A sad case

[Sleeplessbordernights]

33 year old male pt, 330 lbs, 4.9 f. Absolutely no neck extension nor mouth opening.
is admitted because of a bad fournier gangrene secondary to an over the counter Im inyection of decadron her grandma applied to him because flu symtomps, which turns out to be covid, he is desat to 88, can’t lay flat at all but is otherwise doing fine with mask.

His covid is somewhat stable but the gangrene is not getting better so surgery decides to perform a colostomy.

He arrives to OR stable, sat 88 with mask, I perform a RSI with VL (With my attending besides me) I do it quick and on the first try, however he desats to 20, but is up to 92 after bag ventilation. Other than high plateu and peak pressure, the surgery goes fine on our side, surgery on the other hand has a lot on trouble getting the colostomy, they take 3 hours.

After the second hour I point to my attending that there is a lot of green thick secretion on the OT at firt at the base and slowly but steadly getting to the top. My attending points out we won’t be able to extubate him, we will change the OT at the end of the case.

The colostomy ends but surgery say they want to perform a quick debridement. We help by flipping the pt to one side. As they are doing the debridement I notice the secretions are all the way up in the tube and the pt starts desat to 85, 82, 80. My attending tells surgery to stop, we are gonna change the tube, as we put the pt supine, he desats hard to 20, my attending quickly changes the OT but the pt codes and after 30 min we are not able to bring him back.

This case happened 2 months ago but I have been thinking a lot, maybe we should not waited to change the tube, or we should have aspirated the secretions the moment we noticed them, what do you think?

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[GassYous]

Fournier gangrene from a shot of decadron? Was he ball-less?

 

[dchz]

Several things aren't consistent to me. But it sounds like an ischemic cardiac event secondary to hypoxia. Myocarditis and aspiration is also on the differential diagnosis.

The first and most important thing is to take care of your mental health. Do things that you enjoy, spend time with family, friends, and people that ground you.

The next question you're gonna have is did the aspiration intraop cause his demise. No one will know for sure, but isolated aspiration is unlikely to cause his demise that fast alone.

If I was to do things perfectly from the beginning, I would have suctioned the stomach more. And suctioned endotracheal tube prophylactically.

The experienced people tell me that it takes less time to recover mentally from a patient death each time you go through it. I'm not sure that's a good thing but it's certainly somewhat true.

If you had more details on what happened while the patient is coding, we can also give you constructive feedback. The most important thing is to take care of yourself mentally.

 

[Sleeplessbordernights]

Fournier gangrene from a shot of decadron? Was he ball-less?

It started as a gluteal abscess that spread to the scrotum and penis

 

[Sleeplessbordernights]

Several things aren't consistent to me. But it sounds like an ischemic cardiac event secondary to hypoxia. Myocarditis and aspiration is also on the differential diagnosis.

The first and most important thing is to take care of your mental health. Do things that you enjoy, spend time with family, friends, and people that ground you.

The next question you're gonna have is did the aspiration intraop cause his demise. No one will know for sure, but isolated aspiration is unlikely to cause his demise that fast alone.

If I was to do things perfectly from the beginning, I would have suctioned the stomach more. And suctioned endotracheal tube prophylactically.

The experienced people tell me that it takes less time to recover mentally from a patient death each time you go through it. I'm not sure that's a good thing but it's certainly somewhat true.

If you had more details on what happened while the patient is coding, we can also give you constructive feedback. The most important thing is to take care of yourself mentally.

thanks! And sure, my attending ran the code but as the airway is secure we start chest compression, and first adrenaline then atropine, the pt develops V tachi and we defibrillate, we keep doing Chest comp and 2 more adrenalines to no avail

 

[dchz]

thanks! And sure, my attending ran the code but as the airway is secure we start chest compression, and first adrenaline then atropine, the pt develops V tachi and we defibrillate, we keep doing Chest comp and 2 more adrenalines to no avail

What happened before the patient coded? What cardiac rhythm? What was the vitals? Did you have an aline in?

 

[Sleeplessbordernights]

What happened before the patient coded? What cardiac rhythm? What was the vitals? Did you have an aline in?

No a line as we anticipated it would be a quick case, the rhythm was normal as far as I recall, the had a MAP of 65-70, and was slightly tachycardic 100-103, he had more or less those vitals the entire case

 

[Hoya11]

33 year old mala pt, 330 lbs, 4.9 f. Absolutely no neck extension nor mouth opening.
is admitted because of a bad fournier gangrene secondary to an over the counter Im inyection of decadron her grandman applied to him because flu symtomps, which turnos out to be covid, he is desat to 88, can’t lay flat at all but is otherwise doing fine with mask.

His covid is somewhat stable but the gangrene is not getting better so surgery decides to perform a colostomy.

