Another AW case

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LifeofGas said:
Good job Sevo! I would’ve been extremely anxious seeing an airway like that. Reading this gives me the chills.

I had one case similar to this. I was on call and was ask by surgeon to eval an airway for a patient in ICU. It’s a patient with h/o head and neck CA s/p chemo radiation, she recently had a g-tube replacement, but 1 day after procedure, she was found obtunded, hypotensive. She was profoundly septic from the gastric perf and needed to be taken to the OR ASAP for ex lap. Her mouth opening was like the video, can’t even put my pinky through it. She was also obtunded. There was no ENT at our hospital but we did have a thoracic surgeon in ICU rounding who knows how to do traches and the ICU attending happened to be anesthesia trained. So with all these people nearby, I decided to check out her airway in the ICU using a bronch just to see how bad her airway is. We topicalized the S*** out of her nasal passage way and carefully put a small bronch in. Thank god the anatomy appeared normal. So since I got a great view, we shoved a 6.0 ETT nasally. I forgot what meds I gave...probably versed after we secured the tube. So, we basically did everything awake(well...she was obtunded...works in our favor)...and just jammed the tube in. We got extremely lucky as patient was not really reacting to us fidgeting around her airway.

Also of note...her BP was 50/32 on max levophed. With in and out Pulse Ox wave form. So yeah...i was extremely anxious about giving anything. I threw an a-line in after, there was no noticeable pulsatile flow...her pressure was that low. I stayed in the ICU ordered And flooded her with some fluid...(got her pressure up to like 80/40) before taking her to the OR. Case went well...but she expired a day later...she was hypotensive for way too long.
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sounds like icu didnt do a good job of managing patient.
 
sevoflurane said:
Anesthesia… nobody really knows what we do or deal with at all hours of the day and night. Type A dissections, crash C/S’s, major Trauma (recently had a hip disarticulation come through our trauma bay for major MVC with torn illiac arteries- what a case that was), ruptured AAA, exit procedures, VV/VA ECMO, I mean the list just keeps going. Funny how people (and even our fellow physicians) really don’t appreciate what we do day to day. This case is no exception… F’n love this specialty even though we are always the ninja’s hiding in the background.

So someone mentioned it earlier in the thread and I agree with them 100%… these cases suck- especially emergently at 2 am. Not only are they high risk, but careful planing and execution is key or things may spiral out of control quickly. One of my partners had a similar case last year with a 1 y/o pedi patient and the AW was lost. Traumatic for everyone involved.

The Case:

*Review the CT scan and any other images before taking these cases back. This patient demonstrated all the things that scare us regarding neck tumors including mass effect and 3mm hole (probably less) at the narrowest part of the AW. I then looked at the endoscopy pictures to get a feeling to the tumors friability… large ulcerated mass, huge inflamed arytenoids R>L, vocal cords obliterated by the tumor, etc and an extremely small hole the patient is breathing through. The mass over the glottic inlet did not look like a hard mass, but my spider sense was still going off at 1000%.

Note: The options are always the same. Awake trach vs awake/sv glide vs AFOI vs DL. Anyone giving neuromuscular blockers before an appropriate ETCO2 capnogram/wave form is not doing it right.

So ENT sat and reviewed the CT scan with me. My first question is exactly what many of you on this thread were going for and you guys are all correct. Awake trach please. Problem is this patient is a difficult trach due to her exaggerated kyphosis, poor landmarks as well a history of severe anxiety and inability to lie still (or flat for that matter) during her previous endoscopies. Crap. Deck is stacked against both of ENT and myself.

First thing to do with these cases is ALWAYS the same. You NEED to speak the patient and put the fear of god into their head because this is as serious as it gets and they need to be as cooperative as they can be. I told her that we were going to topicalize her, bring her back to the OR and I was going to place a video scope into her mouth for me to further asses her life threatening situation and make some decisions at that time.

The one bone that was thrown at me is that the patient was edentulous and she did not have fixed small mouth opening due to tumor invasion. The only positive of the case.

I tried being opened minded to ENT. She was definitely willing to attempt to do the trach awake, but it would be very difficult. Trach would basically be in the sitting position with difficult landmarks and an uncooperative patient. So I listened and definitely saw the challenge with an awake trach. She wasn’t being lazy or incompetent at all. Just as worried as I was with no great solutions.

