Awake Intubation

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What’s your favorite awake intubation approach/cocktail?

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What’s your favorite awake intubation approach/cocktail?

Massive doses of topical lidocaine bordering on toxicity to provide topical anesthesia and sedation coupled with IV midazolam to prevent seizure.
 
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Spraglottic block- 24g needel, 3cc 2% lidocaine bilaterally just cephalod to thyroid notch or 6cc centrally
Glossopharyngel block - 2cc 2% lidocaine bilateral palitoglossal fold w/ spinal needle bilaterally.
Transtracheal - 5mL 4% lidocaine through crychotryroid membrane (aspirate air before injection. They should cough)
+/- lidocaine neb pre-op

1:1:1 - midaz/fent/ketamine for sedation
hasn't failed yet
 
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What’s your favorite awake intubation approach/cocktail?

Glyco
Transtracheal if good anatomy
5cc 4% lido neb
5% lido paste to posterior tongue and pillars
*Repeated* 4% lido through long atomizer for nares and pharynx
Assess whether you can get Williams airway / long atomizer really far in there comfortably. If you can then topical is def setting up. If they're still coughing and gagging then the solution is more topical, not more sedation
Scope in (I like oxygen tubing connected to suction port to blow secretions out of the way rather than try to suction them). Visualize glottis.
Spray 4% lido on cords. Once through cords spray a bit more in trachea if no transtracheal done
Railroad the tube
Paralytic only after end tidal confirmed


I try to avoid all sedation if possible, but if needed I like to use only versed with some flumaz nearby. I've gotten in trouble with even low doses of fent, ketamine, or precedex.
 
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I've always been curious about this topic. People get ng tubes, esophageal manometry etc all the time with no topicalization at all. Why does pushing a tube between the cords require so much more effort?
 
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I've always been curious about this topic. People get ng tubes, esophageal manometry etc all the time with no topicalization at all. Why does pushing a tube between the cords require so much more effort?

Esophagus is much more accommodating of foreign bodies eg food, the trachea is not. If you aspirate a piece of steak, you’ll have a strong urge to cough it out.
 
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I've always been curious about this topic. People get ng tubes, esophageal manometry etc all the time with no topicalization at all. Why does pushing a tube between the cords require so much more effort?

One is an entry tube the other is not
Same reason for why pushing a tube between the cheeks requires so much more effort
 
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What’s your favorite awake intubation approach/cocktail?
i have tried it a lot of different ways
what i evolved to was this:
4-6mg versed
glyco .4
ketamine 20-40
Glidescope on spontaneously breathing patient
IMO maintaining SV more important than maintaining them being awake
 
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My method is good if you like a relatively fast setup.

Psychoprophylaxis: don't make a big deal about it to the patient or they'll be more nervous. Suggested spiel: "Most patients are all the way asleep when I place a breathing tube, but due to concern for safety in your case, you're going to be partly asleep so you are still breathing, then all the way asleep immediately after. I will use local anesthesia to numb your throat to take away the uncomfortable gagging and choking sensation."

0.3mg glycopyrrolate + remifentanil infusion.

Nasal canula (HFNC if your place is fancy enough for it to have easily is likely better)

5% lidocaine ointment on a tongue depressor. No need to bother with those gauze things to make a lollipop, as they're a waste of time. Progressively apply further back to oropharynx and posterior tongue, taking a break for a few seconds in between when needed and using the tongue depressor to check the gag reflex. Next, test inserting direct or video laryngoscope having patient open mouth and stick tongue out. Or have assistant hold tongue with gauze if using fiberoptic scope. 4% lidocaine Madgic atomizer next angled toward vocal cords, coordinating administration with inhalation. You should be ready for intubation now.

Remifentanil is desirable over midazolam in my view because opioids add to blocking these gagging reflexes and it wears off fast and has a reversal agent. Your aim shouldn't necessarily be to block their memory of the event, but rather to make it not uncomfortable.
 
