Surgical Airway Complications [Medical Malpractice Lawsuit]

[bbc586]

Interesting case here: Surgical Airway Complications

44-year-old man scheduled for elective septoplasty and turbinate resection for OSA.

Multiple DL attempts fail, VL gets grade 2 view but can't pass tube, fiberoptic fails.

Guy gets bagged for.... 2 hours??! Then gets a tracheotomy.

Wish we had the full medical records but fascinating case nonetheless.

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[zizzer]

Sounds like it may have been avoided by using a Glidescope before causing iatrogenic edema from repeated (and presumably forceful) direct laryngoscopy attempts. One additional measure that could have been tried would be FOI guided AEC through an LMA.

It's easy to criticize retrospectively from afar, but unanticipated airway difficulty happens, and rarely backup plans prove difficult as well. Nothing seems egregiously wrong with the management here to me from the description.

 

[OptionOffense]

Interesting case here: Surgical Airway Complications

but fascinating case nonetheless.

Whats so fascinating about it? and if you are able to bag ventilate, why do a tracheostomy. Wake the patient up and send him home or wake him up and do an awake fiberoptic. Remember this IS an elective case.

 

[amyl]

Love the foi aintree through the lma trick… has saved the airway for me a couple times - including last week when a colleague’s omfs case crumped in the pacu.

 

[vector2]

Sounds like it may have been avoided by using a Glidescope before causing iatrogenic edema from repeated (and presumably forceful) direct laryngoscopy attempts. One additional measure that could have been tried would be FOI guided AEC through an LMA.

It's easy to criticize retrospectively from afar, but unanticipated airway difficulty happens, and rarely backup plans prove difficult as well. Nothing seems egregiously wrong with the management here to me from the description.

Reading the link, it sounds like the main crux of the lawsuit was the pharyngeal laceration (and subsequent complications). Which 9/10 stems from someone not looking in the mouth while carefully inserting the tube loaded with a rigid glidescope stylet.

 

[abolt18]

It's amusing to me that it's titled "surgical airway complications" when it should instead be called "difficult airway complications". Finally! Someone blames the surgeon when it's anesthesia's fault!

But in all seriousness, my only question is, why mask for 2 hours when you could just put in an LMA?

OTHERWISE, I take no issue with how this was handled. Varying attempts at DL, followed by VL, followed by calling for help, couple more reasonable attempts by "more skilled hands." And then aborted.

It sucks that there was a pharyngeal injury, but that is a known risk of intubating and something I include in my consent (damage to teeth, gums, lips, tongue, mouth, vocal cords). I hope the insurance rapidly just settles so the patient can get their medical bills paid for, and move on. Just my opinion.

 

[kidthor]

I would have put in an LMA myself, even as a tool to safely wake him up with.

However what they did in the case isn’t unreasonable overall.

 

[GassYous]

33 minute before initial intubation attempt?

 

[dabears505]

The first look should be the best look. Some huge dude , why not just do glidescope from the get go? I never understand why people look at some who use the glidescope as weak.

 

[dannyboy1]

I would have put in an LMA myself, even as a tool to safely wake him up with.

However what they did in the case isn’t unreasonable overall.

Disagree. They fu(ked up. Elective case, can’t intubate (strange in it of itself in this day and age), just mask ventilate/LMA until the patient wakes up. No way a couple of attempts at intubation gives such severe edema that the airway will close. Tracheostomy is a big deal, prolonged hospital stay, fair amount of complications (long term tracheae stenosis). If I showed up for elective sinus surgery and ended up with a trach I’d sure be pissed…..

 

[coffeebythelake]

Elective case, able to mask ventilate so not a CICV scenario. Wake the dude up.

Edit: looks like they tried but pt got agitated and hypoxemic, so they had to reanesthetize. Kind of a weird situation.

 

[DrOwnage]

They probably mask ventilated him for so long because this was before the US approval of sugammadex. Probably gave a big dose of roc. Honestly, in this case where you've already caused so much trauma and you're able to mask ventilate, shoving an LMA might make the situation worse or cause more swelling over time.

 

[GassYous]

Elective case, able to mask ventilate so not a CICV scenario. Wake the dude up.

Edit: looks like they tried but pt got agitated and hypoxemic, so they had to reanesthetize. Kind of a weird situation.

I'd be agitated too if you masked me for 3 hours

 

[patriot6]

Whats so fascinating about it? and if you are able to bag ventilate, why do a tracheostomy. Wake the patient up and send him home or wake him up and do an awake fiberoptic. Remember this IS an elective case.

