Apoxia

[cfdavid]

So, when I was applying to med school I tracked down an old family friend. He's a practicing anesthesiologist and a pretty young guy (only a few years out of residency). He's a great guy and very sharp.

While we were chatting (I went to visit him at the hospital to discuss my AMCAS etc), he told me that a women died under his care when he was right out of residency. I guess she was morbidly obese and was undergoing a pretty straightforward procedure (forgot what it was, but I want to say appendectomy or something like that). At the time, I really didn't ask too many questions in terms of all of the technical details.

By no means did I get the impression that he was at fault. He's the kind of guy that would admit to me if he f..cked up. So, the question is, has this ever happened to any of you? It was a problem with ventilation. He indicated he couldn't hear jack when he was listening to her lungs, and then said the pulse/ox meter just kept getting longer in cycle as he tried to correct the situation.

I know it's speculation, but take us through some hypotheticals as to what can happen in a situation like that. I really don't want to ask him in an email cause it may be sensitive and not something he'd really want to chat about again etc. He indicated that the situation got hectic in a hurry as he tried to alter the outcome, but that she became blue very fast due to hypoxia etc.

Anyone? What would you do in such a situation? I know I'm not making it easy with the lack of details, but let's hear some scenarios from some of the attendings.

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[jetproppilot]

So, when I was applying to med school I tracked down an old family friend. He's a practicing anesthesiologist and a pretty young guy (only a few years out of residency). He's a great guy and very sharp.

While we were chatting (I went to visit him at the hospital to discuss my AMCAS etc), he told me that a women died under his care when he was right out of residency. I guess she was morbidly obese and was undergoing a pretty straightforward procedure (forgot what it was, but I want to say appendectomy or something like that). At the time, I really didn't ask too many questions in terms of all of the technical details.

By no means did I get the impression that he was at fault. He's the kind of guy that would admit to me if he f..cked up. So, the question is, has this ever happened to any of you? It was a problem with ventilation. He indicated he couldn't hear jack when he was listening to her lungs, and then said the pulse/ox meter just kept getting longer in cycle as he tried to correct the situation.

I know it's speculation, but take us through some hypotheticals as to what can happen in a situation like that. I really don't want to ask him in an email cause it may be sensitive and not something he'd really want to chat about again etc. He indicated that the situation got hectic in a hurry as he tried to alter the outcome, but that she became blue very fast due to hypoxia etc.

Anyone? What would you do in such a situation? I know I'm not making it easy with the lack of details, but let's hear some scenarios from some of the attendings.

Wow.

I feel for the dude.

Hard to say what happened.

Sounds like from the scant description that he couldnt ventilate her.

Which is what we are masters at.

Ventilation.

So when you get into a situation where you can't ventilate, you've got a cuppla minutes to rectify the situation.

Or the patients gonna die.

First thing I'd do?

Call for help. Make sure some MD/CRNA/AA, in multiples hopefully, are coming.

Second thing is to do what you are trained to do. Reposition. Try and optimize your oral approach......if you're still trying to bag, insert an oral/nasal airway if not already in place. If you're trying to intubate, rethink your current strategy. Try the Miller 2 again without the pillow. Or place a pillow for a Mac blade. LMA. Something.

In this situation, which I've been in twice, you need to be thinking ahead of what you are doing.......what does that mean?

That means during your third laryngoscopy you are asking yourself

"is the jet ventilator setup in the room? If not, is it coming? When I look this time and don't see a goddammm thing, which way do I turn for the 14 gauge angio to stick this person's cricothyroid membrane?"

Still thinking ahead during the third laryngoscopy..

"When I can't see cords or anything that could justify asking for a Bougie, I'm gonna put down the laryngyscope, turn to my right, grab a 14" angio off the cart. Yep, suction is right here. I remember what the cricothyroid membrane feels like, and I know where to start feeling for it. My right index finger has felt the cricothyroid membrane a thousand times. I'm gonna turn to the right, grab the 14" angio, peel it outta the package, hold it in my left hand, find the cricothyroid membrane with my right index finger...YEP! I FEEL IT!!

My right index finger is holding steadfast on the cricothyroid membrane.

My left hand will now stick that SOB.

Pull out the needle.

Attach jet ventilator setup.

Hopefully, ventilate away.

Moral of the story is always ask yourself "what if what I'm doing doesnt work?"

