What would you do?

[Arch Guillotti]

We could ventilate sats up to 88-91ish. With bagging. Couldn't intubate despite using all modalities and three different providers with increasing skill level. Plus this was his third intubation this admission. He has slowly dwindled down to needing the tube again each time. Should I have just left the LMA in and hooked him to the vent and hoped his sats stayed up? And then stuck the bronchoscope in through LMA? I'm not sure what your getting at arch

I am not really trying to get at anything. Surgical airway is usually for "can't intubate/can't ventilate scenarios". I don't fault you for proceeding down that path since it seems it was the most viable option. Many CRNA's are very good at intubating but most of them fail miserably when standard maneuvers don't work.

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[Bostonredsox]

I am not really trying to get at anything. Surgical airway is usually for "can't intubate/can't ventilate scenarios". I don't fault you for proceeding down that path since it seems it was the most viable option. Many CRNA's are very good at intubating but most of them fail miserably when standard maneuvers don't work.

agree totally. But at my shop you get CRNAs for most everything. there are only 3 gas attendings and one is old and crotchety and tbh, not very good. So if one of the other two attendings are not available, which is 90% of the time, my "backup", is whatever crna shows up. which some times, not always maybe not even often, does not have more skill than me. And only one of them has any experience with a surgical airway and hers is minimal. So for the sake of hospital policy, I call them if I am having trouble intubating. 9 times out of 10 I am simultaneusly calling a surgeon.

 

[netrunner]

I'll post a case from my last night on call since the forum is dead.

RN calls me at 10:00 PM to come see ICU pt for respiratory distress.
Get to the bedside 10 min later.

Morbidly obese WM (50'ish) with RR low 40's sitting upright in bed.
Pulse 115, afib
BP 80/40's by radial A -line
spO2 89% on NRB
Weight 425 lbs
massive subq air extending up to head
Head shape/size of a pumpkin
Can not open eyes due to subq air in eyelids
Awake and will follow commands but not talking
Can open his mouth about 1.5 inches


Quick update by RN:

POD #3 from CABG, EF 45 % pre-op
Extubated POD #1
Still on dobutamine for lowish CI (has triple lumen catheter, no swan)
Chest tube and mediastinal drain removed about 6 hours previously
SQ air first noted about an hour ago - has progressed rapidly

RN and RT have already gotten abg and cxr:
ABG 7.27/65/60
CXR - tons of overlying soft tissue, bilateral pneumos -> right maybe 30%, left maybe 20%

Review intubation note by anesthesia from OR:
Performed by old school anesthesiologist - has been doing cardiac cases for 20+ years
"Grade 4 view with miller 2 - 1st pass with bougie"
This guy almost never goes with a glidescope for his 1st attempt

Available to me at this time of night:
-1 anesthesiologist with 2 crna's
-probably a couple of ER and IM hospitalists in house
-CT surgeon at home kicked back with a glass of scotch

I do 90% of my own airways but I'm not afraid to ask for help when things look ugly.

Call anesthesiologist

-he's bringing back an urgent c-section with 1 crna - doesn't feel comfortable with her starting case alone. Other crna in a case. He can be there in about 30 minutes.

What to do?

1. Calling for is smart--you need a second set of airway hand for this. I practice anesthesia and CCM in the private practice setting and having a second (or third) set of experienced hands is a good idea and will earn you the respect of everyone involved (only rookies don't call for help). The below can be done, however, with only good RT and RN help.

2. Have neosynephrine 100mcg/mL ready for pushes as whatever you give will likely drop his SVR. An EF of 45% preop is not very bad and will likely handle the small doses of neo you may give him
3. Calm yourself--remember it is the patient that is in distress, not you! Here is the good news:
-he is definitely NPO
-he has gotten this obese because his airway is good enough to eat and breathe at the same time...and he probably spends a lot of time eating. (Seriously, this thought has calmed me in a lot of obese intubations)
-You actually have a lot of good help: bedside RN who obviously knows her patient, more anesthesia help than I have usually and C-sections are started and finished very quicikly, RT/ED doc, etc.
-Explain calmly to the pt what you are about to do and why and apologize if he remembers any of it