You didn't click the link. They decided to do a surgical airway after patient was "... very agitated at several points, became hypoxic, and had an episode of bradycardia." I thought their management was good, necessary, and ultimately life-saving.

Edit: eh, in retrospect 1310 - 1350 is a long time to make the decision to wake up. Airway trauma was probably gnarly.

 

[Beeftenderloin]

Another thing you can try when you know you can ventilate and have time: One provider gets a view with VL (or as good a view as they can), second provider drives the fiberoptic. If you’re getting lost with your fiber, just look at the VL screen to re-orient.

I probably would have moved to VL sooner (after 1 attempt with **** view, or on first go if non-reassuring airway exam). But overall nothing terribly egregious with management here. They followed the DAA, tried to wake up (presumably without the benefit of sugammadex), guy started stage 2ing/agitation/fighting but not protecting airway yet, gets hypoxic, bradys down, then they did what they had to do to keep this man from dying.

I get why he’s p!ssed. Thought he was getting his nose fixed and ends up with a trach, a prolonged hospital course and presumably a fat bill. Dude’s lucky he’s not brain dead though.

 

[aneftp]

No mention of bmi.

 

[dabears505]

Also remember hand bagging for an hour, who knows what the co2 was. Some big fat guy, giving 200 ml breaths, his co2 could well have been 80 or higher, and that in itself will keep him confused or asleep. Hindsight is 20 20 though. Obviously in real time things move fast.

 

[BLADEMDA]

I have had 2 cases in my long career where I woke the patient up rather than risk any airway complications. Both times I tried various techniques including the Glidescope without success. The decision to abort the surgery happened within 15 minutes of induction and I still think that was the right call. Both cases needed ETT for the surgery so the LMA was only an option for ventilation. While both patients were unhappy with me there was no significant morbidity and they we rescheduled for 3-4 weeks later. At that time, awake fiberoptic intubation was performed with sedation.

These days it is foolish to put your pride above safety. The only thing that gets hurt by waking the patient up early in the process is your pride. This lawsuit should serve as a lesson to all of you to proceed cautiously and remember failed intubations happen even to the best of us. Hence, if you can ventilate the patient think about all your options before proceeding down the path of no return. These days I would use the Glidescope along with a flexible fiberoptic scope to attempt intubation if I had the same scenario again. I am now more proficient with that technique then I was back then. Still, I don't get 45 minutes to mess around with a potential disaster that can be avoided by waking the patient up!

 

[narcusprince]

Gum Bougie…… drops mic….

 

[Twiggidy]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

 

[OptionOffense]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

This would not be very popular.

 

[IMGASMD]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

Just had a patient with the exactly same physique.
Surgeons shave for their procedures…. Why shouldn’t we ?

 

[chessknt]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

In the ICU I shave that **** off and don't give them a choice. Different environment sure but mask fit is garbage with a beard.

 

[Twiggidy]

Just had a patient with the exactly same physique.
Surgeons shave for their procedures…. Why shouldn’t we ?

Exactly.....and if the patient refused to have their junk shaved for a hernia they would cancel the case

 

[james775]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

One hundred percent agree. Nothing makes me angrier than a large man with a large beard coming to surgery. Completely unnecessary. Pre op should ask them to shave

I know pre op instructions involve no finger nail polish but so many women ignore it. Up to me, I’d cancel the case. Simple insurrections, you gotta follow them

 

[GassYous]

One hundred percent agree. Nothing makes me angrier than a large man with a large beard coming to surgery. Completely unnecessary. Pre op should ask them to shave

I know pre op instructions involve no finger nail polish but so many women ignore it. Up to me, I’d cancel the case. Simple insurrections, you gotta follow them

Yeah i don't tolerate insurrections either

 

[OptionOffense]

People who are unemployed/retired save money on razors etc so they just simply dont shave. Ever work at a VA. All the patients are mountain men.

 

[Urzuz]

Yeah i don't tolerate insurrections either

Hate to break it to you but ~50% of the country does.

 

[norski]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

Agreed, beards suck. Generous lubing along the mask, some extra in the beard if it's really thick, seems to do the trick, though. You can even do it while they're awake,to check for mask seal. I did pull out the 3m buzzer once for a particularly nasty bearded patient. Left his mustache, but his triple chins were definitely showing after.

 

[Beeftenderloin]

For the beards: Poptart size tegaderm with slit cut for mouth. Thank me later.

 

[hiyaman]

For the beards: Poptart size tegaderm with slit cut for mouth. Thank me later.

Genius, I gotta try this

 

[kidthor]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

If you mess with Santa you will never get any presents again….