So to the OR we go:

Ramped her up with a ton of blankets and had the head of the table flexed. Lowered the bed all the way to the ground and grabbed a step up so I could comfortably be positioned over her head. All rescue AW stuff in the room ready to go. I was fairly satisfied with the topicalization so I asked her to stick our her tongue while I placed the glidescope in her mouth. She did well for about 2 nano-seconds before the patient started freaking out, thrashing, etc. I did get a descent view of the tumor and a tiny little hole I assumed led be the glottic opening. Mass effect on the right was very evident… but I did get to take a look at inspiration and expiration and was able to see the arytenoids were not completely stuck in a fixed position. Well ****…. OK that is another positive.

Decision point time:

Some people on the thread here suggested midazolam, remi, ketamine, fentanyl, dexmedatomidine, etc… I think that in an AW like this, you need the most titratable on-off medication we have in our bag. For me this is propofol 100% of the time. I did the most gentle slow sedation known to man. 20 mg pushes while keeping the patient spontaneously breathing all the while assisting/feeling for compliance with my right hand on the bag. After a while I could tell she was getting where I needed her- I reached a depth of anesthesia I felt was good enough to take another look. I did so fully knowing this is likely the one shot I have to get this right. Gave her a final 30 mg of prop and waited 20 seconds before I inserted the low profile glide scope. Took it easy and started with the tongue and worked my way back- the last thing I wanted to do is to insert it too far and make the tumor start to bleed. The mass that was obstructing the glottic opening looked soft… so I gently pushed it out of the way with my 5.0 cuffed tube loaded on the glidescope stylet and then carefully twisted it past the tumor and into the little hole during inspiration to maximize the the caliber of the opening- railroaded off of the stylet. Based on the CT scan, I was pretty confident that there was no tumor that would obstruct ventilation past the vocal cord inlet as it opened up further down the trachea. Once I had ETCO2 I pushed 80mg of roc secured the ETT with a death grip benzoin/silk tape combo and the drama was suddenly over. Brought her iO2 down to 30 and proceeded to trach the patient right above the sternal notch with 2 ENT surgeons doing the work.


Here are a few learning points.

1). Insert the fear of god into patients during your interview to include them in the plan and let them know what to expect.
2). Look at imaging including CXR, CT scans and any endoscopy pictures that may alert you to the complexity of the case.
3). Respect a sitting patient that can hardly talk.
4). Always maintain SV with a drug that is quickly titratable. For me there is no better option than propofol- quick on quick off if performed by a knowledgeable anesthesiologist.
5). Topicalize heavily add some glyco. Regional AW blocks where applicable. Maybe insert a 18G angiocath through the cricoidthyroid membrane and squirt from below.
6). Have an exit plan. Prep the neck if you have to before you give it a go. Always have the option to back out.
7). Work together with ENT and try to understand their surgical issues- we are a team and rely on each other.
8). Don’t $hit your pants. Keep the room calm and collected and smelling good. You loose your $hit then the rest of the room will follow.
9). Call for help if you need to.

Glad things went well and the patient feels much much better after the trach. Comfort care is not quite what I would have wished for this poor patient. It was worth a try to get her the operation so that whatever life is left will be somewhat comfortable. Palliative care for an obstructing laryngeal tumor is an awful way to check out.

Below is the view I captured on the glidescope right before intubation. Nasty tumor, scary looking opening. As opposed to the inflamed hardy looking arytenoids, you get the feeling that the part of the tumor covering the glottic opening is somewhat mobile and pliable.

At the end of the day any strategy that doesn’t kill the patient is a viable strategy. Awake trach, SV intubation as well as palliative. VV ECMO would be the easiest but is institutional dependent. There is no right answer here.

Hope you guys enjoyed the case.
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Is there any reason for propofol over ketamine? Secretions? My only thought was that keeping her spontaneously breathing is at a huge premium.
 
I am a HUGE ketamine fan.
Not for this case. Yes secretions, but more importantly causing a dysphoric state in a patient that is already hard to keep still.

I have done afoi with every drug. Propofol in my hands is as good and better than anything else.

Didn’t want to give any respiratory depressants that was not titratable quickly (fentanyl/remi).