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My method is good if you like a relatively fast setup.

Psychoprophylaxis: don't make a big deal about it to the patient or they'll be more nervous. Suggested spiel: "Most patients are all the way asleep when I place a breathing tube, but due to concern for safety in your case, you're going to be partly asleep so you are still breathing, then all the way asleep immediately after. I will use local anesthesia to numb your throat to take away the uncomfortable gagging and choking sensation."

0.3mg glycopyrrolate + remifentanil infusion.

Nasal canula (HFNC if your place is fancy enough for it to have easily is likely better)

5% lidocaine ointment on a tongue depressor. No need to bother with those gauze things to make a lollipop, as they're a waste of time. Progressively apply further back to oropharynx and posterior tongue, taking a break for a few seconds in between when needed and using the tongue depressor to check the gag reflex. Next, test inserting direct or video laryngoscope having patient open mouth and stick tongue out. Or have assistant hold tongue with gauze if using fiberoptic scope. 4% lidocaine Madgic atomizer next angled toward vocal cords, coordinating administration with inhalation. You should be ready for intubation now.

Remifentanil is desirable over midazolam in my view because opioids add to blocking these gagging reflexes and it wears off fast and has a reversal agent. Your aim shouldn't necessarily be to block their memory of the event, but rather to make it not uncomfortable.
Did I train you?
 
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Remifentanil is desirable over midazolam in my view because opioids add to blocking these gagging reflexes and it wears off fast and has a reversal agent. Your aim shouldn't necessarily be to block their memory of the event, but rather to make it not uncomfortable.
I think opiods blunt the cough reflex and help some. Never heard of reversing remi though.
 
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Did I train you?
My approach but I used nebulized lidocaine in preop 1 mg versed leaving preop 1 mg in room once setup remi infusion. Williams airway in then 2-3 cc down williams airway with a catheter to spray cords. Glidescope assisted foi if I need anterior lift i just use the williams airway or back the mouth with gauze. Easy peazy never had an airway I could not intubate awake.
 
My approach but I used nebulized lidocaine in preop 1 mg versed leaving preop 1 mg in room once setup remi infusion. Williams airway in then 2-3 cc down williams airway with a catheter to spray cords. Glidescope assisted foi if I need anterior lift i just use the williams airway or back the mouth with gauze. Easy peazy never had an airway I could not intubate awake.
I mean thats great and everything but I would be lying if I said they were all easy.
 
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Spraglottic block- 24g needel, 3cc 2% lidocaine bilaterally just cephalod to thyroid notch or 6cc centrally
Glossopharyngel block - 2cc 2% lidocaine bilateral palitoglossal fold w/ spinal needle bilaterally.
Transtracheal - 5mL 4% lidocaine through crychotryroid membrane (aspirate air before injection. They should cough)
+/- lidocaine neb pre-op

1:1:1 - midaz/fent/ketamine for sedation
hasn't failed yet
That's a lot of pokes. Midaz, fent, lido sprays work just as well and probably useable in more patients.

Remi instead of fent even better
 
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I would try to minimize any sedation if possible. 2mg versed for anxiolytics and remi drip at 0.05. But mostly, I do without. For obvious reasons as to not burn bridges but also a cooperative patient allows to open up airway.
Glyco 15 min prior to room if possible 0.2. Spray nares with afrin just in case.
Atomized spray 4% lido. I just spray it like spray paint everywhere in the back of the mouth 2-3cc. Then angulate downward spray with inhalation 2-3cc. That gets close to max lido dose for most normal sized patients. When see cords, spray another 2cc lido. I never really did any airway blocks before.

Does anyone know how max lido dose relates to mucosal spray?
 