He arrives to OR stable, sat 88 with mask, I perform a RSI with VL (With my attending besides me) I do it quick and on the first try, however he desats to 20, but is up to 92 after bag ventilation. Other than high plateu and peak pressure, the surgery goes fine on our side, surgery on the other hand has a lot on trouble getting the colostomy, they take 3 hours.

After the second hour I point to my attending that there is a lot of green thick secretion on the OTl at firt at the base and slowly but steadly getting to the top. My attending points out we won’t be able to extubate him, we will change the OT at the end of the case.

The colostomy ends but surgery say they want to perform a quick debridement. We help by flipping the pt to one side. As they are doing the debridement I notice the secretions are all the way up in the tube and the pt starts desat to 85, 82, 80. My attending tells surgery to stop, we are gonna change the tube, as we put the pt supine, he desats hard to 20, my attending quickly changes the OT but the pt codes and after 30 min we are not able to bring him back.

This case happened 2 months ago but I have been thinking a lot, maybe we should not waited to change the tube, or we should have aspirated the secretions the moment we noticed them, what do you think?

As soon as secretions noticed in the tube yes it should have been suctioned, especially with a persistently low sat, you don't need anything in the tube limiting your delivery of oxygen. Had this been done earlier maybe he would have had more reserve when tube change came.

I think this guy was sicker than anyone realized and had massive pulmonary edema that you saw in the tube.

He couldn't tolerate the hypoxic event that came from the tube change/position change.

Before changing the tube, I would have suctioned a ton, then bronchd to evaluate tube.

I wouldnt be so convinced that the tube needed to be changed right away as much as needed to be suctioned right away.

And especially after the first big desat, your going to want to take this tube out when he has some reserve built up, ideally not when the sats are already low. At that point you try to work with what you have until you get to a more stable situation where you can have a shot at tube change...

I have been there - I had a surgeon ask for a change to a DLT tube during massive trauma case, i did not do it, as i did not think the patient would survive it, still think about it and happy i did not change it.

 

[dchz]

No a line as we anticipated it would be a quick case, the rhythm was normal as far as I recall, the had a MAP of 65-70, and was slightly tachycardic 100-103, he had more or less those vitals the entire case

What did you notice moments before the patient "coded"?

What do you mean coded? What caused you to do chest compressions?

The other thing to consider is how reliable was the pulse ox and BP in a 5 feet tall 330 pound guy? Perhaps the pt was doing much poorly before the code and your monitors didn't give you good information.

 

[Sleeplessbordernights]

As soon as secretions noticed in the tube yes it should have been suctioned, especially with a persistently low sat, you don't need anything in the tube limiting your delivery of oxygen. Had this been done earlier maybe he would have had more reserve when tube change came.

I think this guy was sicker than anyone realized and had massive pulmonary edema that you saw in the tube.

He couldn't tolerate the hypoxic event that came from the tube change/position change.

Before changing the tube, I would make have suctioned a ton, then bronched to evaluate tube.

I wouldnt be so convinced that the tube needed to be changed right away as much as needed to be suctioned right away.

And especially after the first big desat, your going to want to take this tube out when he has some reserve built up, ideally not when the sats are already low. At that point you try to work with what you have until you get to a more stable situation where you can have a shot at tube change...

I have been there - I had a surgeon ask for a DLT tube change during massive trauma case, i did not the the patient would survive it so did not do it, still think about it.

I tought about suggesting to my attending to aspirate the tube but tbh I was scared and did not want to contradict him

 

[Sleeplessbordernights]

What did you notice moments before the patient "coded"?

What do you mean coded? What caused you to do chest compressions?

The other thing to consider is how reliable was the pulse ox and BP in a 5 feet tall 330 pound guy? Perhaps the pt was doing much poorly before the code and your monitors didn't give you good information.

I noticed the secretions filling up the tube, then he started desat and his HR started dropping then his ekg went flat at that moment we started compressions.

Tbh I haven’t considered that but yeah, maybe he was doing way worse

 

[GassYous]

If it makes you feel better, this guy had a low chance of survival as it is. Covid in someone that fat is just not going to go well. Fourniers gangrene means he also has a high chance of doing poorly. He probably has all the metabolic stuff, insulin resistance, crappy blood vessels, crappy heart. At risk for covid related myocarditis, lung consolidation, hypercoagulable, etc. I've seen these guys code and die just from induction/intubation/ppv. I don't think your attending did anything wrong.

 

[coffeebythelake]

33 year old male pt, 330 lbs, 4.9 f. Absolutely no neck extension nor mouth opening.
is admitted because of a bad fournier gangrene secondary to an over the counter Im inyection of decadron her grandma applied to him because flu symtomps, which turns out to be covid, he is desat to 88, can’t lay flat at all but is otherwise doing fine with mask.

His covid is somewhat stable but the gangrene is not getting better so surgery decides to perform a colostomy.

He arrives to OR stable, sat 88 with mask, I perform a RSI with VL (With my attending besides me) I do it quick and on the first try, however he desats to 20, but is up to 92 after bag ventilation. Other than high plateu and peak pressure, the surgery goes fine on our side, surgery on the other hand has a lot on trouble getting the colostomy, they take 3 hours.

