Variceal bleed/hematemesis intubations

[cougarY]

Just wondering what most people do when they encounter a variceal bleed and need to intubate based off a case I had the other night:

60+ yo M, HCV cirrhosis came in after he had 2 episodes of vomiting dark/black blood at home. Last EGD showed 4 grade II varices. We discussed with GI who wanted him intubated then shipped to the ICU for emergent EGD and presumably banding. He was in the ED for 1-2 hours without any further episodes of hematemesis. We pre-oxygenate, push etomidate and succ and lay him down. The second we lay him down (still awake) and he's completely supine, he just starts vomiting and pouring bloody emesis out his mouth/nose and coughing. As a few choice words pass through my head, I quickly lift the head of the bed, suction what I can until the succ kicks in and then lay him back down and intubate. No issues with the tube but he had emesis all over the cords. Throw in an OG tube after and suction out another 600 cc of the dark bloody emesis.

Questions: would you put an NG tube in this guy before you intubate to help prevent this and his likely aspiration event?

Some say NG/OG is contraindicated because of hypothetical case of irritating/rupturing varices with the NG/OG. Thoughts?

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[Janders]

In similar cases (bad SBO, GI bleed) I've taken to intubating them with the glide scope with the head of the bed still up at 30 or more degrees.

 

[shoal007]

I had one of these the other day. Thankfully he didn't vomit prior to tube, but had 250ml bright red emesis. Dropped to 60percent oxygen with preoxy hf nc in 30seconds. These people are very unstable and elective intubation early does make sense. I'm not sure we're the best place or people to do this however.

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[Janders]

I had one of these the other day. Thankfully he didn't vomit prior to tube, but had 250ml bright red emesis. Dropped to 60percent oxygen with preoxy hf nc in 30seconds. These people are very unstable and elective intubation early does make sense. I'm not sure we're the best place or people to do this however.

Sent from my VS986 using Tapatalk

Who else would you suggest intubate and resucitate them?

 

[link2swim06]

Just wondering what most people do when they encounter a variceal bleed and need to intubate based off a case I had the other night:

60+ yo M, HCV cirrhosis came in after he had 2 episodes of vomiting dark/black blood at home. Last EGD showed 4 grade II varices. We discussed with GI who wanted him intubated then shipped to the ICU for emergent EGD and presumably banding. He was in the ED for 1-2 hours without any further episodes of hematemesis. We pre-oxygenate, push etomidate and succ and lay him down. The second we lay him down (still awake) and he's completely supine, he just starts vomiting and pouring bloody emesis out his mouth/nose and coughing. As a few choice words pass through my head, I quickly lift the head of the bed, suction what I can until the succ kicks in and then lay him back down and intubate. No issues with the tube but he had emesis all over the cords. Throw in an OG tube after and suction out another 600 cc of the dark bloody emesis.

Questions: would you put an NG tube in this guy before you intubate to help prevent this and his likely aspiration event?

Some say NG/OG is contraindicated because of hypothetical case of irritating/rupturing varices with the NG/OG. Thoughts?

I always would put the NG tube in these right away for several reasons:

1. A stomach/esophagus full of blood is irritating, having it cleared out makes them feel better sometimes
2. I can tell if they are actively bleeding. If you continually get bright red blood you have an active bleed, not an intermittent bleed.
3. They were presumably eating before all this happened. I can't imagine a NG is going to rub the varices much more than their normal diet did.
4. Make intubation a lot easier.

 

[southerndoc]

I've intubated trauma patients with the suction just left in their oropharynx while I'm actively intubating (the respiratory therapist held the suction catheter).

I probably would've used rocuronium though. It's my go to paralytic. Doesn't cause increases in gastric pressure from fasiculations of abdominal muscles (which can cause vomiting) and doesn't cause diaphragmatic fasiculations (which can cause vomiting). Supposedly SCH increases lower esophageal sphincter pressure, but that's in normal, healthy adults and not in patients who have lower esophageal sphincter problems causing reflux.

Some docs say they don't like using rocuronium because if they can't intubate, the patient wouldn't have an airway. My philosophy is that I'm intubating because they need an airway. If I have trouble getting it, then I need to proceed through my difficult airway steps (up to and including a cric if necessary). Hopefully the FDA will approve sugammadex soon, but they keep rejecting Merck's bid for it. It would reverse the effects of rocuronium.

