Flex Bronchoscopy/mediastinoscopy & Lidocaine

VentdependenT · Nov 28, 2007

In these cases where you "have to" intubate the patient have any of you found decreased post-operative patient discomfort by administer 4% nebulized lido in the holding area pre-op or spritz some juice from a LTA during intubation.

Or is this just a total waste of time.

I haven't done it(at least I don't think so) and I can't remember if I'd asked this before. My aricept needs a refill.

gasnewby · Nov 28, 2007

can you do mediastinoscopy without an incision? the few i did, we really cranked up on the blade to get to the lymph nodes. you don't want the pt awake for that...are we talking about the same thing?

i'm happy to refill your aricept if you don't mind passing along a little provigil for me.

VentdependenT · Nov 28, 2007

gasnewby said:
can you do mediastinoscopy without an incision? the few i did, we really cranked up on the blade to get to the lymph nodes. you don't want the pt awake for that...are we talking about the same thing?

i'm happy to refill your aricept if you don't mind passing along a little provigil for me.

We typically tube folks for a mediastinoscopy. I've read you can do it with MAC but if the surgeon isn't experienced in that then why bother. Plus mediastinal masses can cause all sorts of problems in the supine position with decreased respiratory effort.

Anypoops since we have to tube em for the mediastinoscopy portion I was curious if it would be of benefit to add in our own localization of the airway for the broncoscopic portion?

I suppose the surgeon could just do it through the work port. I guess my questions sucks....now that I think about it.

Disse · Nov 29, 2007

VentdependenT said:
We typically tube folks for a mediastinoscopy. I've read you can do it with MAC but if the surgeon isn't experienced in that then why bother. Plus mediastinal masses can cause all sorts of problems in the supine position with decreased respiratory effort.

Anypoops since we have to tube em for the mediastinoscopy portion I was curious if it would be of benefit to add in our own localization of the airway for the broncoscopic portion?

I suppose the surgeon could just do it through the work port. I guess my questions sucks....now that I think about it.

Well.

I use propofol, ketamine and surgical local. Of course, it isn't mixed, or maybe sometimes it is and then I use a BIS to make sure a number is there (sometimes I just put it on my Jello though.. that number is better than the patient's sometimes). Then, after I've tubed them, I look at that number and decide to bill the patient for either GA, MAC or DOA which is my extra special "only ME know how to do this" trademarked technique.

(Sorry, couldn't resist. Besides I figured I'd just jumpstart the self-aggrandizement 🙂)

VentdependenT · Nov 30, 2007

This thread was dead anyway....

UTSouthwestern · Nov 30, 2007

VentdependenT said:
This thread was dead anyway....

Didn't see the thread earlier.

I do use an LTA with these patients and unless you know you are only going for juicy lymph nodes and not any other kind of mass, I would advise against LMA's or MAC/TIVA. I do usually at least a 70 or 80 of these a year and from my experience with 17 different CT surgeons, the amount of pressure they exert as well as the head extension of the patient with a shoulder roll in place would make it easy to have the airway iatrogenically collapsed.

One patient not done by my group coded when the anesthesiologist chose to just use an LMA with immediate airway collapse on induction with a patient with a moderate sized mediastinal mass.

Also, if the surgeon gets too aggressive pulling pulmonary window lymph nodes and tears the pulmonary artery, you want to be ready for a quick median sternotomy and not fudging around with an RSI.

Back to the original question, yes an LTA is useful and provides some, if not total relief from pain caused by bronchoscopic biopsies.

Cut your ETT short (25-26 cm) and try to use a half size larger than normal (7.5 or 8.5) to facilitate easier maneuvering through and visualization of the tracheobronchial tree. After the bronch, you can also inject another 5 cc's of lido down the tube and allow it to settle and distribute while the patient undergoes the CME.

CremeSickle · Nov 30, 2007

I use an LTA religiously.

The only reason i know it works is because my brother had an FOI where the CRNA used it and he said he didnt feel a thing

VentdependenT · Nov 30, 2007

CremeSickle said:
I use an LTA religiously.

The only reason i know it works is because my brother had an FOI where the CRNA used it and he said he didnt feel a thing

Why does it matter who used it?

Anyways for FOI I go though the work port of the scope.

I've found LTA's/Lita tubes to be fairly useless for post op bucking. Thats a somewhat different stimulus from a biopsy of the tracheobronchial tree.

johankriek · Dec 1, 2007

CremeSickle said:
I use an LTA religiously.

The only reason i know it works is because my brother had an FOI where the CRNA used it and he said he didnt feel a thing

My uncle also had a procedure where the CRNA used it and it was awesome. CRNAs are awesome too i must add. If it wasnt for crnas where would we be? still using ether i presume and nobody using LTA

dhb · Dec 1, 2007

could someone define LTA for me thx

numbmd · Dec 2, 2007

LTA lido lasts for about 20 min. Nebulized lido lasts 10 minutes. Surgeon would have to be pretty fast......

VentdependenT · Dec 2, 2007

dhb said:
could someone define LTA for me thx

http://dailymed.nlm.nih.gov/dailymed/image.cfm?id=791&name=laryngOJet%2Dimage02%2Ejpg&CFID=1845824&CFTOKEN=7f46af406684007f-9AF90F94-EB0A-23B9-D2C51F84230BAD4D&jsessionid=ca308c896ca13f226f19

Its basically a bougie that shoots lidocaine through it. So once you see cords, you slip this little bugger through and squirt in about 160mg of lido onto the Larynx and Trachea.

Supposedly lasts up 2 two hours. I've had limited success with this device. In fact its probably my onboard narcotics which ablate the cough response and not this thing/IV lido.

anypoops here is a paper:http://www.anesthesia-analgesia.org/cgi/content/full/99/4/1253

numbmd · Dec 3, 2007

Thanks for the source vent. My info was much older and apparently incorrect.

Laurel123 · Dec 4, 2007

VentdependenT said:
Its basically a bougie that shoots lidocaine through it. So once you see cords, you slip this little bugger through and squirt in about 160mg of lido onto the Larynx and Trachea.

Supposedly lasts up 2 two hours. I've had limited success with this device. In fact its probably my onboard narcotics which ablate the cough response and not this thing/IV lido.

anypoops here is a paper:http://www.anesthesia-analgesia.org/cgi/content/full/99/4/1253

Thanks for the link. I have been meaning to find some literature on the use of LTA.

Personally - I am a fan of the LTA. Procedures that are not very painful, but require intubation for a short period of time, like a lap tubal seem to respond very well to LTA for me. They generally don't get a lot of narcs, since the pain is usually pretty well controlled with some ketoralac, but with the LTA, they don't seem to buck and cough much, despite being minimally narcotized.

Flex Bronchoscopy/mediastinoscopy & Lidocaine

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