After the second hour I point to my attending that there is a lot of green thick secretion on the OT at firt at the base and slowly but steadly getting to the top. My attending points out we won’t be able to extubate him, we will change the OT at the end of the case.

The colostomy ends but surgery say they want to perform a quick debridement. We help by flipping the pt to one side. As they are doing the debridement I notice the secretions are all the way up in the tube and the pt starts desat to 85, 82, 80. My attending tells surgery to stop, we are gonna change the tube, as we put the pt supine, he desats hard to 20, my attending quickly changes the OT but the pt codes and after 30 min we are not able to bring him back.

This case happened 2 months ago but I have been thinking a lot, maybe we should not waited to change the tube, or we should have aspirated the secretions the moment we noticed them, what do you think?

First I hope it was well established by everyone that this is a high risk case jn a patient with active covid. The likelihood of a prolonged hospital course even without needing surgery is pretty high if he had sats of 88% at baseline and unable to lay flat. I also hope everyone was wearing PPE and had negative pressure room and set up.

The dramatic drop in saturation with apneia and intubation should have clued in that this patient had minimal to no pulmonary reserve and should be handled as such. Having intubated many covid patients in extremis in thr ICU we see this often. HfNC or BiPaP on 100% fio2 with adequate preozygenation that desat within seconds. Also remember than pulse oximeters typically have a 6 to 8 second time averaged measurement so there is a lag before u see thr sats drop or come back up. That should give u more appreciation for just how poor their pulmonary reserve is.

Placing an art line for a septic patient with bad lungs might help intraop management (to declare a sick patient for who he is) although unclear if it would have changed the intraop mortality outcome. i actually prefer to place them pre induction as these patients may have dramatic hemodynamic swings with induction and PPV. If there was no intent to extubate him it would make me feel even stronger for an art line.

Since you used VL you should have noticed frank aspiration with intubation which you did not, so I doubt the patient had a massive aspiration event.

Soft suction down secretions might be helpful but again with covid you gotta do stuff to protect yourself also. Secretions are due to fluid overload? Bad heart? Covid? Seems like vent settings had higher pressures during most of maintenance phase but nothing crazy? What was your fio2, peep, i:e, compliance? If plateau and peak pressures are about the same it would suggest lung parenchyma issue, while a peak pressure much higher than plateau might suggest airway kinking or blockage. Again I'm thinking art line might be helpful.

The part I'm most disconcerted with during this is changing out the ETT while thr patients sats were critically low. If you are moving air and giving reasonable TV there is no need for this... literally bottom of the list on thr things to do. What exactly was thr thought process behind this?

 

[IlDestriero]

He wasn’t going to leave the hospital on his feet. Too many things against him. I don’t think that you did anything wrong either, so don’t beat yourself up.
I’ve had a couple cases over the years that caused me a lot of distress even though I knew that I managed the patients appropriately, well even, but they still had bad outcomes and caused me distress that I just internalized, probably at the (temporary) expense of my mental well being. Don’t be afraid to reach out to someone and talk about what happened, your stress, etc. The hospital or department may have a system in place, and you can always fall back onto your program director for support or at least direction. You don’t need to be suffering alone.
Since you asked I would have done a couple things differently. In a super obese icu patient who has significant disease, potentially sepsis, major comorbidities, etc. I’d place an A-line. The ICU would probably have placed or asked for a central line as well. Even if he did well in the OR, he’s getting worse before he gets better, much worse. Having lines you can send an ABG, lactate, whatever else, though it sounds like he was doing fine until he acutely decompensated. You could have had a baseline to follow and accurate BPs. Maybe a CVP? Would it have changed this outcome? No, not this time.
When I saw crap in the ETT, I would have suctioned it out. To clear the airway and characterize the goo. This guy is a pulmonary cripple, anything you can do to help mitigate that will make your life easier. Was it an aspiration? Did you suction his stomach? Did it look the same? Covid folks can have endless garbage collecting in their airways. Was it just purulent fluid from a brewing pneumonia? Junk churned up on PPV for 3 hours? It doesn’t really matter, but it’s better out than in. If he had a sudden collapse, it could also be right heart failure, pulmonary edema, etc. maybe he threw a clot when turned and had a massive PE? Seen it.
The other thing I would not have done is extubate the patient. If the ETT is in the airway and not kinked or clogged, only bad things can happen removing that tube. And they did. I vetoed an attending about to make a bad decision a couple times by clearly stating my concern for why X is a bad idea and Y is probably better for this patient. If they insist on Y, at least you can sleep at night knowing you tried to keep the train on the tracks, and they derailed it. A fiber might have been useful in this situation as well. You can try to suction, clear the ETT, etc. The only ETT I could not clear with suction and maybe a saline bullet was a 3.0 ett with a blood concretion.
None of that was your fault.