I would try to minimize any sedation if possible. 2mg versed for anxiolytics and remi drip at 0.05. But mostly, I do without. For obvious reasons as to not burn bridges but also a cooperative patient allows to open up airway.
Glyco 15 min prior to room if possible 0.2. Spray nares with afrin just in case.
Atomized spray 4% lido. I just spray it like spray paint everywhere in the back of the mouth 2-3cc. Then angulate downward spray with inhalation 2-3cc. That gets close to max lido dose for most normal sized patients. When see cords, spray another 2cc lido. I never really did any airway blocks before.

Does anyone know how max lido dose relates to mucosal spray?
Keep giving it until they seize.
 
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Spraglottic block- 24g needel, 3cc 2% lidocaine bilaterally just cephalod to thyroid notch or 6cc centrally
Glossopharyngel block - 2cc 2% lidocaine bilateral palitoglossal fold w/ spinal needle bilaterally.
Transtracheal - 5mL 4% lidocaine through crychotryroid membrane (aspirate air before injection. They should cough)
+/- lidocaine neb pre-op

1:1:1 - midaz/fent/ketamine for sedation
hasn't failed yet
I mean thats fine until they cant open their mouth. Or badly coagulopathic.
 
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Hate to quote myself but the needles and blocks seem doomed to failure in a head and neck cancer patient.
Young patients, especially male will not tolerate all those needles coming at their mouth/neck either... There's plenty of patients this isn't suitable for...

Probably the most common reason for foi for me has been large abscess either submandible or elsewhere. No way I'm poking needles near anything there
 
Does anyone know how max lido dose relates to mucosal spray?

I've given ~20-25+ cc of 4% lido in some combination of nebulized + topical to many normal/large sized adults without issue. So much goes into the GI tract that it's almost impossible to get LAST.
 
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I've given ~20-25+ cc of 4% lido in some combination of nebulized + topical to many normal/large sized adults without issue. So much goes into the GI tract that it's almost impossible to get LAST.
I remember as a resident I was heavy handed with lido and gave 10cc before realizing and I freaked out! Haha. Tried to look up any literature and couldn’t find any.
 
So here’s one for you: 4% lidocaine neb in preop, 3ml is fine. 0.4mg glycopyrrolate 20 min prior to OR. Take patient to OR, once there give small amount midazolam (1mg) and start remifentanil no bolus at 0.1mcg/kg/min.
Sit them up 30 degrees or so, and use a tongue depressor to gently apply lidocaine paste to center and lateral sides of tongue as well as tonsillar pillars. Coat an ovassapian or berman airway with same.
Use a Devilbiss atomizer with 4% lidocaine hooked up to 8pm oxygen to spray uvula, tonsillar pillars and posterior pharyngeal walls. Coordinate several sprays with deep breaths.
Once this is done place the airway in and instruct the patient to gently bite down on it. If they are properly topicalized then they can do this without gag or discomfort.
Proceed with intubation.

Of all of the methods I have used in 20+ years, including all of the needles/injections, this method is the one that provides the smoothest results for me.
 
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I know it was said above, and I know I've stated my routine before, but I think it's worth reiterating the point about psychoprophylaxis, both for the patient and the surgeon. Calling it "awake" just stresses everyone out, and the worst part is it isn't even true (to wit: all the sedation regimens above).

So I say exactly what Zizzer says above. I do give glyco, and I do paint the tongue with 5% ointment in 3 progressively more posterior swipes. I have them hold their tongue against their palate to topicalize that as well.

To the room, midazolam, monitors, NC oxygen with EtCO2. I keep them in the gurney sitting upright lookin at me. I personally think anxiolysis is the sedation goal and that opiates don't add much, but I know others feel some opiate helps with the gag. My belief is that if they're gagging, they need more local. I find the upright position is less intense for the patient than being flat in their back with a mysterious presence looming over their head.

Then it's 4% spray to the glottis. Then, assuming no contraindication, it's a 2% transtracheal block. Then an Ovassapian airway, then the tube.

With this approach, I'm typically able to intubate them and have them move themselves from the gurney to the bed with the ETT in place. Not every time, but most of the time.
 