4. Get ready for chest tubes/drains--with bilateral ptx and subcut emphysema, there is a good likelihood this guy will pre-code on you when you drop his CO with meds and then give PPV part of which will likely go through the leak that is causing his subcut emphysema as well as drop his venous return even more. They will be hard due to his obesity--especially to suture in effectively. High risk for falling out. I would consider a long percutaneous chest drain with a spinal needle and maybe just go anterior since you can simply use ultrasound to locate his rib edges and walk off. If you just need air evacuated out a drain is sufficient and easier to suture securely. If you don't have drains, then use a central line. I have even seen a foley used but they only have 1 hole at the end so not as good. The below airway stuff is he doesn't get better or crashes during your chest tube attempt.


5. Get your equipment and decide which route:
-standard intubation equipment
-LMAs of course, but remember how heavy his cheat is--it will be VERY hard to ventilation with an LMA. If you have a Supreme which seals better you might do well with one of those (shaped like a Fastrach)
Glidescope
Fiberoptic scope with ETT loaded and lubed, cuff checked (smaller tube is ok)
Cricothyrotomy needle and guidewire (in case you need to go retrograde)
Get his ideal body weight (for meds and vent)--no need for actual since you will not need SUX for this as he is NPO
Palpate and mark his trachea where you think a needle will enter (midline is fine). If you are nice, some lidocaine here pre-emptively is good since you want the lidocaine weal to go away and this takes a few minutes.

a. Keep him breathing spontaneously
-the trouble here is he is sitting straight up. If you sedate him--even if you were brave enough to use ketamine, the amount needed to get him to lie down a bit would probably cause him to obstruct his airways and the spontaneous breathing will do you little good.
-get some esmolol and glycopyrrolate in your hand--give little doses of both to dry up secretions if any and esmolol to keep glyco from making his HR too fast--turning off dobut for now might also help this. If you really need to, go ahead and trickle in some versed/ketamine but be ready to go to full paralysis mode below
-tropicalize his nose with atomizer with 4% lidocaine and explain what you are about to do
-fiberoptic via the nose (is easier in the sitting patient, a straighter shot to the cords, pt cannot bite your scope)
-once you visualize the arytenoids, wallop him with Amidate (or just a lot of versed if BP is low), 1mg/kg of rocuronium (ideal weight), and 100mcg of neosynephrine, I give all and then flush.
-A nasal RAE is longer and is nice to have, but most oral tubes will reach airway just fine.
-A little Afrin in both nostrils is a nice thing to do if you don't want a lot of bleeding--however, I would think you aren't going to shove the ETT in there until your fiberoptic is in the trachea anyway. High flow O2 or jet vent can be hooked up to suction port adapter on fiberoptic in case you struggle with the ETT passage.

b. Full paralysis
-will give you the best look
-you gotta make sure you can bag this guy after--he is NPO but you may need an LMA (Fastrach or Supreme can handle higher pressures)--does he have a beard? Any teeth?
-Once all this stuff is ready, you will likely have your CRNA and/or anesthesiologist there.
-Make sure there is a good "ramp" to get optimal "sniffing" position once patient lies down
-One person will suction and quickly place a glidescope or MAC 4 to get tissue out of the way--intubate if able; if not able of poor grade view, then keeping the blade there, come in from behind with the fiberoptic

Notes:
1. If no teeth, you can place fiberoptic friendly oral airway or even glidescope with minimal sedation/local. Supreme LMAs and Fastrach don't work as well without teeth--they tend to veer off to one side or another and have a hard time staying midline unless someone is manually holding them steady.
2. If he has a beard, don't be afraid to Bic off his facial hair to save his life if you have the time!
3. If you need to do a retrograde, get a needle that is long enough--don't worry about hitting other things as his airway is of paramount importance--stay midline. Remember the wire will come out his NOSE unless you reach in with Magill forceps and get it from his posterior pharynx. Then, thread the wire through the suction port of the fiberoptic and use the wire as a guide for the fiberoptic to go into the trachea (the fiberoptic serves as your "stiffener" since ETT will NOT pass via a simple wire due to its floppiness). Once fiber is in, thread the ETT.