 

[GassYous]

Well if you think the sats are low because there's a blockage that you can't suction out, removing the tube and placing a new one makes sense. I've had to extubate and reintubate a few covid people because of hard secretions.

I also see why you would line up a covid patient but I've had them come in for i&ds of the arm 2/2 being a druggie and just tubed em for the case only.

 

[dabears505]

Bad things happen in Anesthesia. Some are your fault, some are the patient pathology. That's why I hate this job and wish I had done psych or pmnr.

 

[DrOwnage]

Yeah this was a difficult case to start with and you had a lot going against you. However, I disagree with the fact that the tube had to be changed at that point in time in an already tenuous patient with no pulmonary reserve. If you can stick a suction catheter down and clear the tube that would be enough for me. If no visible aspiration on VL and the cuff was still functional I'm leaving that thing in.

 

[coffeebythelake]

Bad things happen in Anesthesia. Some are your fault, some are the patient pathology. That's why I hate this job and wish I had done psych or pmnr.

Most of medicine involve dealing with some sort of risk. Even with psych (and maybe PM&R)

 

[chessknt]

33 year old male pt, 330 lbs, 4.9 f. Absolutely no neck extension nor mouth opening.
is admitted because of a bad fournier gangrene secondary to an over the counter Im inyection of decadron her grandma applied to him because flu symtomps, which turns out to be covid, he is desat to 88, can’t lay flat at all but is otherwise doing fine with mask.

His covid is somewhat stable but the gangrene is not getting better so surgery decides to perform a colostomy.

He arrives to OR stable, sat 88 with mask, I perform a RSI with VL (With my attending besides me) I do it quick and on the first try, however he desats to 20, but is up to 92 after bag ventilation. Other than high plateu and peak pressure, the surgery goes fine on our side, surgery on the other hand has a lot on trouble getting the colostomy, they take 3 hours.

After the second hour I point to my attending that there is a lot of green thick secretion on the OT at firt at the base and slowly but steadly getting to the top. My attending points out we won’t be able to extubate him, we will change the OT at the end of the case.

The colostomy ends but surgery say they want to perform a quick debridement. We help by flipping the pt to one side. As they are doing the debridement I notice the secretions are all the way up in the tube and the pt starts desat to 85, 82, 80. My attending tells surgery to stop, we are gonna change the tube, as we put the pt supine, he desats hard to 20, my attending quickly changes the OT but the pt codes and after 30 min we are not able to bring him back.

This case happened 2 months ago but I have been thinking a lot, maybe we should not waited to change the tube, or we should have aspirated the secretions the moment we noticed them, what do you think?

ICU background here.

A few thoughts:
1-Not sure how you guys intubated and probably preaching to the choir here but doing them in a a near sitting/upright upright position with a BiPAP/CPAP on can help immensely with the massive decruitment that occurs with RSI.

2-Any time there are suddenly massive secretions in an ETT (or by OT do you mean an oral gastric tube?) I think bleed vs aspiration vs pulmonary edema (I suppose there are others that you guys have to worry about but probably not in this non-thoracic case). You can usually tell which by the color and consistency of the fluids. With aspiration/mucus plug it can be helpful to put one side down (usually the right), crank up PEEP and ventilate the plug down to protect ventilation in a single lung while someone is getting a bronchoscope and you are passing the biggest suction catheter possible through the ETT repeatedly getting **** out of it. Using a bronch to suction an airway has an art to it but once youve done it enough you dont even need to see anything, just aim it to the lung you are protecting (in this case the up lung) shove it down until you feel some resistance, flex up so the working channel is dragging along the posterior wall of the bronchus, and drag it up to the ETT->withdraw->flush->repeat ad nauseum (and collect 2 rvus no matter how long it takes!)

3-Most importantly--COVID and Fournier gangrene dont have 100% survival. This guy had the odds stacked hard against him and even though he died it sounds like he received good care. This happens and it is ok to feel bad about it but don't feel responsible. One of these is a healthy empathy the other is an unhealthy response that makes you doubt yourself when you are forgetting about all of the other hard cases you successfully got out of the OR fine.

 

[Volatile]

I noticed the secretions filling up the tube, then he started desat and his HR started dropping then his ekg went flat at that moment we started compressions.

Tbh I haven’t considered that but yeah, maybe he was doing way worse

Anytime you are flipping a sick ICU patient in the OR be prepared for a code. I don’t know if it’s PE or large fluid shifts stressing the heart but it’s not uncommon for badness to occur.
Also, bradycardia is a bad omen in sick patients. Once his HR started to drop I would be mentally preparing for a code, and would tell the surgeons to hurry the **** up.
Bad things are going to happen in our field, don’t beat yourself up. This guy was sick having emergent surgery. I have a partner who lost a healthy patient having elective surgery, that’s rough

 

[MirrorTodd]

Sounds like this guy was gonna code with disconnecting the circuit to do the suctioning anyway.

