Another patient disaster. What would you have done differently?

[gasp]

Basically, when you say you will wake up the pt to deal with the airway you basically imply an awake fiberoptic ( or whatever you do, but awake fiberoptic is the cadillac of all intubations). If you can mask her, you might as well do an asleep fiberoptic intubation as not to put a patient through the torture of awake intubation. An awake fiberoptic doesn't bring anything to the table over an asleep fiberoptic if masking is ok.

So, waking a patient up happens when you cannot mask or ventilate them. That is not an elective decision, it is a Hail Mary.

Have you ever "had to wake up a patient"?

I think you misunderstood the point I was trying to make. I was stating that in an elective scenario (baby was doing fine) but you have to induce GETA (failed spinal), I would NOT tell the surgeon to cut until I have confirmed ETT in the trachea. This is because if he cuts, and for some reason I cannot ventilate/intubate/lma wont seat/whatever, I still have the OPTION of waking up the patient (and coming up with a new plan) whereas I would lose this option if he had already cut the belly open. Also you are implying that you have a fiberoptic scope ready to go and someone to help u right when you figure out you are having trouble masking/intubating, this is usually not the case. Also awake fiberoptic intubations are not "torture" if done correctly. Also, I dont agree with you that an awake fiberoptic doesnt bring anything to the table over asleep fiberoptic if masking is ok. Just because you can mask her currently doesn't mean she will be maskable through the entire case. And even if you could mask her the entire case, the risk of aspiration by this method is still going to be higher than the risk of aspiration if you did an AFOI.

The only time masking is suggested is if the situation is an emergency and you cannot wakeup the mother and you are able to mask, you should continue masking. Otherwise the usual concensus is to wake up the patient to come up with a different plan. It is not suggested that you should mask ventilate a pregnant patient for a non emergent case just because you can if you have the option of waking them up. And yes I have heard of "waking up the patient"

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[urge]

I think you misunderstood the point I was trying to make. I was stating that in an elective scenario (baby was doing fine) but you have to induce GETA (failed spinal), I would NOT tell the surgeon to cut until I have confirmed ETT in the trachea. This is because if he cuts, and for some reason I cannot ventilate/intubate/lma wont seat/whatever, I still have the OPTION of waking up the patient (and coming up with a new plan) whereas I would lose this option if he had already cut the belly open. Also you are implying that you have a fiberoptic scope ready to go and someone to help u right when you figure out you are having trouble masking/intubating, this is usually not the case. Also awake fiberoptic intubations are not "torture" if done correctly. Also, I dont agree with you that an awake fiberoptic doesnt bring anything to the table over asleep fiberoptic if masking is ok. Just because you can mask her currently doesn't mean she will be maskable through the entire case. And even if you could mask her the entire case, the risk of aspiration by this method is still going to be higher than the risk of aspiration if you did an AFOI.

The only time masking is suggested is if the situation is an emergency and you cannot wakeup the mother and you are able to mask, you should continue masking. Otherwise the usual concensus is to wake up the patient to come up with a different plan. It is not suggested that you should mask ventilate a pregnant patient for a non emergent case just because you can if you have the option of waking them up. And yes I have heard of "waking up the patient"

1 If you cannot ventilate/intubate, that baby better come out before mom is dead.
2 I have yet to meet a patient who thought an awake fiberoptic was fun.
3 Do you want to mask until pt wakes up, then topicalize the airway and do a fob intubation, vs mask ventilate until the fob comes to the room and do a fob intubation? One of them seems more straight forward to me.

PS: I said HAD to wake a patient up.

 

[Mman]

Really? Your full term patients stay saturated for 1-2 minutes so that you can dink around with airway? Not in my experience.
What if it was a crash c/s? What if baby was in jeopardy and your preoxygentation consisted of a couple of deep breaths. What then?

I'm not even sure where you are going with this. Your argument to not confirm etCO2 prior to returning to surgical intervention is that I'm dinking around with the airway? I'm not. I've already got the tube in. I'm just waiting the 5-10 seconds to confirm CO2. If I don't have CO2 what I'm saying is I'd rather not have a surgeon pressing up on the patient's abdomen causing her to vomit into her mouth while I'm doing another DL. You are FAR more likely to end up in a cannot intubate/cannot ventilate situation if the surgeon is actively messing around in their abdomen. I'm talking about a controlled situation with a preoxygenated mother. I'm not talking about "crash c/s" since this is a situation with an inadequate spinal we've already presumed we had time to place a spinal. If you'd like to discuss how to take care of a "crash c/s", please do so.

 

[cincincyreds]

This is just going to be the future of medicine. You are gonna have more of these midlevels making deadly decisions because there is no way for them to make an informed decision without the proper training of an MD/DO.

Obama wants things done on the cheap. The cRNA wanted to prove how awesome they are to the OB and the patient leaves in a body bag. I mean, god forbid you wake the patient up after a failed intubation and do an awake fiberoptic intubation. Really, you are wasting the surgeon/OB's time. At least that person will be alive.

 

[napman]

I think waking the patient is definitly a option
If you are able to ventilate the patient and it is an elective c section and you attempted intubation and think that patient is difficult to intubate, you can wake the patient up come back with another plan later . you can repeat a neuraxial block later or do a graded epidural.
I did wake up the patient when I was not able to ventilate and did the case next day ( not in OB)
If you ask the surgeon to cut immediatly after you push sux and prop you are loosing this option

Even when it is a difficult mask ventilation most often you can ventilate enough to maintain oxygenation till patient wakes up, using LMA or othe adjuncts

Basically, when you say you will wake up the pt to deal with the airway you basically imply an awake fiberoptic ( or whatever you do, but awake fiberoptic is the cadillac of all intubations). If you can mask her, you might as well do an asleep fiberoptic intubation as not to put a patient through the torture of awake intubation. An awake fiberoptic doesn't bring anything to the table over an asleep fiberoptic if masking is ok.

So, waking a patient up happens when you cannot mask or ventilate them. That is not an elective decision, it is a Hail Mary.

Have you ever "had to wake up a patient"?

 

[Noyac]

All good points. The take home message here might be, every case is different. This one is different from the crashing c/s and therefore, could be handled in a different way. The morbidly obese pt might be handled differently than the skinny pt with normal airway anatomy. That's what makes us different from mid levels, the ability to adjust and think thru different situations quickly and effectively.

 

[Ronin2258]

Were combitubes available in 1994? I would think they would be as an emergency way to at least to ventilate a patient, and they would be more available than the then-relatively-newly minted LMAs