A Simple Question, but everyone seems to disagree

[Precedex]

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A very straightforward scenario that i would appreciate comments on from some of the more seasoned folks.

ASA I or II not predicted to be a difficult intubation but perhaps obese (or OSA or some predictor for a difficult mask) gets induced with propofol (no paralytic). Efforts at mask ventilation are comletely ineffective: capnograph is flatlined. You try changing head position, oral/nasal airways, two handed mask etc and make no progress. Sat begins to drop. What is your move now?

Some attendings will go ahead and give sux and proceed with DL which I suspect many of you would agree with. Others argue that under no circumstances should a paralytic be given if you cannot mask ventilate: the move would then be to place an LMA or otherwise go down the emergency pathway of the difficult airway algorithm and wait until the propofol wears off and dude starts breathing sponaneously again.

Thanks

 

[Planktonmd]

A very straightforward scenario that i would appreciate comments on from some of the more seasoned folks.

ASA I or II not predicted to be a difficult intubation but perhaps obese (or OSA or some predictor for a difficult mask) gets induced with propofol (no paralytic). Efforts at mask ventilation are comletely ineffective: capnograph is flatlined. You try changing head position, oral/nasal airways, two handed mask etc and make no progress. Sat begins to drop. What is your move now?

Some attendings will go ahead and give sux and proceed with DL which I suspect many of you would agree with. Others argue that under no circumstances should a paralytic be given if you cannot mask ventilate: the move would then be to place an LMA or otherwise go down the emergency pathway of the difficult airway algorithm and wait until the propofol wears off and dude starts breathing sponaneously again.

Thanks

If you gave the induction agent and couldn't ventilate the next step should be laryngoscopy and try to intubate without muscle relaxant, If you can't intubate place LMA and ventilate.
I don't know why people like to ventilate before giving the muscle relaxant,
If you think you are going to have trouble just give a little dose of the induction agent without any other drugs and take a look.
Otherwise just induce anesthesia and give yourself the best intubation conditions from the beginning.

 

[Noyac]

Give sux. It will wear off just like the propofol if you still can't ventilate.

 

[militarymd]

If you think you can intubate....give the sux.

When you review cases of aspiration (M&M director at a residency program for 5 years...along with a partner whose done the same)...and subsequent ARDS...with prolonged stays in the ICU.....and maybe even death.

it is usually preceeded by patients gagging/coughing/straining during a botched attempt at laryngoscopy...usually without muscle relaxants or after they have worn off.

 

[pd4emergence]

Trach him.

Pd4

 

[Planktonmd]

Give sux. It will wear off just like the propofol if you still can't ventilate.

I understood that he gave the induction agent then tried to ventilate for what sounded like a long time (He tried to ventilate, then adjusted the head and tried, then placed an oral airway and tried, then placed a nasal airway and tried 🙂 ), and now the saturation is dropping, do you think he needs to give Sux now?

 

[Planktonmd]

Trach him.

Pd4

Exactly, You can never go wrong with a tracheostomy. 😀

 

[pd4emergence]

Trach him.

Pd4

Just kidding, If I thought I could ventilate him somehow (even with two hands or an LMA) in the beginning the sux would have already been pushed. I think either you feel that you can ventilate/intubate by your initial airway exam or you don't.

 

[Planktonmd]

Just kidding, If I thought I could ventilate him somehow (even with two hands or an LMA) in the beginning the sux would have already been pushed. I think either you feel that you can ventilate/intubate by your initial airway exam or you don't.

Exactly.
Do it early, not after you wasted all your good preoxygenation .

 

[fakin' the funk]

Give sux. It will wear off just like the propofol if you still can't ventilate.

Doesn't it take longer for it to wear off than it does for a fatty to desat to 70s/60s/50s? Something like 6-8m vs. 4-6m?

 

[urge]

Sux is probably not a good idea. Chances are intubation will not be difficult. But, if it is then you have a brain dead pt. Lma would be the safest thing to try. However, you may approach it as you like.

 

[jetproppilot]

Maximize the success of your intubation.

Dont go into the induction with a we'll see attitude.

Position the patient/bed to your liking. Add some reverse T berg.

Do a real preoxygenation.....mask firmly on face so no room air is entraining....lettem breathe this for a cuppla minutes to maximize the patient's already-diminutive FRC with pure O2.

Give propofol and follow it with sux immediately since you'll have a limited amount of time to intubate. Pay attention to your sux dose....your goal is to achieve brief paralysis so you can take a quick-but-thought-out-and-not-rushed look.
Mil's beloved 100mg dose is what I'd use.

As soon as she's apneic, start opening her mouth and getting your blade into position.....not rushing, but rather getting-into-position so you can start applying force when the sux hits. If you wait to start this process you'll burn about 15 seconds.....15 seconds that you could've used hunting with your eyes for the chords after you've exposed.

Use all the tricks you've personally learned....manipulating the glottis with your right hand during exposure, giving that last little-bit of wrist movement to expose more anterior....etc etc

Give this ONE look your absolute best effort.

It'll probably work.

And if it doesnt, like Noy said, the sux will wear off in time for whatever plan B is.

If you are REALLY worried, take time to mark the cricothyroid membrane with a sharpy before induction and have the jet setup in the room.

 

[snowman8]

What do you say to the judge when the defendants lawyer asks you "Why did you paralyze the patient and take away his ability to breath when you knew you were unable to do so for him?". If you are not doing a RSI and pushing the SUx with the propofol, I believe it is a bad idea to give Sux 3-4 minutes after you have attempted to mask ventilate. Let the propfol wear off. If you preoxygenated your patient and they have a decent reserve they should spontaneously breath before they become too hypoxic. If you can't mask ventilate with an oral airway in place with two hands, (and have failed a DL) you should be inserting an LMA and paging ENT for an emergent crich.