 

[abolt18]

A few things on my mind.

1. I definitely would have placed an art line. Though I doubt that would have "saved" him, I believe it could have helped with the intraop and intra-code management.

2. That first sign of "thick secretions" I would have suctioned that tube. You know he has COVID, so those secretions are just going to keep coming. People normally cough that up. Since he's anesthetized and he cannot, you have to help him with that. Likely numerous times during the case. Then changing positions can easily lead to displacement of mucous from the dependent portions of the lungs and acutely occlude the oETT. This has happened to me every time I have an already intubated patient that I have to take to the OR for a prone case... Yuck.

3. Also, I can't believe the tube was pulled upon desaturation rather than attempting to suction the ETT that you already knew was full of crud.

In reality, as has been stated, this guy's chance of getting it of the hospital without severe debility, let alone surviving, is very low. And there is a possibility that this decompensation could be from a combination of things.

P.S. are you in the U.S? Just curious. You used a few abbreviations and terms that seemed non-standard to me. Also, I don't know of any OTC steroid injections you can get here.

 

[Hork Bajir]

Wow it doesn’t sound like it was the case here, I had a Covid patient code from autopeep due to crazy impacted secretions in the ETT. I watched as the RT kept bagging, pulse pressure got narrower and narrower... Then went flat. I had been consulted to the ICU for a tube exchange and I was outside of the room donning my PPE and watching this happen, I still had about 30 seconds left to get all of my gear on. I yelled through the glass to the RT “EXTUBATE NOW Fu8!? DO IT”. Just hoping I was right... As soon as the tube came out, got ROSC- and then desatted like a stone. Thankfully in the next few seconds I finished getting my PPE on, kicked open the door to the room, and re-intubated.

it was one of the scarier calls I have had to make, and ever since I have a whole new understanding of autoPEEP!

 

[chocomorsel]

Wow it doesn’t sound like it was the case here, I had a Covid patient code from autopeep due to crazy impacted secretions in the ETT. I watched as the RT kept bagging, pulse pressure got narrower and narrower... Then went flat. I had been consulted to the ICU for a tube exchange and I was outside of the room donning my PPE and watching this happen, I still had about 30 seconds left to get all of my gear on. I yelled through the glass to the RT “EXTUBATE NOW Fu8!? DO IT”. Just hoping I was right... As soon as the tube came out, got ROSC- and then desatted like a stone. Thankfully in the next few seconds I finished getting my PPE on, kicked open the door to the room, and re-intubated.

it was one of the scarier calls I have had to make, and ever since I have a whole new understanding of autoPEEP!

Bigger question is, did he make it out of the unit alive? Or out of the hospital?

 

[Planktonmd]

Did you say that you had to change the ETT??? Why on earth would anyone do that? If there are secretions in the tube just suction it! Why would a new tube be better than the old tube? It seems to me that your attending is not the sharpest tool in the shed... sorry
But for your future... if a tube is in the trachea, and you are having problems (regardless of what problems they are) never... ever remove the tube!

 

[IMGASMD]

Most of medicine involve dealing with some sort of risk. Even with psych (and maybe PM&R)

There are a few cases after discharges, patient went home and committed suicides, can’t be good.

PM&R, I am not sure what can be acute enough to “cause” death. Probably less job satisfactions for me. Not sure what I remembered about my PMNR rotations other than we did EMGs in the afternoons....

 

[chocomorsel]

Did you say that you had to change the ETT??? Why on earth would anyone do that? If there are secretions in the tube just suction it! Why would a new tube be better than the old tube? It seems to me that your attending is not the sharpest tool in the shed... sorry
But for your future... if a tube is in the trachea, and you are having problems (regardless of what problems they are) never... ever remove the tube!

Alright FFP Junior. At least you didn’t call he or she a straight up idiot!
I get you though.

 

[chocomorsel]

OP, I already figured the ending after seing the 4’9’ and 330lb line.
In my experience over the past year, patients with BMIs in the 70s with Covid ALWAYS die, if they end up in the intubated from Covid. If you meant 4.9 feet which equals 4’11” that BMI is still 66 equaling a 100% chance of death, especially in the Hispanic population. I believe you are South of the US border?
I have taken care of a Caucasian dude w BMI in the high 50s or low 60s who never got intubated but lost a 27 year old Hispanic kid. BMI was 50. Just how it is. Sorry. Should have suctioned and not swapped tubes, but he was headed for the morgue. Don’t beat yourself up. It is so sad. I took care of Non Covid patients last week and was swamped, but was still happy 6/7 days because I wasn’t discharging to the morgue.
It is what it is.
The minute he needed to be intubated, he was a done deal unfortunately.
Take care of yourself.

