bend, I can push the tube against pharyngeal structures, get a fulcrum to change the tip angle, and advance. I'm not making this **** up, I do it every day.

You are right, and it is the hardest thing for me to get folks (paramedics, ICU docs) to visualize when I am teaching them to intubate. I find the manipulation to be more reliable with a stiff, styleted tube, but any bent tube can be manipulated by rotating and moving in and out.

- pod

 

[Bertelman]

I should add that I am not critical of Anesthesiologists that do not use a stylette for every intubation.

And I should add that I developed my practice at an institution where the circulators were gossiping in the corner while we intubated. Granted, I had an attending, but my goal was to present myself as an independent practitioner. Aside from a convenient tug on the side of the mouth to open my passage, I wanted to practice without their assistance.

That's all changing for me in a couple months, and I may end up styleting every one of my intubations, because I will be getting the 2nd or 3rd look. We'll see.

 

[dhb]

You're selling out?

 

[Bertelman]

You're selling out?

It's unfortunate, and believe me, I have my regrets. But we have to make compromises sometimes, and for me it is working in an ACT. I sleep better at night assuming this is an inevitable consequence in most markets.

 

[pgg]

... and it costs 2 dollars.

The pennypinchers around here clean and re-use stylets so the cost is essentially $0.

I put one in every tube - just don't see the downside.

 

[IlDestriero]

The pennypinchers around here clean and re-use stylets so the cost is essentially $0.

I put one in every tube - just don't see the downside.

As I'm sure they're labeled for single use only, or equivalent, that's verboten in the ivory tower.