I think Dex is garbage for afoi... and I don’t like mixing multiple drugs as synergism btw/ multiple drugs can be unpredictable.

While it’s nice to have a reversible drug (midaz/narcs), I have never had to actually reverse any afoi in 15+ years of doing this.

Slow easy sedation w/propofol is not hard (and has not failed me as of yet).

But again... it’s not the drug... it’s how you use it. 😀
 
FiO2@21 said:
I guess my only thought as someone who hasn’t really had to do this yet is that remi is the definition of titratable. I’ve only used it for extubation but found it comes off within 3-5 minutes.
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Yeah titratble... but answer me this... how long does it take your patient to start breathing after you turn off remi during a spine case? Sure different context... but the principle is the same. It sticks around longer than proofol. Propofol in 20 mg aliquots is the definition of titratable in my book. But again, we are discussing anesthesiologist preferences. There is a reason that 50% of what we do is science and the other 50% is art. 🤘🏽
 
FiO2@21 said:
I guess my only thought as someone who hasn’t really had to do this yet is that remi is the definition of titratable. I’ve only used it for extubation but found it comes off within 3-5 minutes.
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sevoflurane said:
Yeah titratble... but answer me this... how long does it take your patient to start breathing after you turn off remi during a spine case? Sure different context... but the principle is the same. It sticks around longer than proofol. Propofol in 20 mg aliquots is the definition of titratable in my book. But again, we are discussing anesthesiologist preferences. There is a reason that 50% of what we do is science and the other 50% is art. 🤘🏽
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Agree but would def use much smaller dose than compared to spine case
 
sevoflurane said:
Yeah titratble... but answer me this... how long does it take your patient to start breathing after you turn off remi during a spine case? Sure different context... but the principle is the same. It sticks around longer than proofol. Propofol in 20 mg aliquots is the definition of titratable in my book. But again, we are discussing anesthesiologist preferences. There is a reason that 50% of what we do is science and the other 50% is art.
Click to expand...

Sometimes I’ve started at the end of a case for fun at ~0.03 and worked my way up to 0.08 mcg/kg/min after they already started breathing. It worked really well, even if I accidentally overdid it.

I agree it’s different from waking up from it after I had them apneac all case.
 
My point is that once you reach the apnea threshold, recovery to spontaneous ventilation is much quicker w/ propofol that has been administered in micro doses.
That’s the bottom line for me during these cases. Keeping that exit window wide open.
 
I agree with everything you say sevo! Great discussion here esp dex for afoi. Not very useful.
But i will give a shout out to micro dosea of remi. It blunts the larynx 'dance' like no other...

But as you say, its all about how you use it
 
FiO2@21 said:
I guess my only thought as someone who hasn’t really had to do this yet is that remi is the definition of titratable. I’ve only used it for extubation but found it comes off within 3-5 minutes.
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Remi is predictable.

Predictable is not the same as fast.
 
Wow great case and so interesting to see everyone’s approach. @sevoflurane was the main reason you wanted to do sedated VL was because ENT didn’t want to do awake trach? Do you think awake trach would still be your preference all things being equal? I think precedex is great for sedation as an adjust mostly and often is too slow onset. That’s why Id agree to keep it one drug so not too many competing meds. I am in the remifentanyl camp though. I feel like it’s shorter acting than propofol at the same doses. But propofol I admit is the drug I’m most comfortable with as well. Any drug well titration could work though.
 
Katheudontas parateroumen said:
Wow great case and so interesting to see everyone’s approach. @sevoflurane was the main reason you wanted to do sedated VL was because ENT didn’t want to do awake trach? Do you think awake trach would still be your preference all things being equal? I think precedex is great for sedation as an adjust mostly and often is too slow onset. That’s why Id agree to keep it one drug so not too many competing meds. I am in the remifentanyl camp though. I feel like it’s shorter acting than propofol at the same doses. But propofol I admit is the drug I’m most comfortable with as well. Any drug well titration could work though.
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Katheudontas parateroumen said:
Yeah dude. I asked ENT for an awake trach first. All things being equal with no surgical issues awake trach would be the way to go with an AW like that.
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Newtwo said:
I agree with everything you say sevo! Great discussion here esp dex for afoi. Not very useful.
But i will give a shout out to micro dosea of remi. It blunts the larynx 'dance' like no other...