 

[chmd]

The only answer here is awake FOB. If you topicalize thoroughly there shouldnt be any issues.

Also put in chest tubes.

 

[imfrankie]

You definitely don't need a fancy intubating LMA. Try this on your bench then you'll be confident to use it in emergency: Grab scissors, cut off half the stem of your favorite LMA. You may be surprised to find, your circuit will likely fit onto the cut-off conduit, and if not a smaller ET tube placed into the LMA barrel then inflated gives you a universal attachment for your circuit. Fiber through the LMA or ETT-LMA combo per usual. Since your LMA has been shortened, a standard length ETT can be advanced to protrude sufficiently through the LMA so as to make it all the way through the glottis. In short, put the LMA in, cut it off short to make an oral airway-ETT guide that's a lot shorter than your ETT.
P.S. those little grates on a standard LMA that people talk about cutting off--don't waste time worrying about them; just turn the ETT before advancing and the bevel takes care of business.

 

[imfrankie]

I'm just a simple anesthesiologist, but here's how I do a lot of awake or prepositioned intubations: Patient stays awake sitting up, gargles or swallows some viscous lidocaine; while facing the patient I am just going to take a look with a "tongue depressor"--the glide scope. Once you see the glottis (this is great positioning for the morbidly obese), take a deep breath and PTFTI (put the tube in).

 

[europeman]

Great discussion! I had a similar situation last month. Few thoughts from y perspective as an ICU doc and trauma surgeon:

Chest tubes are not easy in the morbidly obese. Two months ago a patient had a pigtail put into the liver by the micu for a tension that I had to take to the OR. Now.... The patient had a tension and needed a tube and I don't fault them for trying. My point is though it's not easy. If the patient is sitting up it's actually more difficult because the axillary panus is flopping down.... Whereas ideally you have the patient totally flat and a bit to the side in a manner where you can move as much of the panus out of the way. Alternatively, you can always do an ANTERIOR chest tube.... But again you have to sorta know what you are doing because you want to make sure you are lateral to the mammary vessels/heart and also be aware that the rib spaces are smaller and it's potentially more difficult to get a tube past.

Needle decompressions for tension in my experience rarely work well and I can decompress a chest quicker with a clamp knife and my finger ( or if really in a bind just a pair of scissors and my finger) just as quick.

Anyway this patient clearly needed chest tubes. It is a bit off because post cabg patients don't usually have lung trauma but if they do the surgeon typically leaves a tube. I'm not quite sure what the precious person meant by sternal wires causing pneumo..... When I close a sternotomy I make sure I can see everything below. My point is this is not a common phenomenon.

What is more common is instead a pneumo from when the pleura was violated during the cabg...... But this is a result surgery.... Not because he lung is damaged per se.... These pneumos don't grow. The point is with post op chest surgery pneumos can be more complicated.

If this patient was in my icu and anesthesia wasn't available to help I would have done the following.

Call one of my ER colleagues to come give me a hand.

Start the patient on whatever drug made sense given situation/hemodynamics. This isn't an easy chest tube with easy placement of local in the perfect intercostal space kind of patient. So some ketamine or precidex on board would be nice.

Place tubes while getting ready to Place on non invasive. Lido the neck too and make sure everyone in room is aware that an emergency airway is very possible in the algorithm of this patients plan.

Re-assess. If patient then needs to be intubated then either have my colleague do an awake if appropriate (I don't do awakes). If I was alone and in a bind I would simply personally give an induction dose of ketamine and attempt a glide scope intubation. If I got the feeling I just needed a little better relaxation to go with a tube I would paralyze....If unable to even see anything I would then proceed with a surgical airway.... Something I'm very comfortable in even with obese patients.

Hard case.