 

[GassYous]

Anytime you are flipping a sick ICU patient in the OR be prepared for a code. I don’t know if it’s PE or large fluid shifts stressing the heart but it’s not uncommon for badness to occur.
Also, bradycardia is a bad omen in sick patients. Once his HR started to drop I would be mentally preparing for a code, and would tell the surgeons to hurry the **** up.
Bad things are going to happen in our field, don’t beat yourself up. This guy was sick having emergent surgery. I have a partner who lost a healthy patient having elective surgery, that’s rough

Depends on what you're flipping them to but usually you have some bolsters under the belly. You get compression of vasculature and decreased venous return. This is exacerbated by obesity.

Everyone is going nuts about the tube removal but again, sometimes the covid secretions are rock hard and there's no way you can suction or ventilate past the obstruction. The attending here did not necessarily do the wrong thing. But in other patients yeah I'd be suctioning and leaving that tube in place.

 

[chessknt]

Depends on what you're flipping them to but usually you have some bolsters under the belly. You get compression of vasculature and decreased venous return. This is exacerbated by obesity.

Everyone is going nuts about the tube removal but again, sometimes the covid secretions are rock hard and there's no way you can suction or ventilate past the obstruction. The attending here did not necessarily do the wrong thing. But in other patients yeah I'd be suctioning and leaving that tube in place.

Not my experience. I've changed 0 tubes in 100+ icu intubated covid cases for ventilation issues. Regardless a brand new ett won't have rock hard secretions in it.

 

[abolt18]

Depends on what you're flipping them to but usually you have some bolsters under the belly. You get compression of vasculature and decreased venous return. This is exacerbated by obesity.

Everyone is going nuts about the tube removal but again, sometimes the covid secretions are rock hard and there's no way you can suction or ventilate past the obstruction. The attending here did not necessarily do the wrong thing. But in other patients yeah I'd be suctioning and leaving that tube in place.

But this tube has only been in for a few hours! Never seen the mucous solidify in a tube that quickly.

 

[dannyboy1]

Couple of thoughts
1) super morbidly obese, covid +, and satting 88% on face mask. Thats a case where you tell the surgeon to reschedule. Diverting ostomy is not an emergency. Maybe his lungs get better, maybe not but either way he doesn’t die in your OR
2). If it has to be done why not try an epidural. Intubating this guy is pretty much a death sentence and should be avoided at all costs.

 

[chocomorsel]

Couple of thoughts
1) super morbidly obese, covid +, and satting 88% on face mask. Thats a case where you tell the surgeon to reschedule. Diverting ostomy is not an emergency. Maybe his lungs get better, maybe not but either way he doesn’t die in your OR
2). If it has to be done why not try an epidural. Intubating this guy is pretty much a death sentence and should be avoided at all costs.

It’s Nec Fasc. There is no waiting on Nec Fasc.

 

[GassYous]

But this tube has only been in for a few hours! Never seen the mucous solidify in a tube that quickly.

That's true

Couple of thoughts
1) super morbidly obese, covid +, and satting 88% on face mask. Thats a case where you tell the surgeon to reschedule. Diverting ostomy is not an emergency. Maybe his lungs get better, maybe not but either way he doesn’t die in your OR
2). If it has to be done why not try an epidural. Intubating this guy is pretty much a death sentence and should be avoided at all costs.

Fourniers gangrene is a surgical emergency. I would have skipped the ostomy but they needed to do an i&d. I bet an epidural would be stupid hard in this patient.

 

[Katheudontas parateroumen]

33 year old male pt, 330 lbs, 4.9 f. Absolutely no neck extension nor mouth opening.
is admitted because of a bad fournier gangrene secondary to an over the counter Im inyection of decadron her grandma applied to him because flu symtomps, which turns out to be covid, he is desat to 88, can’t lay flat at all but is otherwise doing fine with mask.

His covid is somewhat stable but the gangrene is not getting better so surgery decides to perform a colostomy.

He arrives to OR stable, sat 88 with mask, I perform a RSI with VL (With my attending besides me) I do it quick and on the first try, however he desats to 20, but is up to 92 after bag ventilation. Other than high plateu and peak pressure, the surgery goes fine on our side, surgery on the other hand has a lot on trouble getting the colostomy, they take 3 hours.

After the second hour I point to my attending that there is a lot of green thick secretion on the OT at firt at the base and slowly but steadly getting to the top. My attending points out we won’t be able to extubate him, we will change the OT at the end of the case.

The colostomy ends but surgery say they want to perform a quick debridement. We help by flipping the pt to one side. As they are doing the debridement I notice the secretions are all the way up in the tube and the pt starts desat to 85, 82, 80. My attending tells surgery to stop, we are gonna change the tube, as we put the pt supine, he desats hard to 20, my attending quickly changes the OT but the pt codes and after 30 min we are not able to bring him back.

This case happened 2 months ago but I have been thinking a lot, maybe we should not waited to change the tube, or we should have aspirated the secretions the moment we noticed them, what do you think?