But as you say, its all about how you use it
Click to expand...

Dex is useful for calm patients. Not useful for agitated or air hungry ones. Agree 100%
 
A resident had one of these cases for an M&M (from a 2am threatened airway) and elected to go for glycopyrrolate, ketamine, alfentanil, AFOI --> went poorly. All the good old boys were riding the Sevo-train into the sunset. I wouldn't use Sevo, but they made some good points re: titration + maintaining -ve pressure spont. vent until the last possible second.
 
woopedazz said:
A resident had one of these cases for an M&M (from a 2am threatened airway) and elected to go for glycopyrrolate, ketamine, alfentanil, AFOI --> went poorly. All the good old boys were riding the Sevo-train into the sunset. I wouldn't use Sevo, but they made some good points re: titration + maintaining -ve pressure spont. vent until the last possible second.
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The boys are fools!
 
woopedazz said:
A resident had one of these cases for an M&M (from a 2am threatened airway) and elected to go for glycopyrrolate, ketamine, alfentanil, AFOI --> went poorly. All the good old boys were riding the Sevo-train into the sunset. I wouldn't use Sevo, but they made some good points re: titration + maintaining -ve pressure spont. vent until the last possible second.
Click to expand...
If you mask induce this lady it will be a race to see if the initial dysphoric, agitated shallow breathing or the occurring-later relaxed pharyngeal musculature causing total obstruction kills her first.
 
woopedazz said:
What about good old sevo?
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To expand on the comments above -

Inhalation inductions are very slow in adults. They're even slower in people with impaired minute ventilation like this one. Ain't no way you could even approach the fabled "single breath induction" given her tiny tidal volumes. Even if you could get some gas into her, there'd be a much longer period in stage 2 with the associated risks for breath holding, laryngospasm, and other shenanigans that would be catastrophic in this patient.
 
woopedazz said:
A resident had one of these cases for an M&M (from a 2am threatened airway) and elected to go for glycopyrrolate, ketamine, alfentanil, AFOI --> went poorly. All the good old boys were riding the Sevo-train into the sunset. I wouldn't use Sevo, but they made some good points re: titration + maintaining -ve pressure spont. vent until the last possible second.
Click to expand...
What happened? Too heavy on the alfentanil --> apnea? Or too fast with the ketamine bolus? Or something completely different?
 
FiO2@21 said:
What happened? Too heavy on the alfentanil --> apnea? Or too fast with the ketamine bolus? Or something completely different?
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They were massively out of their depth and senior support was at home >30mins away.

From what I gather:
1. Delayed too long (waiting for boss +ENT) --> started to decompensate.
2. Panicked and decided to proceed rather than delay another 5 minutes for the cavalry to appear (perhaps the correct call, but probably not).
3. Gave ketamine prior to the glyco.
4. Gave too much ketamine (and a homoeopathic drop of alfentanil) and they ?obstructed (hard to tell if they were able to spont. vent. with some jaw thrust vs actually apnoeic?).
5. Couldn't see a thing with the "A"FOI due to anatomy + secretions.
6. Panic ++++
7. Pushed entire vial of ketamine and sux and tried with a CMAC.
8. M&M meeting.
 
woopedazz said:
They were massively out of their depth and senior support was at home >30mins away.

From what I gather:
1. Delayed too long (waiting for boss +ENT) --> started to decompensate.
2. Panicked and decided to proceed rather than delay another 5 minutes for the cavalry to appear (perhaps the correct call, but probably not).
3. Gave ketamine prior to the glyco.
4. Gave too much ketamine (and a homoeopathic drop of alfentanil) and they ?obstructed (hard to tell if they were able to spont. vent. with some jaw thrust vs actually apnoeic?).
5. Couldn't see a thing with the "A"FOI due to anatomy + secretions.
6. Panic ++++
7. Pushed entire vial of ketamine and sux and tried with a CMAC.
8. M&M meeting.
Click to expand...

****kkkkkkk

That's the kind of thing that messes with your head for months
 
One of those happened in residency, luckily I wasn’t in OR. Big neck mass, opted for sevo induction with thoracic there/ready and all the airway equipment. They either got inpatient or too deep with sevo, lost SV and couldn’t ventilate.