 

[DrZzZz]

This is sort of on topic but also off topic....

I get very frustrated when high BMI men come into the OR with Santa Claus beards. I'm not sure if we've addressed this before on this forum, but I've always wondered if I ever had the "right" to make someone shave in this case. I know there are all sorts of options to getting a tube in their trachea and letting them maintain their beard, but as "safety" has been mentioned in this thread, in my book, one way to increase safefty would be if they just shaved. Sorry for the side rant.

Had an attending where I trained that often shaved his patients' beards in preop. He was always very convincing when discussing with them why it was safer that way. While that's fine if the patient is on board, I don't think I could ever come across a patient and cancel a case if they refused to shave. I don't cancel hysterectomies in Jehovah witnesses as long as they understand that lack of transfusion might kill them. As long as risks are explained adequately, it's on them to make that choice.

 

[Twiggidy]

Had an attending where I trained that often shaved his patients' beards in preop. He was always very convincing when discussing with them why it was safer that way. While that's fine if the patient is on board, I don't think I could ever come across a patient and cancel a case if they refused to shave. I don't cancel hysterectomies in Jehovah witnesses as long as they understand that lack of transfusion might kill them. As long as risks are explained adequately, it's on them to make that choice.

Refusing blood for religious reasons is one thing versus something cosmetic that will grow back in a month on most of these guys.

 

[Ronin786]

Had an attending where I trained that often shaved his patients' beards in preop. He was always very convincing when discussing with them why it was safer that way. While that's fine if the patient is on board, I don't think I could ever come across a patient and cancel a case if they refused to shave. I don't cancel hysterectomies in Jehovah witnesses as long as they understand that lack of transfusion might kill them. As long as risks are explained adequately, it's on them to make that choice.

If only our legal system worked that way.

 

[OptionOffense]

Had an attending where I trained that often shaved his patients' beards in preop.

IN real life, you offer patients this y ou WILL be fired. I promise you that.

 

[turkeyjerky]

I'm EM, so apologies in advance for the incursion. But I had the following thought on management in this case: I wonder if they had tried non-invasive ventilation on the patient during the bridging period from requisite BVM to awakening (correct me if I'm wrong, but basically he was getting hypoxic and bradying down during his stage 2 anesthesia, which negated the possibility of just waking him up, right?).

The santa clause beard thing is interesting. I had a covid patient awhile back w/ one (big fat boy too). He was desatting into the 80s on high flow but lucid so I told him we had to cut it off. He refused, said he understood he might die as a result. His wife who was sitting right there gave her okay too. Documented the hell out of it.

 

[Blockit]

in the old days, it used to be relatively common practice to forgo the succinylcholine to avoid myalgias and just use rocuronium if you could mask the patient easily. Before the days of sugammadex. I remember being in the operating room many years ago when another anesthesiologist (who was not known for being thorough with airway exams) put a patient to sleep in this manner and then could not intubate. He made repeated attempts at direct laringoscopy with different blades, etc., and then called in another colleague who did the same. At some point what was initially “sufficient“ mask ventilation became “insufficient“.
The guy was there to have his wang operated on and he ended up with a trach.

It only takes a couple of dings with a laryngoscope blade in one of these fat puffy sleep apnea airways to get it to swell up.

Thank heavens for the two greatest inventions that I have seen in my career: the glide scope, and sugammadex.

 

[DrZzZz]

IN real life, you offer patients this y ou WILL be fired. I promise you that.

? Where do you work? Iran? Seriously, what nut job authoritarian state are you in that offering something like this would get you fired? You have some weird takes

 

[DrZzZz]

Refusing blood for religious reasons is one thing versus something cosmetic that will grow back in a month on most of these guys.

That's fair. But I still think they're comparable. And dying from anemia is more likely in my opinion than running into a CICV situation these days with all the advanced airway devices we have at our disposal. I don't know, maybe it's just the Gyn "surgeons" I work with. Maybe I'd feel differently if I worked in a smaller joint or in a 3rd world country without glidescopes and fiberoptics, but where I am, I've never felt strongly enough about a patient's beard to even bring it up. Straight to glidescope if I'm concerned.

 

[Twiggidy]

That's fair. But I still think they're comparable. And dying from anemia is more likely in my opinion than running into a CICV situation these days with all the advanced airway devices we have at our disposal. I don't know, maybe it's just the Gyn "surgeons" I work with. Maybe I'd feel differently if I worked in a smaller joint or in a 3rd world country without glidescopes and fiberoptics, but where I am, I've never felt strongly enough about a patient's beard to even bring it up. Straight to glidescope if I'm concerned.