 

[militarymd]

I've had patients die...especially in the ICU....I can't say it is directly because of me, but I know I certainly contributed in some way...

Bottomline...patients will die....we need to get used to it...

but that is harder in this day and age of such HIGH expectations.

Talk to folks who used to practice in the 40's and 50's to get some perspective.

 

[UTSouthwestern]

It's the worst feeling you can have, but even worse if you can't correct what's going on.

I had a similar patient that was doing very well during a routing on pump CABG but in the ICU, gradually stopped oxygenating his blood. PE (massive or shower of emboli)? Delayed protamine reaction? Intrinsic, undiagnosed interstitial lung pathology? Hemoglobinopathy?

Everything checked or treated for. Finally head back to the OR and go back on pump. Everything goes back to normal. TEE back in, 55% EF, right heart not distended or even strained (beating heart bypass). Come off again and the heart looks great, but ABG shows PO2 30 on 100% O2.

Yes, I checked the tube multiple times with a fiberoptic scope as well, but to no avail. Open the pleura and the lungs look pink without even punctate hemorrhages or discoloration of any kind and they feel soft.

Recommend ECMO, but equipment not available for ECMO at this institution. Patient dies of essentially hypoxia.

You will hopefully see only a couple of these kinds of no win situations, more if you are in a high risk practice like mine.

Learn from any mistakes you may have made or thought you may have made and move on. Failure to do so makes you either over cautious or gives you a mental block from doing any difficult case in the future.

For myself, I finished that case at 2 am, then was back in the hospital at 6 am for another heart.

 

[Monty Python]

......Bottomline...patients will die....we need to get used to it...

but that is harder in this day and age of such HIGH expectations.

Talk to folks who used to practice in the 40's and 50's to get some perspective.

I've heard similar comments from two different perspectives: my retired MD father-in-law who practiced before penicillin became widely available, and two members of my choir.

I sit between a retired (bored) psychiatrist and a retired (bored) orthopod in choir. They like to pimp me for what's new in the hospital scene, I guess to still feel connected to that social structure. To summarize the pod's saying: "I could do the world's best hip replacement (insert anesthesia) but if it's their time to go, there's nothing I can do about it. Likewise I can do the world's worst hip replacement (insert anesthesia) and if it's not their time, they'll sail right through the operation.

 

[blackjack]

what's apoxia?

 

[rmh149]

what's apoxia?

....no oxygen in the blood stream.

 

[jeesapeesa]

not to be annoying, but isn't that hypoxemia? i know of anoxia, but haven't really heard of apoxia.

 

[rmh149]

not to be annoying, but isn't that hypoxemia? i know of anoxia, but haven't really heard of apoxia.

Hypoxia would be "low" oxygen. Apoxia is "no" oxygen.

LOL, I had to look it up to make sure. I have never heard of it either....not a common term in anesthesia thank goodness.

 

[jetproppilot]

Hypoxia would be "low" oxygen. Apoxia is "no" oxygen.

LOL, I had to look it up to make sure. I have never heard of it either....not a common term in anesthesia thank goodness.

Have never heard the word either....

but I knew what he meant.

 

[Mman]

Hypoxia would be "low" oxygen. Apoxia is "no" oxygen.

LOL, I had to look it up to make sure. I have never heard of it either....not a common term in anesthesia thank goodness.

I think it is more commonly seen by pathologists

 

[cfdavid]

Great responses guys. lol, it's funny cause I was in the process of studying for a neuro exam when I posted. I guess I just figured apoxia was the most extreme form of hypoxia. That and I was thinkng of aphasia, alexia, ataxia, apraxia, agraphia, agnosia........... So, what the hell, why not apoxia while we're at it!

 

[swpm]

That means during your third laryngoscopy you are asking yourself

"is the jet ventilator setup in the room?

Two questions ...

LMA first, right?

Second, one of my attendings hates jet ventilators as much as he hates the BIS monitor ... he's fond of saying words to the effect of "No one should die without a cut neck, and every second you **** around with angiocaths and the never-checked never-used never-setup jet ventilator is a second you're not cutting the neck. Grow a pair and cut the ****ing neck already." He's prone to hyperbole, but I can see his point. Someday I'll find myself with a blue patient I can't intubate & can't ventilate, and if the ASA-algorithm-recommended LMA doesn't work, I think I'd reach for the #11 blade rather than mess with some complicated device in a bag on the back of my machine. Can you expand on why you're a fan of the jet ventilator?