This is really tough. This was a traumatic experience with the pressure of the situation and of course it's hard not to just do what your attending says plus COVID. I hope you can see to talk about the case here on this forum and feel supported. I know you're just trying to process it all. First you need to give yourself some space. Definitely not your fault. This guy was super sick to begin with. Once you come to terms with that, then you can start reading some of the advice here and in a similar situation, maybe do things differently. it's always healthy to look back and see what you can do better. But do it from a place of peace, not guilt. Our job is super stressful, you're not alone.

In any case, like someone said before, colostomy doesn't sounds urgent. I/D for gangrene, sure that would make more sense. but all things said, you probably get pushed to do the case anyways. Someone with known COVID and barely maintaining saturation on NRB is super sick ICU status. Especially with this body habitus. So we will treat this like ICU case. He needs art line, definitely will help with peri-code situation but also labs, plus will definitely leave intubated if he made it through the case etc for the ICU. Epidural was suggested would be good except this patient you described can't lay flat and makes sense since he's so hypoxic already. So I think GETA was appropriate. As for the junk in the tube, you were correct, definitely try to suction the tube first, both with suction catheter and then bronchscope when available. I would only exchange the endotracheal tube if you couldn't pass a suction catheter down which means there's some mucus plug or junk that's too hard to ventilate through. Last resort for sure as this patient would not be able to tolerate any apnea time as you saw.

 

[coffeebythelake]

Depends on what you're flipping them to but usually you have some bolsters under the belly. You get compression of vasculature and decreased venous return. This is exacerbated by obesity.

Everyone is going nuts about the tube removal but again, sometimes the covid secretions are rock hard and there's no way you can suction or ventilate past the obstruction. The attending here did not necessarily do the wrong thing. But in other patients yeah I'd be suctioning and leaving that tube in place.

the only times we have exchanged ETT in covid patients in ICU are those with either concern for cuff leak and not able to deliver the appropriate ventilation, or inadvertent extubation due to their high sedation requirements. they make a fair amount of secretions, and they might be particularly thick and nasty but i wouldn't expect that to form from a few hours in the OR

 

[coffeebythelake]

That's true



Fourniers gangrene is a surgical emergency. I would have skipped the ostomy but they needed to do an i&d. I bet an epidural would be stupid hard in this patient.

i don't think epidural is going to work if the patient can't even lay flat for the surgery after

 

[chessknt]

This is really tough. This was a traumatic experience with the pressure of the situation and of course it's hard not to just do what your attending says plus COVID. I hope you can see to talk about the case here on this forum and feel supported. I know you're just trying to process it all. First you need to give yourself some space. Definitely not your fault. This guy was super sick to begin with. Once you come to terms with that, then you can start reading some of the advice here and in a similar situation, maybe do things differently. it's always healthy to look back and see what you can do better. But do it from a place of peace, not guilt. Our job is super stressful, you're not alone.

In any case, like someone said before, colostomy doesn't sounds urgent. I/D for gangrene, sure that would make more sense. but all things said, you probably get pushed to do the case anyways. Someone with known COVID and barely maintaining saturation on NRB is super sick ICU status. Especially with this body habitus. So we will treat this like ICU case. He needs art line, definitely will help with peri-code situation but also labs etc for the ICU. Epidural was suggested would be good except this patient you described can't lay flat and makes sense since he's so hypoxic already. So I think GETA was appropriate. As for the junk in the tube, you were correct, definitely try to suction the tube first, both with suction catheter and then bronchscope when available. I would only exchange the endotrachial tube if you couldn't pass a suction catheter down which means there's some mucus plug or junk that's too hard to ventilate through. Last resort for sure as this patient would not be able to tolerate any apnea time as you saw.

You can ventilate past a tube and mainstem bronchus obstruction by cranking peep to max and giving a hard squeeze or 3 (one caveat is a fixed obstruction which wouldn't be the case here). You need to push it down far enough to recover some lung to ventilate with then go get it out when the pt isn't pericoding. If the pt isn't hypoxic and had some reserve then you have time and tolerance for an exchange. Doesn't always work but I would always advocate for that over removing an airway in a patient who can't meaningfully cough.

 

[coffeebythelake]

Wow it doesn’t sound like it was the case here, I had a Covid patient code from autopeep due to crazy impacted secretions in the ETT. I watched as the RT kept bagging, pulse pressure got narrower and narrower... Then went flat. I had been consulted to the ICU for a tube exchange and I was outside of the room donning my PPE and watching this happen, I still had about 30 seconds left to get all of my gear on. I yelled through the glass to the RT “EXTUBATE NOW Fu8!? DO IT”. Just hoping I was right... As soon as the tube came out, got ROSC- and then desatted like a stone. Thankfully in the next few seconds I finished getting my PPE on, kicked open the door to the room, and re-intubated.

it was one of the scarier calls I have had to make, and ever since I have a whole new understanding of autoPEEP!

how was this detected? presumably from the ventilator alarming that the inhaled breath volumes were not the same as exhaled breaths?