 

[TooMuchResearch]

Keep them up at 30-45 degrees with RSI, consider awake fiberoptic if you have the capability. Decompress stomach before paralytic probably good.

 

[Cynic]

Attending here. Here's some thoughts from my practice...

I personally like pre-treating with reglan/erythromycin. Usually I'm volume resuscitating these patients and providing O2 via high flow NC+Non-rebreather and if you give it right away, then it has time to work while you are resuscitating/oxygenating/setting up to intubate these patients.

I intubate with the head of bed at at least 30-45 degrees always

Avoid bagging these patients if at all possible. The most experienced operator tubes these patients. Period. Aggressive pre-oxygenation is the order of the day. I don't know why some people push paralytics and then proceed to ambubag the patient who's sats are 100%. I've seen attendings and experienced RT's do this, and the only thing you're doing is potentially insufflating the stomach more. It adds zero benefit.

Everyone of these intubations gets a dual suction setup. Two yankauers, two canisters, two wall suction ports...If you can't do that, then piggyback the canisters inline so you don't run out of space. Also, you can have one yankauer and a "suction as you go" ETT (search EM crit for this, it's pretty spiffy). The time to construct this setup/figure it out is on a slow day when you have time and not right before you intubate them.

Awake fiberoptic is great, I use 2mg/kg of ketamine IV, then I can suction, place NG, etc if I need to before I push paralytics.

Agree with comments above about Roc, but I also think there is some value to using succinylcholine in these patients because its onset of action is faster than rocuronium, especially if you are going to just do RSI with etomidate as opposed to a facilitated/awake look or delayed sequence intubation. What you don't want is the etomidate-induced myoclonus in these patients, which occurs in around 10% of patients.

 

[gro2001]

Just wondering what most people do when they encounter a variceal bleed and need to intubate based off a case I had the other night:

60+ yo M, HCV cirrhosis came in after he had 2 episodes of vomiting dark/black blood at home. Last EGD showed 4 grade II varices. We discussed with GI who wanted him intubated then shipped to the ICU for emergent EGD and presumably banding. He was in the ED for 1-2 hours without any further episodes of hematemesis. We pre-oxygenate, push etomidate and succ and lay him down. The second we lay him down (still awake) and he's completely supine, he just starts vomiting and pouring bloody emesis out his mouth/nose and coughing. As a few choice words pass through my head, I quickly lift the head of the bed, suction what I can until the succ kicks in and then lay him back down and intubate. No issues with the tube but he had emesis all over the cords. Throw in an OG tube after and suction out another 600 cc of the dark bloody emesis.

Questions: would you put an NG tube in this guy before you intubate to help prevent this and his likely aspiration event?

Some say NG/OG is contraindicated because of hypothetical case of irritating/rupturing varices with the NG/OG. Thoughts?

I would RSI (probably etomidate and rocuronium) and DL them with the head of bed at 45 degrees.

-Intubating with the head of bed up is easier most of the time, particularly in the obese, less likely to vomit
-Sometimes I have an assistant keep one or even two suction catheters turned on and in the mouth of these people just in case the above happens anyway
-Would stay away from any fiberoptic stuff or glidescope because a splash of blood in the wrong place would obscure my view and potentially make me switch to DL anyway
-I would not be too concerned dropping an NG... As others have said, I don't think a regular NG catheter is going to do anything to the walls of the varix that the BigMac and fries he had on the way to the ER didn't already
-Have all the back ups including cric available
-Would intubate as early as possible.

 

[dotcb]

If the patient is stable and cooperative and the intubation is semi-elective, then I would try to get a NGT in.

If it is more emergent, then RSI - ketamine, roc, 2 suctions, HOB 30 degrees up, pre-ox, HF NC on.

 

[turkeyjerky]

A lot of good stuff above. I would avoid placing an NGT prior to intubation, not b/c of a theroretical risk of rupturing a varix (which has been disprove I believe) but because of the high likelihood of inducing emesis, as well as disrupting the LES tone. The big key though, is to not place them flat at least until you're ready to tube and preferably not at all.

I think a FOI is a recipe for disaster in this circumstance given the time involved and the high likelihood of an obscured view. Also an issue w/ VL, but less so.