Tried glide couldn’t see anything. Sats tanking, thoracic went with rigid scope to get past obstruction, ripped hole in friable mass in trachea, cracked chest emergently, retro sternal trach placed. Probably 7-10 min of no oxygenation...

Somehow the guy woke up fine the next morning when I came in for my ICU shift, neuro intact. Discharged a few weeks later after some radiation to neck and resection.

I’ve never tried sevo induction since.
 
Shimmy8 said:
One of those happened in residency, luckily I wasn’t in OR. Big neck mass, opted for sevo induction with thoracic there/ready and all the airway equipment. They either got inpatient or too deep with sevo, lost SV and couldn’t ventilate.

Tried glide couldn’t see anything. Sats tanking, thoracic went with rigid scope to get past obstruction, ripped hole in friable mass in trachea, cracked chest emergently, retro sternal trach placed. Probably 7-10 min of no oxygenation...

Somehow the guy woke up fine the next morning when I came in for my ICU shift, neuro intact. Discharged a few weeks later after some radiation to neck and resection.

I’ve never tried sevo induction since.
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For the residents:

Sevoflurane can induce apnea and is a muscle relaxant. Worst combo for spontaneous ventilation. Plus it's hard to titrate and its "overdose" cannot be easily reversed in such a patient. Inhalational induction should never be used in patients who cannot be mask-ventilated, if necessary.

Even propofol titrated carefully is better, because it redistributes (i.e. wears off) faster.

Best are always medications that one is comfortable with and that can easily be reversed. One should use as little sedation as one can get away with, just enough to make the patient cooperative while still awake. This is not the time to be cavalier and cocky ("I am so good I can intubate this patient even asleep, unlike all those other losers"). Respect (the anesthesiologist who respects) the airway.
 
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woopedazz said:
They were massively out of their depth and senior support was at home >30mins away.

From what I gather:
1. Delayed too long (waiting for boss +ENT) --> started to decompensate.
2. Panicked and decided to proceed rather than delay another 5 minutes for the cavalry to appear (perhaps the correct call, but probably not).
3. Gave ketamine prior to the glyco.
4. Gave too much ketamine (and a homoeopathic drop of alfentanil) and they ?obstructed (hard to tell if they were able to spont. vent. with some jaw thrust vs actually apnoeic?).
5. Couldn't see a thing with the "A"FOI due to anatomy + secretions.
6. Panic ++++
7. Pushed entire vial of ketamine and sux and tried with a CMAC.
8. M&M meeting.
Click to expand...
Arent points 1 and 2 a little contradictory?
I know you werent there and it wasnt your case but from the sounds of it that is 100% not the residents fault and 100% the staff mans fault.

Any anesthesiologist that chooses to drive/live more than 30 mins from his hospital in 2021 while on call better have excellent insurance cause its gonna be used.

Sorry for going a bit off topic of the thread, but for airway cases this is very important. I avoid home call locums like the plague
 
woopedazz said:
They were massively out of their depth and senior support was at home >30mins away.

From what I gather:
1. Delayed too long (waiting for boss +ENT) --> started to decompensate.
2. Panicked and decided to proceed rather than delay another 5 minutes for the cavalry to appear (perhaps the correct call, but probably not).
3. Gave ketamine prior to the glyco.
4. Gave too much ketamine (and a homoeopathic drop of alfentanil) and they ?obstructed (hard to tell if they were able to spont. vent. with some jaw thrust vs actually apnoeic?).
5. Couldn't see a thing with the "A"FOI due to anatomy + secretions.
6. Panic ++++
7. Pushed entire vial of ketamine and sux and tried with a CMAC.
8. M&M meeting.
Click to expand...
Damn 🙁 as a CA3 at a program that lets us kinda run the show at night, stories like this mess me up. I would delay as much as possible waiting for staff but looks like even that last 5 minutes is wayyyy too long for an airway issues. Can’t wait when that pulse ox is going down or patient is gurgling. That’s rough.
 
Katheudontas parateroumen said:
Damn 🙁 as a CA3 at a program that lets us kinda run the show at night, stories like this mess me up. I would delay as much as possible waiting for staff but looks like even that last 5 minutes is wayyyy too long for an airway issues. Can’t wait when that pulse ox is going down or patient is gurgling. That’s rough.
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Stories like these should make you gain a new level of disrespect for your program. 😉

It's one thing to run the show, it's another thing not to have the safety net sit in the corner of the OR, instead of the call room.
 