 

[Lidolover]

The lesson I have learned over time and I remind myself over and over again is to always “fear” those “short cases”. Don’t take things lightly and don’t rush.

Secondly, aside from the nec fasc which for me are always “big” cases, covid makes the case way more complicated. Even if pts have overcome active covid, operating on them within the first 12 weeks (for the ones with DM and other comorbidities) increases substantially their morbidity and mortality. So watch out.

Last, you guys were awesome in highlighting all points but wanted to clarify one thing: I hope u meant u would not remove the ETT if you have established a baseline good ventilation. Ppl have died from fixation errors when the team knows the tube is through the vocal cords and it’s a mystery why they cannot ventilate... and ppl get wasted trying to figure out why. Always bronch or if no time available always throw a confirmatory bougie... ETT can get folded and u can uncover that only if you pull the tube on time or with post mortal chest X-rays...

PS. Thnx for these wonderful educational cases and very insightful opinions.

 

[chocomorsel]

how was this detected? presumably from the ventilator alarming that the inhaled breath volumes were not the same as exhaled breaths?

With each breath, BP kept dropping along with the sats in a high suspicion case where he was consulted for a tube exchange?
Plus we all know how excited nurses and RTs get with bagging patients. Soon as bag inflates, here’s the next breath.

 

[dannyboy1]

It’s Nec Fasc. There is no waiting on Nec Fasc.

From what the OP posted it sounds like the fourniers had already been operated on, this was just an ostomy to help healing..

 

[Sleeplessbordernights]

A few things on my mind.

1. I definitely would have placed an art line. Though I doubt that would have "saved" him, I believe it could have helped with the intraop and intra-code management.

2. That first sign of "thick secretions" I would have suctioned that tube. You know he has COVID, so those secretions are just going to keep coming. People normally cough that up. Since he's anesthetized and he cannot, you have to help him with that. Likely numerous times during the case. Then changing positions can easily lead to displacement of mucous from the dependent portions of the lungs and acutely occlude the oETT. This has happened to me every time I have an already intubated patient that I have to take to the OR for a prone case... Yuck.

3. Also, I can't believe the tube was pulled upon desaturation rather than attempting to suction the ETT that you already knew was full of crud.

In reality, as has been stated, this guy's chance of getting it of the hospital without severe debility, let alone surviving, is very low. And there is a possibility that this decompensation could be from a combination of things.

P.S. are you in the U.S? Just curious. You used a few abbreviations and terms that seemed non-standard to me. Also, I don't know of any OTC steroid injections you can get here.

Yeah I’m just south of the border in a large city in a big Trauma hospital

 

[dabears505]

What is the litigation environment in mexico?

 

[Southpaw]

read the first couple lines and was like 'no way this dude makes it out'. tell surgeon no chance at the ostomy. you have to deal with the gangrene. you could get creative with a saddle block or slowly dosed epidural but from what we know intubating a morbidly obese person with bad covid is basically game over.

no point in changing out the ETT. the problem is distal to the ETT, and it's a bad bad bad problem. suction the tube, but no way I'm taking that ETT out. Ever. It stays.

 

[Planktonmd]

Alright FFP Junior. At least you didn’t call he or she a straight up idiot!
I get you though.

I was trying to be nice...

 

[Sleeplessbordernights]

What is the litigation environment in mexico?

Not nearly as bad as in USA as far as I can tell, however all My attendings have liability insurance

 

[coffeebythelake]

Not nearly as bad as in USA as far as I can tell, however all My attendings have liability insurance

Maybe not as bad for malpractice insurance... but Are u concerned about violence toward Healthcare workers? Is that more common in Mexico?

 

[2Fast2Des]

You were screwed as soon as you rolled in the door. Pulling out a previous functional tube was the icing, but I can understand in a sick pt in a world of hurt things happen quickly and badly where pulling out the tube was a rushed judgement to fix a problem acutely. That being said agree with the others, it's a VL, no way it's going to get dislodged unless pt bucking and going nuts, just gotta suction and pray. Don't blame yourself, you learned how things can go so acutely wrong in a very sick patient. Makes you, and hopefully others appreciate our role and specialty a bit more, we try to turn a turd into a chocolate truffle and sometimes it just don't happen. Next time suction the tube and fiber-optic, unless you are absolutely confident pt can handle a relook at the airway, which in this scenario wasn't really a great option sounds like

 

[Ronin786]

Reminds me of an argument I had with the MICU when they called me as a resident to exchange an ETT in a patient with some sort of lung CA bleed/DAH. Blood pouring out of the ETT. Flat out had to tell them this patient is too far gone, they're going to die from their bleeding and I want no part in changing the cause of death to a failed airway.

Boards answer in situations of alveolar bleeding involve a DLT and isolation of the affected lung. In my limited experience, when you're called to situations like this, most times it's too far gone and nobody has a true idea of where the bleeding is coming from. DLT in a bloody pair of lungs isn't fun.