I also don't see any reason to do an awake intubation in this case rather than an RSI unless other predictors of a difficult intubation are present, and the better speed of an RSI makes it much preferable in my mind.

 

[Cynic]

I tend to use fiberoptic and video laryngoscopy interchangably, but was referring to VL.

 

[Arch Guillotti]

Awake fiberoptic is great, I use 2mg/kg of ketamine IV

 

[deleted547339]

If you have time --> IVF, NGT, blood if necessary, PCCs/FFP, reverse trendelenburg, most experienced operator at HOB, have VL and DL, double suction canisters set up (taping two yankauers together is a nice little trick I learned recently), bougie at bedside, pre-oxygenate well, leave nasal canula on during intubation, don't bag at all, go fast.

If you don't have time --> pray, goose the yankauer, go fast.

 

[Apollyon]

What's the problem? Honest question. I've never given ketamine, but that looks from my view as the loading dose.

Extrapolate on your icons, because any input is welcome.

 

[Hamhock]

Agree with most of above.

Etomidate was called Vomidate when I was in training (especially when sux NMB hasn't kicked in or is kicking in). Just use "high-dose" (really, should be consider "appropriate RSI dosing) roc.

I have never understood laying patients flat. No gain, lots of loss. I know some of the anesthesia guys like T-burg for some potential assist from gravity keeping vomit from the larynx, but that seems to make intubating more difficult and I am not convinced of the benefit. I am definitely a 30 degrees head up doc (for reasons as listed above).

I wouldn't recommend the average ED doc who typically isn't familiar with awake intubation start on this patient...seems like you are just asking for gagging and coughing to be quickly followed by vomiting all over your bronchoscope and cords and lower airways. DSI? Sure, consider it if you are experienced in this area; but I would not traditional "awake" fiberoptic without lots of experience and another reason to not RSI/DSI.

What I find most interesting is the discussion regarding NG tubes before ETT. My current practice is to place them in awake and at least somewhat cooperative patients. I like the idea of less blood in the stomach. However, I am always wondering how much this compromises the LES...I would really like to read more opinions about this. Anyone else what to comment on this?

HH

 

[Arch Guillotti]

What's the problem? Honest question. I've never given ketamine, but that looks from my view as the loading dose.

Extrapolate on your icons, because any input is welcome.

2 mg/kg is an induction dose, and a large one at that for a potentially unstable patient.

 

[Apollyon]

2 mg/kg is an induction dose, and a large one at that for a potentially unstable patient.

Thank you for that. The upper end of the induction dose was listed as 4 mg/kg. I didn't even know!

 

[Hamhock]

2 mg/kg is an induction dose, and a large one at that for a potentially unstable patient.

I am not sure much a difference will be seen between 1-1.5 mg/kg and 2mg/kg...both will likely dissociate completely.

I am also not sure how 2mg/kg ketamine is of particular concern in a "potentially unstable patient" vs. pretty much any other sedative or induction agent. In fact, it sounds like a great choice.

HH

 

[Arch Guillotti]

I am not sure much a difference will be seen between 1-1.5 mg/kg and 2mg/kg...both will likely dissociate completely.

I am also not sure how 2mg/kg ketamine is of particular concern in a "potentially unstable patient" vs. pretty much any other sedative or induction agent. In fact, it sounds like a great choice.

HH

Friend, I agree there probably isn't a big difference in the doses you have listed above.

In the original scenario, the patient is old, sick, and probably volume depleted and anemic so personally I would be very careful with inducing them. I would use the lower end of the induction dose (and probably even lower than that).

However my point was that someone was claiming to do an "awake" intubation after a dose of 2 mg/kg ketamine. The typical induction dose of general anesthesia is 1-2 mg/kg. I would say that after 2 mg/kg of ketamine that the patient is actually under general anesthesia. One could argue that they are in the "dissociative state" of profound analgesia/amnesia but this is not a state that I would want a patient in while I was instrumenting their airway on a full stomach. The total dose of ketamine that I have given before to facilitate awake intubations (after the patient has been numbed up) has never been greater than 20 mg.

 

[deleted547339]

Friend, I agree there probably isn't a big difference in the doses you have listed above.