FFP said:
Stories like these should make you gain a new level of disrespect for your program. 😉

It's one thing to run the show, it's another thing not to have the safety net sit in the corner of the OR, instead of the call room.
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Haha I feel you. It depends on the staff at night. They are in house but are usually floors away and sleeping. So it won’t be 30 min for them to come but it won’t be instant either
 
Katheudontas parateroumen said:
Haha I feel you. It depends on the staff at night. They are in house but are usually floors away and sleeping. So it won’t be 30 min for them to come but it won’t be instant either
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We had ob attending in house. In situations like these, I used to call before I even see the patient. NEVER did I get any ****. I also called my peds attending from home a few times. Either it turns out to be nothing, or they let me intubate/take charge of the case when they’re there. But should NEVER fear call too early, especially from a CA3.

As an attending I make it a rule, never yell at anyone for situations they don’t feel comfortable in. My crna calls for “difficult” intubations or covid intubations. My crna wants to move the intubation to OR and with gen surg at bedside? Sure. Never can have too many hands.... only too few.
 
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IMGASMD said:
We had ob attending in house. In situations like these, I used to call before I even see the patient. NEVER did I get any ****. I also called my peds attending from home a few times. Either it turns out to be nothing, or they let me intubate/take charge of the case when they’re there. But should NEVER fear call too early, especially from a CA3.

As an attending I make it a rule, never yell at anyone for situations they don’t feel comfortable in. My crna calls for “difficult” intubations or covid intubations. My crna wants to move the intubation to OR and with gen surg at bedside? Sure. Never can have too many hands.... only too few.
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Why is the CRNA making a decison like this instead of you?
 
Question from an ICU colleague. In peds cases of croup/epiglottis sevo inductions seem to be the standard. Do you run into the same problems of reduced drug delivery, loss of airway tone and laryngospasm that you guys have mentioned here?
 
economycian said:
Question from an ICU colleague. In peds cases of croup/epiglottis sevo inductions seem to be the standard. Do you run into the same problems of reduced drug delivery, loss of airway tone and laryngospasm that you guys have mentioned here?
Click to expand...

“Classic” teaching is you don’t want to stick an IV in a kid who’s in resp distress. I think that’s more of the reason for inhalational induction.

But I will let other peds guys chime in.
 
IMGASMD said:
“Classic” teaching is you don’t want to stick an IV in a kid who’s in resp distress. I think that’s more of the reason for inhalational induction.

But I will let other peds guys chime in.
Click to expand...

I'm out of my depth here when it comes to volatiles but that'd be my guess. Not specifically respiratory distress as we will stick IVs all the time in kids for status asthmaticus / ARDS etc, but for croup and epiglottitis because agitation is going to worsen your dynamic extrathoracic airway obstruction
 
IMGASMD said:
Bingo....

“We” take home calls, crnas take in house calls. Didn’t make the rules, ain’t gonna to fight this one.
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I get it, you have to work within the system you are a part of. You are “on the hook” as far as I know for the ultimate outcome of the airway though as far as I am concerned. Lots of nuances here but if something goes wrong I think there is potential liability.
 
Arch Guillotti said:
I get it, you have to work within the system you are a part of. You are “on the hook” as far as I know for the ultimate outcome of the airway though as far as I am concerned. Lots of nuances here but if something goes wrong I think there is potential liability.
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Of course. Just like KP who is a ca3, or the junior/senior resident in the case. At end of the day, YOU are on the hook.

I am sure everyone “heard” of a lost airway story somewhere along the way. We had a lost pediatric airway in training. Certainly made a lot of systemic changes afterwards. Some not for the better. Of course the attending, who was not in house, was hosed with the settlement.
 
IMGASMD said:
I am sure everyone “heard” of a lost airway story somewhere along the way. We had a lost pediatric airway in training. Certainly made a lot of systemic changes afterwards. Some not for the better. Of course the attending, who was not in house, was hosed with the settlement.
Click to expand...
I find it hard to believe an academic medical center doesn’t have an attending anesthesiologist in house at all times.

I find it especially hard to believe this happened on a peds airway. Wonder what the circumstances were.
 
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