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What’s your favorite awake intubation approach/cocktail?

I think it's worth mentioning that it depends why I'm doing an awake intubation.

The sedation for an angioedema patient who's dyspneic on high flow oxygen, is worlds different than the tongue cancer patient who's a year s/p resection and radiation but coming in for something elective in a calm and NPO state.

Topicalization is key. I am a fan of transtracheal lidocaine and the ointment applied directly. Less a fan of nebulized lidocaine - it doesn't seem to work as well or as long as liquid, gel, or paste applied directly. And I do wonder a little about systemic absorption via the inhaled route, vs the ingested route that enjoys the protection of first-pass metabolism.
 
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I've given ~20-25+ cc of 4% lido in some combination of nebulized + topical to many normal/large sized adults without issue. So much goes into the GI tract that it's almost impossible to get LAST.
Not so sure. Remember, after we give our dosage of lidocaine, the patient is intubated under GA which will mask lots of toxicity that other wise would be apparent if the patient were awake. I don't know if there are any studies or anecdotes of people drawing lidocaine levels post awake intubation. Also there is this horrific case:

 
Not so sure. Remember, after we give our dosage of lidocaine, the patient is intubated under GA which will mask lots of toxicity that other wise would be apparent if the patient were awake. I don't know if there are any studies or anecdotes of people drawing lidocaine levels post awake intubation. Also there is this horrific case:


What a strange scenario— the patient had the bronch; felt well enough to be discharged from PACU; then developed dyspnea 2 hours after the procedure?

Doesn’t really sound like typical LAST.
 
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4% lidocaine injected into the inspiratory limb of a high flow circuit
 
Not so sure. Remember, after we give our dosage of lidocaine, the patient is intubated under GA which will mask lots of toxicity that other wise would be apparent if the patient were awake. I don't know if there are any studies or anecdotes of people drawing lidocaine levels post awake intubation. Also there is this horrific case:


That story doesn't really strike me as being LAST.

She completed the bronch and then spent 90 minutes in Obs. Was able to go home. Started having trouble breathing there and then returned to the hospital half an hour later.

Delayed LAST (AFAIK) is usually from having a depot of local from a block that eventually seeps intravascular. There shouldn't be any depot when talking about bronchs....it either goes in the gut or is absorbed in the blood stream pretty quick through mucosa.


That being said, I do go easier when we're talking about extremes of small size or old age.
 
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I think it's worth mentioning that it depends why I'm doing an awake intubation.

The sedation for an angioedema patient who's dyspneic on high flow oxygen, is worlds different than the tongue cancer patient who's a year s/p resection and radiation but coming in for something elective in a calm and NPO state.

Topicalization is key. I am a fan of transtracheal lidocaine and the ointment applied directly. Less a fan of nebulized lidocaine - it doesn't seem to work as well or as long as liquid, gel, or paste applied directly. And I do wonder a little about systemic absorption via the inhaled route, vs the ingested route that enjoys the protection of first-pass metabolism.
One of my worst FOI experiences is watching a contractor in the navy push ketamine and wash away all his topicalized lidocaine and fail at a afoi. Ketamine the way he used it was terrible for afois.
 
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One of my worst FOI experiences is watching a contractor in the navy push ketamine and wash away all his topicalized lidocaine and fail at a afoi. Ketamine the way he used it was terrible for afois.
I'm really not a fan of ketamine for foi. Maybe as a minor adjunct but mostly lido, benzo, remi for me... ketamine doesn't have any role when those are used and working well
 
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That story doesn't really strike me as being LAST.

She completed the bronch and then spent 90 minutes in Obs. Was able to go home. Started having trouble breathing there and then returned to the hospital half an hour later.

Delayed LAST (AFAIK) is usually from having a depot of local from a block that eventually seeps intravascular. There shouldn't be any depot when talking about bronchs....it either goes in the gut or is absorbed in the blood stream pretty quick through mucosa.