 

[Fah-Q]

Second, one of my attendings hates jet ventilators as much as he hates the BIS monitor ... he's fond of saying words to the effect of "No one should die without a cut neck, and every second you **** around with angiocaths and the never-checked never-used never-setup jet ventilator is a second you're not cutting the neck. Grow a pair and cut the ****ing neck already." He's prone to hyperbole, but I can see his point. Someday I'll find myself with a blue patient I can't intubate & can't ventilate, and if the ASA-algorithm-recommended LMA doesn't work, I think I'd reach for the #11 blade rather than mess with some complicated device in a bag on the back of my machine. Can you expand on why you're a fan of the jet ventilator?

Don't forget to call your local ,friendly ENT in the above situation. Every hospital should have an "airway team" with an "airway cart" that can be rolled into any room at any time.

By the way, if you do have to slash someone....reach for #10 blade or maybe a #15 blade. An #11 blade would be much harder.

 

[fakin' the funk]

what's apoxia?

let's go with anoxia...?

 

[Planktonmd]

Two questions ...

LMA first, right?

Second, one of my attendings hates jet ventilators as much as he hates the BIS monitor ... he's fond of saying words to the effect of "No one should die without a cut neck, and every second you **** around with angiocaths and the never-checked never-used never-setup jet ventilator is a second you're not cutting the neck. Grow a pair and cut the ****ing neck already." He's prone to hyperbole, but I can see his point. Someday I'll find myself with a blue patient I can't intubate & can't ventilate, and if the ASA-algorithm-recommended LMA doesn't work, I think I'd reach for the #11 blade rather than mess with some complicated device in a bag on the back of my machine. Can you expand on why you're a fan of the jet ventilator?

OK,
From personal experience, cutting the neck can be a real bloody mess, I have done it once and I hope I never have to do it again, but the patient lived.
My advice: always be 2 steps ahead of the game and have plans for every possible failure, the ASA algorithm is just a tool but you need to know your strengths and your weaknesses, and always do whatever you do best.
Emergency situations are not the time to try new things.

 

[2ndyear]

I think it would be a great learning experience for us residents for you to walk us through the case where you cut the neck. Pt identifiers removed of course.

 

[jetproppilot]

Two questions ...

LMA first, right?

Second, one of my attendings hates jet ventilators as much as he hates the BIS monitor ... he's fond of saying words to the effect of "No one should die without a cut neck, and every second you **** around with angiocaths and the never-checked never-used never-setup jet ventilator is a second you're not cutting the neck. Grow a pair and cut the ****ing neck already." He's prone to hyperbole, but I can see his point. Someday I'll find myself with a blue patient I can't intubate & can't ventilate, and if the ASA-algorithm-recommended LMA doesn't work, I think I'd reach for the #11 blade rather than mess with some complicated device in a bag on the back of my machine. Can you expand on why you're a fan of the jet ventilator?

Yep. I'd try an LMA first.

And Plankton makes a very good point about the ASA algorhythm...

Second, the jet ventilator device isnt complicated. As you know its a pressure tube that you connect directly to the oxygen source, with a different, more flexible tube at the end, which connects to the end of the angiocath. Then you just pull the trigger for the jet of oxygen.

I worked with a really old ENT guy who we did vocal cord polyps with jet ventilation....not through a stuck-neck....but through an instrument he'd put through the cords after the patient was positioned...point being I've done jet ventilation many, many times this way, which validated what I already knew since I've had to stick 2 necks in my career. One with the help of an attending in residency, and one in private practice. Also just remembered when I rotated through Childrens Hospital in New Orleans as a resident we did something there with jet ventilation, but I cant remember what type of cases....Trinity, do you remember? These cases were sometimes 20 minutes long....done with a jet ventilator....and we woke these patients up and sent them home. So the jet ventilation mode works.

I wrote a year or so about a difficult intubation I was called for in the ER. Several people had tried. I knew it was bad since there were several teeth laid out on the ER counter....always take this as a bad sign. The first thing I did before taking over the airway management (somebody was bagging the dude) was identify the cricothyroid membrane and marked it with a sharpie I asked for...the ER people were looking at me like....WTF is that for? Thinking ahead. Thats what thats for. I was able to intubate him so the mark wasnt needed but I woullda known right where to go since I anticipated the situation. And me and the CRNA who came with me had brought a jet setup with us...so we were prepared.