Few comments:

Emergency crics are not revised to clean them out. My operative crics are done in a sterile field... But it's all show. There is absolutely nothing sterile about the procedure. Instead they are revised to get the tube placed in more appropriate level to prevent sub glottis stenosis, sometimes to establish hemostasis, and generally to get a look around. For me something I revise and sometimes we don't. Depends on the situation and patient. Cervical CT scan can sometimes help you decide because if you have a cric which was done way high right next to the thyroid membrane, sometimes you can inadvertently injure the thyroid membrane and potentially vocal cords. Perc trach I think dangerous of course in true crash situation.... But if you are bagging and have 5 minutes and want to do it fine. I personally like to take all the complicating variables out though and just do it surgically

 

[Nuriko]

Oooh, a brain teaser. What the hell, I'm in.

IMHO, I think the 'right' answer here really depends on what your background is and what you are most comfortable doing. I am an anesthesiologist by training. With that in mind:

1. I would have someone call the surgeon and have him get his ass to the hospital ASAP. While I'm waiting...

2. I see a morbidly obese patient with barely any mouth opening, hypotension, potentially unstable arrythmia, with hypercarbia and hypoxemia. My absolute first priority is to secure the airway. For this patient, I would go straight to an awake FOI. I don't screw around with the glidescope/bougie if I suspect a true difficult intubation and difficult ventilation. Additionally, this patient is stable enough that this would be considered an elective intubation (ie, I would have time to set up an awake FOI). I agree with topicalization, glycopyrrolate, and having LMA/trach kit on standby. I would probably anesthetize this woman minimally, maybe 0.5 mg Versed, tops. I would probably avoid Dex as this patient is already hypotensive.

3. I am not a surgeon. My experience with chest tubes is 5-6 (total) as a fellow, with none during residency. My surgical interns have done more chest tubes than I have (and often 'supervised' me during my fellowship). Although I agree that PTX is a huge part of the problem, I sure as hell would not feel comfortable doing a chest tube alone in the middle of the night, on a morbidly obese patient with subQ emphyseyma no less. If I had this skill set, I would probably agree with chest tube placement as opposed to intubating. From what it sounds like, the surgeon is not getting to the hospital anytime soon. I would much rather take my chances doing bilateral needle decompressions if **** really hit the fan.

4. What makes post-op cardiac patients particularly scary is that the differential for hemodynamic/respiratory collapse is so much more extensive than in the typical SICU patient. Yes, this pt has PTX, but they could easily have any number of other issues occurring simultaneously: graft occlusion, tamponade, volume overload, acute RV failure secondary to hypercarbia/hypoxemia, etc. Without knowing any further details of this patient's OR and ICU course thus far, my next move would be to slide a TEE probe and figure out what the hell was going on. I would then send a more extensive critical lab panel, including chemistry, CBC, coags, and a repeat ABG. I would want to ensure that the hypoxemia/hypercarbia improved, that they had no life threatening electrolyte disturbances, no significant anemia, thrombocytopenia, coagulopathy, or leukocytosis (ie, sepsis), and would then transfuse as needed.

Just my 2 cents.

 

[Katheudontas parateroumen]

Stumbled upon this. Great case.

As a trainee, it's still hard to translate real life and books. This appears on paper to be emergent airway given his O2 sat is borderline on NRB PaO2 60 and his PCO2 rising (probably has sleep apnea though) and breathing probable unsustainable 50 breaths/min. I think the books would say that Awake FOI are not recommended for emergent airways given it does take time for set up for success and crumping patients most likely won't comply. But then again, putting this guy to sleep with a known difficult airway and shock is also a recipe for a code too. How does one decide between doing awake vs asleep in these situations are nuances Im still learning. Thoughts and wisdom? I don't feel comfortable with chest tubes, and a pigtail seems tough in this case as well. I would have tried the bilateral needle decompressions first and called on-call surgeon for help pronto for both surgical airway and chest tubes. Even if the decompression works, I probably would have attempted to secure the airway until surgical chest tubes could be in place as I'd be wary of all that subq emphysema and the amount of time he's been in distress. Or watch this guy like a hawk all night. I probably would have tried Awake FOI first with all my induction/code meds in hand as well. Appreciate the many perspectives above.

PS. Props to the old school anesthesiologist who tubed a grade 4 with a bougie first pass. I hope to develop those skills as time comes too