That being said, I do go easier when we're talking about extremes of small size or old age.

I mean... medical examiners can be wrong, but I assume she had a complete autopsy that found no physical reason for her to have a heart attack, along with very high plasma concentrations of lidocaine.
 
I mean... medical examiners can be wrong, but I assume she had a complete autopsy that found no physical reason for her to have a heart attack, along with very high plasma concentrations of lidocaine.

The article alludes to a lidocaine level but it also states "The cause of death has not yet been determined, pending the examination and report of the county medical examiner."
 
The article alludes to a lidocaine level but it also states "The cause of death has not yet been determined, pending the examination and report of the county medical examiner."

From another source,
"Her autopsy revealed that the Lidocaine levels she received were lethal, causing her heart to stop beating and her organs to shut down. She had a heart attack the day of the study, in fact, after initial struggles with breathing and then going to the emergency room. Her parents settled with the university."


"They overdosed her with Lidocaine," administered during a procedure, Beno said of the death of Wan. As the chief toxicologist at the county Medical Examiner's Office, it was Beno's job to help decide just how Wan died."
 
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From another source,
"Her autopsy revealed that the Lidocaine levels she received were lethal, causing her heart to stop beating and her organs to shut down. She had a heart attack the day of the study, in fact, after initial struggles with breathing and then going to the emergency room. Her parents settled with the university."


"They overdosed her with Lidocaine," administered during a procedure, Beno said of the death of Wan. As the chief toxicologist at the county Medical Examiner's Office, it was Beno's job to help decide just how Wan died."

Yeah, I can see someone getting a toxic dose in this case:


Ms. Wan agreed to have a tube inserted through her mouth into her lungs to collect cells to be used in a 15-year-old study on how the lungs defend themselves against infection and pollutants. The procedure, called bronchoscopy, is a common test to diagnose lung infections and tumors, and it is performed under a local anesthetic like Lidocaine.

In Ms. Wan's case, the doctors took far more cell samples and used far more anesthetic than called for under the original proposal, in 1981, for their study. Ms. Wan was discharged after the procedure despite feeling weak and suffering severe pain. Two days later her heart stopped, and the medical examiner determined that a lethal level of Lidocaine was the cause.​

If they're doing a gazillion brushes and they keep giving lidocaine (that's getting into the lungs) to someone who may have been a smaller lady, LAST is definitely a possibility.
 
Unlikely that LAST would present 2 days after the procedure. The risk of LAST should decline over time. She was not getting a continuous infusion of local anesthetic. And why would she have severe pain? My first thought would be some type of mechanical injury to the tracheobronchial tree that got worse over time. But the medical examiner did not find that.

She went to the ER about 2 hours after leaving the bronchoscopy lab. She died 2 days after the procedure. Intralipid wasn't known at the time to help with LAST.. and it might not have made a difference if she already suffered major organ damage from seizure or cardiac arrest.
 
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She went to the ER about 2 hours after leaving the bronchoscopy lab. She died 2 days after the procedure. Intralipid wasn't known at the time to help with LAST.. and it might not have made a difference if she already suffered major organ damage from seizure or cardiac arrest.


Oops thanks. I reread the article and saw that. I deleted my post.
 
Less a fan of nebulized lidocaine - it doesn't seem to work as well or as long as liquid, gel, or paste applied directly. And I do wonder a little about systemic absorption via the inhaled route, vs the ingested route that enjoys the protection of first-pass metabolism.
Lidocaine nebulizer "peace pipe" was the way we were taught to topicalize. I don't do it anymore. It's highly patient effort dependent, and in most cases, patients are less than enthusiastic about an AFOI. Most patients just sit there with the nebulizer hanging out of their mouth and nose breathe and are not even close to being topicalized when they reach the OR. Then you're forced to spray the posterior oropharynx with more lidocaine anyway. These days I premedicate with glyco if the HR allows, and use a flexible spray wand attached to 10cc of 4% lidocaine. I'll tell them this will suck and that I'm sorry, then squirt a few cc's at a time as far back as they'll let me and have them gargle/spit or swallow. After the second or third spray I can usually bury the spray wand in their throat and they don't bat an eye. Here most of us use either a low dose remifentanil or dexmed infusion, and +/- HHFNC for the actual intubation.
 