You can get practice doing this in a controlled environment...especially as a resident, if you get the opportunity to do an awake intubation the nerve block route....where you can justify, along with your other nerve blocks, transtracheal lidocaine injection. Take your time, mark the membrane, infiltrate with a little intradermal lido, and stick it....the only difference being since you wont be ventilating through it you'll use a 20 gauge instead of a 14 or 16. Controlled environment so great learning opportunity for when you've gotta do it in an emergency.

Yes, it is intimidating to think about it. But familiarize yourself with the equipment, and take every opportunity while you are in training to stick the cricothyroid membrane in controlled, nonpressure environments.

Take the jet ventilator hose out yourself and plug it in next time youre in the OR waiting on a case. Take out a 14 or 16 gauge angio, take the needle out, and screw the jet ventilator on. Squeeze the trigger to see what it feels like to do it. Get involved in a case that uses jet ventilation if the opportunity arises.

Feel your cric membrane. Feel your girlfriends. Your wifes/husbands. Your resident buddy. Whatever. The more times you feel it the quicker you'll be if the need ever arises when you've got only a few seconds.

Know where the jet setup is at your hospital. Maybe theres one in every room. or know who to call.

SOOOOO, sounds like your attending has never used a jet ventilator. Simple setup, simple hookup.

All youve gotta do is stick the neck.....in the right place. Which is why you get paid the big bucks.

The BIG moral of the story, though, boys and girls, is how important it is in this biz to train yourself very early to think ahead just in case what youre doing doesnt work.

 

[bigeyedfish]

How many have put a 14g in someone's neck? Or let their sack drop and picked up the knife. Let's hear some cases. (por favor)

 

[2ndyear]

How about the Cook kits, anyone use one? We have them on our difficult airway carts but I've never seen one used.
Here's a nice diagram:
http://www.aic.cuhk.edu.hk/web8/dilational_cricothyrotomy.htm

This is an awesome link here, total MacGruder:
http://www.brooksidepress.org/Produ...erationalmed/Procedures/Cricothyroidotomy.htm

 

[Monty Python]

....Also just remembered when I rotated through Childrens Hospital in New Orleans as a resident we did something there with jet ventilation, but I cant remember what type of cases....Trinity, do you remember? ]

Got me on that one. Lasering HPV growths on pedi vocal cords ??

 

[rmh149]

 

[rmh149]

How many have put a 14g in someone's neck? Or let their sack drop and picked up the knife. Let's hear some cases. (por favor)

Never....hope it stays that way.

I keep a 14g angiocath and a 3cc syringe in my side pack just in case.

I also keep an eschmann tube introducer....have used that many many times.

 

[Noyac]

How many have put a 14g in someone's neck? Or let their sack drop and picked up the knife. Let's hear some cases. (por favor)

During my last year of residency I was on call one night and a lady came in with angioedema from ACE inh. I saw her in the ER and she was talking fine but her lips were protruding so far that she was drooling. We decided to intubate her b/4 she was is real trouble and called the OR to tell them we were on our way. By the time I got her upstairs to the OR (10 minutes) she could no longer speak. We went straight into the room and I was planning an awake FOB. I did a transtracheal injection with a 14g angiocath but instead of removing it after the injection I just left it in place incase I needed to jet ventilate. Surgeons were scrubbed and ready for surgical airway. I decided that she was progressing too fast now to screw around with a awake FOB so I induced and took a look. I could see nothing but I got lucky and put the tube in a shadow that I thought was probably the tracheal area. It was and I never had to jet ventilate but I was ready too.

I have done the pedi HPV jet vent cases though. It works really well.

 

[Fah-Q]

I worked with a really old ENT guy who we did vocal cord polyps with jet ventilation....not through a stuck-neck....but through an instrument he'd put through the cords after the patient was position

Also just remembered when I rotated through Childrens Hospital in New Orleans as a resident we did something there with jet ventilation, but I cant remember what type of cases....Trinity, do you remember? These cases were sometimes 20 minutes long....done with a jet ventilator....and we woke these patients up and sent them home. So the jet ventilation mode works.
[/B]

It's called a Hunsaker catheter (very bad picture below). Old-school ENT's like it. They now make "laser safe" Hunsakers.
We do kiddie papilloma with spontaneous breathing, no tube. Usually a quick case unless it's their first debulking.