In the original scenario, the patient is old, sick, and probably volume depleted and anemic so personally I would be very careful with inducing them. I would use the lower end of the induction dose (and probably even lower than that).

However my point was that someone was claiming to do an "awake" intubation after a dose of 2 mg/kg ketamine. The typical induction dose of general anesthesia is 1-2 mg/kg. I would say that after 2 mg/kg of ketamine that the patient is actually under general anesthesia. One could argue that they are in the "dissociative state" of profound analgesia/amnesia but this is not a state that I would want a patient in while I was instrumenting their airway on a full stomach. The total dose of ketamine that I have given before to facilitate awake intubations (after the patient has been numbed up) has never been greater than 20 mg.

How often do you used ketamine? I ask because talking to anesthesia at my program, they are not particularly firmiliar with the drug - they look at me like I'm crazy when I talk about it. (I'm not trying to imply that you don't have experience with it, just asking).

I've never given a dose of ketamine under 0.5mg/kg. I would say that 50% of the time that gets me to the level of sedation I need. For procedural sedation, that's where I start and just keep doing 0.5 until I'm there. If I'm intubating, I'll go 1.

Also, this may just be where I work, but anesthesia and I have very different definitions of awake intubation. When I've seen them doing awake intubations, their patients are just sedated enough that they don't smack them in the face - they are very awake. When we do awake intubations, we have them fully dissociated. Our definition of "awake intubations" tends to simply be that they are still spontaneously breathing. This may be where the disconnect is.

 

[gro2001]

How often do you used ketamine? I ask because talking to anesthesia at my program, they are not particularly firmiliar with the drug - they look at me like I'm crazy when I talk about it. (I'm not trying to imply that you don't have experience with it, just asking).

I've never given a dose of ketamine under 0.5mg/kg. I would say that 50% of the time that gets me to the level of sedation I need. For procedural sedation, that's where I start and just keep doing 0.5 until I'm there. If I'm intubating, I'll go 1.

Also, this may just be where I work, but anesthesia and I have very different definitions of awake intubation. When I've seen them doing awake intubations, their patients are just sedated enough that they don't smack them in the face - they are very awake. When we do awake intubations, we have them fully dissociated. Our definition of "awake intubations" tends to simply be that they are still spontaneously breathing. This may be where the disconnect is.

I was just going to comment that I think a lot of ER docs misuse the term. When they say 'awake' they really mean 'fully induced but with preserved airway reflexes and spontaneous respiration', which is different. Hence the confusion of the anesthesiologist.

 

[southerndoc]

Thank you for that. The upper end of the induction dose was listed as 4 mg/kg. I didn't even know!

It doesn't matter. Doses above 2 mg/kg do not provide for deeper sedation but only a more prolonged effect. So if you give them 4 mg/kg (which is usually an IM dose) it will only prolong their sedation. This can be beneficial when using rocuronium.

 

[TooMuchResearch]

How often do you used ketamine? I ask because talking to anesthesia at my program, they are not particularly firmiliar with the drug - they look at me like I'm crazy when I talk about it. (I'm not trying to imply that you don't have experience with it, just asking).

I've never given a dose of ketamine under 0.5mg/kg. I would say that 50% of the time that gets me to the level of sedation I need. For procedural sedation, that's where I start and just keep doing 0.5 until I'm there. If I'm intubating, I'll go 1.

Also, this may just be where I work, but anesthesia and I have very different definitions of awake intubation. When I've seen them doing awake intubations, their patients are just sedated enough that they don't smack them in the face - they are very awake. When we do awake intubations, we have them fully dissociated. Our definition of "awake intubations" tends to simply be that they are still spontaneously breathing. This may be where the disconnect is.

We don't call this awake.

For awake, I'd think about 0.1-0.3 mg/kg IV ketamine + good and numb.

 

[engineeredout]

This discussion reminds me of one of my true nearly ****-my-pants moments thus far in residency.

Covering ICU overnight in a community hospital. I'm pretty much the only one there - somewhere in the building there is a theoretical hospitalist who is avoiding the ICU like a plague. Have a 40 something year old patient with cirrhosis s/p banding of varices earlier that day. Nurse suddenly grabs me saying that he just vomited a MASSIVE amount of bright red blood. Run in the room and BP is 50/30 and there is blood everywhere.