Spraglottic block- 24g needel, 3cc 2% lidocaine bilaterally just cephalod to thyroid notch or 6cc centrally
Glossopharyngel block - 2cc 2% lidocaine bilateral palitoglossal fold w/ spinal needle bilaterally.
Transtracheal - 5mL 4% lidocaine through crychotryroid membrane (aspirate air before injection. They should cough)
+/- lidocaine neb pre-op

1:1:1 - midaz/fent/ketamine for sedation
hasn't failed yet
My guess is you trained at awake?
 
I know it was said above, and I know I've stated my routine before, but I think it's worth reiterating the point about psychoprophylaxis, both for the patient and the surgeon. Calling it "awake" just stresses everyone out, and the worst part is it isn't even true (to wit: all the sedation regimens above).

So I say exactly what Zizzer says above. I do give glyco, and I do paint the tongue with 5% ointment in 3 progressively more posterior swipes. I have them hold their tongue against their palate to topicalize that as well.

To the room, midazolam, monitors, NC oxygen with EtCO2. I keep them in the gurney sitting upright lookin at me. I personally think anxiolysis is the sedation goal and that opiates don't add much, but I know others feel some opiate helps with the gag. My belief is that if they're gagging, they need more local. I find the upright position is less intense for the patient than being flat in their back with a mysterious presence looming over their head.

Then it's 4% spray to the glottis. Then, assuming no contraindication, it's a 2% transtracheal block. Then an Ovassapian airway, then the tube.

With this approach, I'm typically able to intubate them and have them move themselves from the gurney to the bed with the ETT in place. Not every time, but most of the time.
With transtracheal block, do you inject with a catheter syringe and inject with just the flexible plastic catheter in? I did once with just the needle and they coughed so bad I thought thr needle went right through the other side of trachea (it didn’t), but I said never again after that.
 
With transtracheal block, do you inject with a catheter syringe and inject with just the flexible plastic catheter in? I did once with just the needle and they coughed so bad I thought thr needle went right through the other side of trachea (it didn’t), but I said never again after that.

They are supposed to cough. You use the needle to get in but leave the catheter only for the spray
 
With transtracheal block, do you inject with a catheter syringe and inject with just the flexible plastic catheter in? I did once with just the needle and they coughed so bad I thought thr needle went right through the other side of trachea (it didn’t), but I said never again after that.
Just a 22g needle.
 
They are supposed to cough. You use the needle to get in but leave the catheter only for the spray
With transtracheal block, do you inject with a catheter syringe and inject with just the flexible plastic catheter in? I did once with just the needle and they coughed so bad I thought thr needle went right through the other side of trachea (it didn’t), but I said never again after that.
I haven't seen them in years, but there used to be a very short 19g needle which eliminated this risk.
 
I use the term “awake-ish.” Neb lido, versed. ketamine for sure - precedex depending on patient and let them breath down on sevo. Glidescope.
They never remember. K hole plus sevo and they just lay there and breath
 
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I use the term “awake-ish.” Neb lido, versed. ketamine for sure - precedex depending on patient and let them breath down on sevo. Glidescope.
They never remember. K hole plus sevo and they just lay there and breath
I mean whats the point of all this if you are just going to let them breathe on sevo?
 
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I use the term “awake-ish.” Neb lido, versed. ketamine for sure - precedex depending on patient and let them breath down on sevo. Glidescope.
They never remember. K hole plus sevo and they just lay there and breath
Do you spray cords before ett? How much sevo?
 
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