 

[jetproppilot]

It's called a Hunsaker catheter (very bad picture below). Old-school ENT's like it. They now make "laser safe" Hunsakers.
We do kiddie papilloma with spontaneous breathing, no tube. Usually a quick case unless it's their first debulking.

Thanks alot for posting that!

 

[militarymd]

Here's something I learned after entering private practice.

Get a central line kit...triple lumen or cordis.

Put the 18ga angiocath into the cricothyro membrane...very easy.

Put the guide wire into the angiocath into the tracheal....very easy.

Put the vessel dilator into the tracheal ...Seldinger technique...very easy.

Jet ventilate through the vesel dilator...very easy.

Advantage over 14 gauge angiocath:

1) durable...won't kink...you can do a whole case with it
2) lenght....long enough for the FATTEST necks
3) everything you need is in a central line kit.....prep, drap, local, etc.

 

[jetproppilot]

Here's something I learned after entering private practice.

Get a central line kit...triple lumen or cordis.

Put the 18ga angiocath into the cricothyro membrane...very easy.

Put the guide wire into the angiocath into the tracheal....very easy.

Put the vessel dilator into the tracheal ...Seldinger technique...very easy.

Jet ventilate through the vesel dilator...very easy.

Advantage over 14 gauge angiocath:

1) durable...won't kink...you can do a whole case with it
2) lenght....long enough for the FATTEST necks
3) everything you need is in a central line kit.....prep, drap, local, etc.

YA SEE WHY THIS DUDE'S IMPORTANT HERE???

Great frikkin idea.

One thing I have to say though is...in reference to the SWPM's post....

heres another private practice dude attesting to the ease of sticking the cricothyroid membrane with a catheter....albeit with a cooler technique than mine.

Much better, quicker approach to ventilation in a cant-ventilate-cant-intubate patient than slashing the neck with a scalpel, IMHO.

 

[toughlife]

Here's something I learned after entering private practice.

Get a central line kit...triple lumen or cordis.

Put the 18ga angiocath into the cricothyro membrane...very easy.

Put the guide wire into the angiocath into the tracheal....very easy.

Put the vessel dilator into the tracheal ...Seldinger technique...very easy.

Jet ventilate through the vesel dilator...very easy.

Advantage over 14 gauge angiocath:

1) durable...won't kink...you can do a whole case with it
2) lenght....long enough for the FATTEST necks
3) everything you need is in a central line kit.....prep, drap, local, etc.

and what do you attach to the vessel dilator to then hook up to your circuit?

 

[jetproppilot]

and what do you attach to the vessel dilator to then hook up to your circuit?

Not to the circuit, tough.

To your jet ventilator setup.

 

[dhb]

You can find commercial kits for percutaneous Seldinger cricotomy that will work like mil's description but with a larger diameter i think you can even hook it up tp the vent...

 

[Planktonmd]

Here's something I learned after entering private practice.

Get a central line kit...triple lumen or cordis.

Put the 18ga angiocath into the cricothyro membrane...very easy.

Put the guide wire into the angiocath into the tracheal....very easy.

Put the vessel dilator into the tracheal ...Seldinger technique...very easy.

Jet ventilate through the vesel dilator...very easy.

Advantage over 14 gauge angiocath:

1) durable...won't kink...you can do a whole case with it
2) lenght....long enough for the FATTEST necks
3) everything you need is in a central line kit.....prep, drap, local, etc.

Great Idea!
I love it.

 

[Anesthesia1979]

A bit of a lesson i learned from an old ENT dude in collaboration with some of my attendings, when providing O2 via jet venitlation...

0) in down times, know where jet ventlator is and how to hook it up quickly 1) start with jet ventilator hooked up but completely closed off... 2) squeeze the trigger 3) slowly open the valve that provides O2 4) when you get to a point where you see the chest rise, you no longer need to open the valve... just fire that trigger

Both attending and ENT dude told me that they have seen plenty of PTX/barotrauma in the past from anesthesia residents with eager trigger fingers


Also I concur to do trantracheal blocks with awake fibers... always feels like I'm practicing

 

[Pharm Life]

This is a little off the original topic, but I'm curious. Do you guys do anything different in the OR if the patient is morbidly obese to deal with that? Because I know that makes them at higher risk for things like atelectasis. Maybe that's what happened with this patient? We keep hearing in school all the time about how much obesity is increasing all over the world including the U.S. How can anesthesia be made safer for obese people?