Yell multiple things simultaneously, including "GET A BLAKEMORE, CALL FOR UNCROSSMATCHED BLOOD, PAGE ANESTHESIA, CALL GI" etc. My ICU team is awesome and get everything to the bedside that I need. CRNA shows up, I say we need to get this guy intubated, and she REFUSES. States that she doesn't think the patient needs to be intubated. "We might do more harm than good. You should call GI first".

I was absolutely livid.

I'm sorry but CRNAs (and anesthesiologists for that matter) are probably good at what they do in the OR, good at doing the job of putting the plastic through the cords, but in a critical airway situation (not just talking about technically difficult airway) they suck.


Sorry for the off topic rant.

 

[southerndoc]

Our anesthesiologists won't allow an EGD to be performed without intubating someone. They say it's too difficult to control the airway from aspiration, etc. So literally every EGD that is done in my hospital gets intubated and then is extubated when their propofol starts wearing off.

 

[Apollyon]

States that she doesn't think the patient needs to be intubated. "We might do more harm than good. You should call GI first".

How did she even figure that? That is cowardice and incompetence, black letter. What would happen? Tube either goes into trachea, or into esophagus. Trachea is good. Esophagus? Geyser-like eruption of blood, and you know you're not in. Pull it (or leave it), and put a second tube in.

This sounds like a case of "the CRNA doesn't know what she doesn't know". My CRNAs will not, ever, ever sedate a patient in the ED. 100% to the OR.

 

[Arch Guillotti]

I'm sorry but CRNAs (and anesthesiologists for that matter) are probably good at what they do in the OR, good at doing the job of putting the plastic through the cords, but in a critical airway situation (not just talking about technically difficult airway) they suck.

Unfortunate that this has been your experience.

I have never called an ED doc to the OR to manage an airway. It isn't often but I have managed a number of airways that the ED doc had trouble with over the years.

 

[Arch Guillotti]

Our anesthesiologists won't allow an EGD to be performed without intubating someone. They say it's too difficult to control the airway from aspiration, etc. So literally every EGD that is done in my hospital gets intubated and then is extubated when their propofol starts wearing off.

Does this include elective EGD's? If so, that is a very unusual practice pattern.

 

[Arch Guillotti]

Yell multiple things simultaneously, including "GET A BLAKEMORE, CALL FOR UNCROSSMATCHED BLOOD, PAGE ANESTHESIA, CALL GI" etc. My ICU team is awesome and get everything to the bedside that I need. CRNA shows up, I say we need to get this guy intubated, and she REFUSES. States that she doesn't think the patient needs to be intubated. "We might do more harm than good. You should call GI first".

I was absolutely livid.

Why didn't you just intubate the patient yourself?

 

[Arch Guillotti]

My CRNAs will not, ever, ever sedate a patient in the ED. 100% to the OR.

This is weak for sure. Are the CRNA's supervised by an anesthesiologist?

 

[deleted547339]

This is weak for sure. Are the CRNA's supervised by an anesthesiologist?

You are aware of the multi-reply function, right?

 

[Doctor Bob]

I have never called an ED doc to the OR to manage an airway. It isn't often but I have managed a number of airways that the ED doc had trouble with over the years.

I've come to the OR to intubate someone for the anesthesiologist who was unable to get the airway a handful of times.

I will admit that these were very abnormal situations.

 

[Apollyon]

This is weak for sure. Are the CRNA's supervised by an anesthesiologist?

The supervising anesthesiologist is a pain guy, so that's all he does. He doesn't go into the OR (unless those are where he does the RFAs, but he doesn't do the anesthesia).

We're a rural hospital.

 

[Arch Guillotti]

You are aware of the multi-reply function, right?

 

[engineeredout]

Why didn't you just intubate the patient yourself?

Cause I'm a resident. Not allowed to intubate by myself. Even if I could have, I wouldn't be crazy about managing an airway like that without backup.

 

[gro2001]

Unfortunate that this has been your experience.

I have never called an ED doc to the OR to manage an airway. It isn't often but I have managed a number of airways that the ED doc had trouble with over the years.

I LOLed imaging a cargo pants and scrub top wearing ED doc with shears tucked into the waist band running into the OR to help and getting destroyed by the scrub nurse.