 

[snowman8]

On the other hand what do you do for the pt that you have pushed an induction dose of propofol, you are unable to ventilate or intubate, and as they start to lighten up and breath, they then start to breath hold and clamp their jaw shut and become hypoxic? This has happened to me on emergence and extubation after a GETA (not after induction). I just gave another dose of propofol, but I already knew I could mask and intubate. What if, as just I just proposed, it happens after the can not ventilate or intubate scenario?

 

[Planktonmd]

What do you say to the judge when the defendants lawyer asks you "Why did you paralyze the patient and take away his ability to breath when you knew you were unable to do so for him?". If you are not doing a RSI and pushing the SUx with the propofol, I believe it is a bad idea to give Sux 3-4 minutes after you have attempted to mask ventilate. Let the propfol wear off. If you preoxygenated your patient and they have a decent reserve they should spontaneously breath before they become too hypoxic. If you can't mask ventilate with an oral airway in place with two hands, (and have failed a DL) you should be inserting an LMA and paging ENT for an emergent crich.

You should not give the induction agent, try to ventilate, then try to intubate (I know you are being taught that day in and day out), here is why:
If you feel pretty confident about your ability to intubate a certain airway just push the drugs initially and do it, your inability to ventilate after the induction agent is most of times caused by incomplete relaxation.
If you have strong doubts then start from beginning with an alternate technique(Fiberoptic, glidescope, light wand....whatever), but don't do half an induction of GA and waste time trying to ventilate because this is when you get in trouble.
If you find yourself in this unpleasant situation (and you shouldn't) where you have already given an induction agent, can't intubate and can't mask ventilate and you have already wasted valuable time trying to ventilate and the SPO2 is dropping and you are hearing the dreaded low frequency song of the puls-ox I wouldn't push Sux if I were you, I would place an LMA and ventilate.

 

[Planktonmd]

On the other hand what do you do for the pt that you have pushed an induction dose of propofol, you are unable to ventilate or intubate, and as they start to lighten up and breath, they then start to breath hold and clamp their jaw shut and become hypoxic? This has happened to me on emergence and extubation after a GETA (not after induction). I just gave another dose of propofol, but I already knew I could mask and intubate. What if, as just I just proposed, it happens after the can not ventilate or intubate scenario?

I assume you are talking about a patient that you couldn't ventilate even with an LMA (extremely rare), in that case I will have a very low threshold for sticking an angiocath in the cricothyroid and jet ventilate until he is not trying to die.

 

[Precedex]

i appreciate all the discussion.
With respect to to the above, are you referring specifically to succinylcholine with induction? I see your point that others have also made about giving the relaxant right off the bat. But unless you are choosing sux, you will have to wait a few minutes anyway to achieve maximal relaxation. If you do that with a nondepolarizer and cant mask and cant intubate you're down the emergency pathway and no chance of it wearing off (without sugammadex at least). If you do it with sux (like 0.6 mg/kg), you might have enough time for it to wear off... but then it seems you would need to use sux for everyone and every case would be an RSI of sorts.

 

[urge]

You should not give the induction agent, try to ventilate, then try to intubate (I know you are being taught that day in and day out), here is why:

That's crazy talk Plank. Newbies don't know the difference between the scope and their arse. Ventilation before paralytics is the safest route for them, and for all of us. All it takes in this business is 1 brain dead pt. Why risk it?

 

[Planktonmd]

i appreciate all the discussion.
With respect to to the above, are you referring specifically to succinylcholine with induction? I see your point that others have also made about giving the relaxant right off the bat. But unless you are choosing sux, you will have to wait a few minutes anyway to achieve maximal relaxation. If you do that with a nondepolarizer and cant mask and cant intubate you're down the emergency pathway and no chance of it wearing off (without sugammadex at least). If you do it with sux (like 0.6 mg/kg), you might have enough time for it to wear off... but then it seems you would need to use sux for everyone and every case would be an RSI of sorts.

The choice of muscle relaxant depends on each case and how you feel about the airway.
I give the muscle relaxant upfront unless I have a strong doubt about the airway then I don't give an induction dose of the induction agent and I do something else on a case by case basis.
If I am going to use a muscle relaxant with a slow onset (other than Roc) I might give the muscle relaxant a minute or two before the induction agent.
And every case is a RSI because I like to put the tube in before every one else in the room falls asleep.

 

[Planktonmd]

That's crazy talk Plank. Newbies don't know the difference between the scope and their arse. Ventilation before paralytics is the safest route for them, and for all of us. All it takes in this business is 1 brain dead pt. Why risk it?

Disclaimer:
This is my personal way of doing things, and I am very good at intubating Jet's pregnant fire ants, If anyone feels that my approach is too crazy please don't do it.
🙂

 

[drccw]

Sounds like this is a case of "test ventilation"...

which is preached by sum...
To what I say BS.....

If I am going to induce someone, I am not going to half a$$ it....
induction agent, relaxant, laryngoscopy.... if I am concerned about an airway then I use sux... hell with suggamadex coming out you can bang in 2 mg/kg of ROC and when you cant intubate the patient just bang in 16 mg/kg of suggamadex and everything will be all right...if I am really concerned about an airway then it's awake FOB.... dont test ventilate.

This case it sounds like its too late for sux... sats are dropping. If you give the sux you've got another 30-45 secs of that annoyning bass line... so throw in the LMA.. vent for a while and then take another crack... I'm not a huge fan of layngoscopy without relaxant, unless I'm intubating a dead patient....