I agree with you. I was just offering it up as food for thought. Video laryngoscopy has changed the game in anesthesiology which is why other specialities and RNs think they can do our job. *knocks on wood* There has been maybe enough to count of one hand "near non-glidescopeable (word?)" patients I've come across in my career. One was a repeat patient one of our surgeons like to bring in for just silly procedures that he really wasn't improving her situation with and I actually told him, "We're playing with luck here. She's that difficult that one day she's not going to survive airway management". He hasn't brought her back since because even he watched several different anesthesiologists have trouble, and not to toot our own horn, most if not all of us in our group are pretty good and pretty safe regarding airway so it's not for lack of skills.

But yes, you're correct, even glidescopes have improved so much with bigger screens and better optics that I would guess you should be able to see cords in like greater than 95% of patients.

 

[nimbus]

I'm EM, so apologies in advance for the incursion. But I had the following thought on management in this case: I wonder if they had tried non-invasive ventilation on the patient during the bridging period from requisite BVM to awakening (correct me if I'm wrong, but basically he was getting hypoxic and bradying down during his stage 2 anesthesia, which negated the possibility of just waking him up, right?).

The santa clause beard thing is interesting. I had a covid patient awhile back w/ one (big fat boy too). He was desatting into the 80s on high flow but lucid so I told him we had to cut it off. He refused, said he understood he might die as a result. His wife who was sitting right there gave her okay too. Documented the hell out of it.

She didn’t like him that much. Maybe she thought this was her chance to move on from him.

 

[nimbus]

IN real life, you offer patients this y ou WILL be fired. I promise you that.

We have an old school plastic surgeon who gives all his homeless long haired, bearded patients a shave and a haircut. They do look nicer cleaned up TBH. Full service.

 

[shotgunlagoon]

We have an old school plastic surgeon who gives all his homeless long haired, bearded patients a shave and a haircut. They do look nicer cleaned up TBH. Full service.

how many homeless patients is a plastic surgeon seeing??!

 

[nimbus]

how many homeless patients is a plastic surgeon seeing??!

This guy takes trauma call every night. He does mandible/maxilla fractures, orbital fractures, zygomatic fractures, dog bites, hand surgery, etc. I’d say half his hospital cases are homeless. Probably 5-6/week. We joke that his block time is 9pm.

 

[Drägerman]

This guy takes trauma call every night. He does mandible/maxilla fractures, orbital fractures, zygomatic fractures, dog bites, hand surgery, etc. I’d say half his hospital cases are homeless. Probably 5-6/week. We joke that his block time is 9pm.

There’s a plastics guy in SD that does the same thing at a similar hospital. Might be the same guy lol

 

[ranvier]

For the beards: Poptart size tegaderm with slit cut for mouth. Thank me later.

Get some ioban from the scrub. Much more robust and sticky if you really worried about a beard and BMV.

 

[chessknt]

I'm EM, so apologies in advance for the incursion. But I had the following thought on management in this case: I wonder if they had tried non-invasive ventilation on the patient during the bridging period from requisite BVM to awakening (correct me if I'm wrong, but basically he was getting hypoxic and bradying down during his stage 2 anesthesia, which negated the possibility of just waking him up, right?).

The santa clause beard thing is interesting. I had a covid patient awhile back w/ one (big fat boy too). He was desatting into the 80s on high flow but lucid so I told him we had to cut it off. He refused, said he understood he might die as a result. His wife who was sitting right there gave her okay too. Documented the hell out of it.

Nah. I tell people this isnt IHOP and that their plan of Ivermectin and prayer failed so it was my turn for my plan now and part of that plan was getting the beard off so I can safely take care of the patient. If they are bad enough to need bipap in the ED they are almost always going to be intubated.

 

[Beeftenderloin]

Nah. I tell people this isnt IHOP and that their plan of Ivermectin and prayer failed so it was my turn for my plan now and part of that plan was getting the beard off so I can safely take care of the patient. If they are bad enough to need bipap in the ED they are almost always going to be intubated.

Whole lot easier to play the my way or the highway card when you’re talking to a critically ill patient admitted to your closed ICU compared to someone coming in from home for elective surgery.

 

[chessknt]

Whole lot easier to play the my way or the highway card when you’re talking to a critically ill patient admitted to your closed ICU compared to someone coming in from home for elective surgery.

Well the post I responded to was a hypoxic covid patient. But even still I think you guys have a responsibility to be safe, if it isnt safe then shave it off... What is the worst that will happen, a patient complaint to some pointless committee that won't do anything anyways?