Hello, CA1 here. Long time lurker and first time poster. I've seen a few airway mis-adventures this year, especially on the floor and ICU and wanted to know your thoughts.
1. RSI. When do you do true vs modified? From what i've seen and read, if patient has poor pulmonary reserve and starts de-satting while waiting for paralysis to kick in then it is OK to give gentle breaths. Do you give breaths or always wait for because fear of aspiration? What is the risk benefit of A) Waiting for paralysis to fully kick in, B) giving some gentle positive pressure breaths while waiting, C) Taking a look and trying to intubate before patient fully paralyzed?
2. Paralysis. From reading and clinical experience, paralysis helps with ventilation and intubation. Say I only gave hypnotic and having hard time ventilating/intubating. Would you then work your way down difficult airway pathway or would you give paralytic? From what i've read it seems that you would probably give paralysis to ICU and floor patients whose clinical condition will only worsen and won't benefit from waking up? I feel that is pretty cavalier to do outside of the OR. Thoughts?
Intubations on the floor or ICU are notoriously bad, for a variety of reasons.
1) Patients are rarely "optimized," otherwise they wouldn't be needing intubation.
2) Necessary equipment or personnel may not be available.
3) Patient positioning is suboptimal.
4) Depending on where you train, ED or IM docs (or heaven forbid RT) might attempt the airway before calling you.
5) This means there is barely a Plan A, much less a Plan B, C, or D.
6) You've taken a floundering patient, hypoventilated them for awhile, chewed up the airway, and now you walk into the middle of it.
So a few pointers:
1) Figure out how urgent the situation is. Does this patient need to be intubated in 5 seconds (rare), 5 minutes, 0.5hrs, or 5 hours?
2) Based on (1) and a quick history and some quick data (last K+, at least), come up with a Plan A, B, C, at least, if not D. This might be DL, Glidescope, LMA, trach, or whatever. Paralysis vs no paralysis. Ventilation vs no ventilation. Etc etc.
3) Make sure you have all the equipment you need. Suction, oral airways, working blades, tubes, Ambu, etc. A lot of times you'll be the first to think of this. I started dragging a Glidescope to floors/ICUs that didn't have them, and it saved me multiple times.
4) Positioning! At least a shoulder roll if possible. Another trick is to slide them up on the bed so that their head is actually over the corner of the bed; with some incline this can get them in a decent sniffing position.
5) Control the room, as much as possible. Call a timeout, figure out names, who's doing what, etc.
6) Make sure there's a follow-up plan with the primary team. Vent settings, that they're getting sedation set up, etc. Also hemodynamics.
1) Coding patients don't need anything, they're already dead.
2) Paralysis is better than no paralysis. Sux if possible, roc if not (though RSI dose roc can get you into a heap of trouble in the wrong situation).
3) Don't go crazy on the anesthetic. A little propofol chased with phenylephrine or some midaz are usually more than enough. Ketamine also good for certain situations.
4) A lot of patients will crump after you intubate, either from knocking out their sympathetic drive or from the decreased preload from PPV. Be ready with phenyl or epi.
5) I find these intubations to be interesting, in a way. No two are alike and they all have their own peculiarities. It can also differentiate the people who can plan and adapt from those who can't. Lots of thinking involved with some of these.
Favorite ICU intubation story from residency: 0300 on a Saturday, called to MICU. Arrive to find 60-70y gentleman, sitting straight up in bed. Sats around the same as his age. Mentating appropriately, somehow (hypoxic preconditioning?). MICU fellow trying unsuccessfully to bronch him, but can't "get around the corner." Why? Hx of head/neck cancer s/p surgery and radiation, hx of post C-spine fusion, no flex/ext, limited mouth opening (of course). Good news is, he has no gag reflex because all of the nerves in his mouth have apparently been severed/burned away. Able to squeeze a Glidescope in sideways and then turn 90deg. CRNA pulls forward on the Glidescope and I steal the FO from the MICU fellow and use it as a steerable stylet for the tube. Through cords, done. Spontaneously breathing, maybe a little midaz after through the cords? Can't remember. There's a big blood clot acting like a ball-valve in his right mainstem that they then start trying to break up.
Back story was the guy had had some ortho procedure (hip?) earlier in the week, transferred on Wednesday for hypoxia and concern for difficult airway. ...Yes, in house for >72hrs during the week, and they decide to wait to let us know until 0300 on the weekend when things start going south...
If there's one thing to take home from this thread and the hemodynamic management thread, it's that anesthesia just has a very different way of thinking about things than most other specialties. We like anticipating problems and therefore we like having options. Lots of access (a-line, CVL, PIVs), lots of data (ABGs, lytes, etc), lots of plans (A, B, C, D).