Called to ED....

[Coastie]

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In residency, not many. We would jet ventilate for ENT procedures and on occasion when the airway looked awful we would put an angiocath through the cricothyroid membrane for a trans tracheal injection of lidocaine and leave it in place in case we couldn't intubate we could jet ventilate. It isn't very difficult. I scrubbed in on some trach's as an intern on the trauma service and again on my ICU rotations (we did some at bedside).

In PP I have jet ventilated a couple times.

I wish we had the op. I think my residency program doesn't really "believe in jet ventilation", although they have the equipment necessary. It'd be a handy trick to learn. Also, we never cannulate the cricothyroid membrane, which would be another useful tool. I plan on scrubbing some trachs before I'm done if I get the chance.

 

[Arch Guillotti]

How long does it take to put a knife in the neck and establish a surgical airway? Not long.

How many emergency trachs have you seen? I have seen several and they weren't always pretty. The worst one was with a general surgeon and the pt. had an enormous neck with an incredible amount of soft tissue with clearly difficult landmarks. An emergency airway isn't always pretty.

 

[Arch Guillotti]

We had a grand rounds last year on the extreme danger of exchanging tubes of any kind over exchangers, esp in this kind of situation. What are the experiences of the board?

They can be very dangerous and were some of my least favorite calls when I was the resident carrying the airway pager. The worst experience I had was when the airway ws briefly lost and the pt. coded for a short period of time (resuscitated only to die later from the terminal illness that he was so sick from in the first place). I have also had one go awry in the OR - wasn't that big of a deal since the pt. was easy to ventilate.

I was always highly suspicious of calls for tube changes. The vast amount of the time they were not emergencies (actually I can't one that ever was). I made sure I grilled the requesting service up and down over the phone and then if I thought it was necessary I would go up there and double check everything just to be sure.

 

[Fastrach]

I've used I-gels at the VA, they're great, but not the end all, IMHO.

We had a grand rounds last year on the extreme danger of exchanging tubes of any kind over exchangers, esp in this kind of situation. What are the experiences of the board?

I can see how a tube exchanger could cause trouble, but as long as you keep an eye on the markings to watch your depth it's hard to create too much havoc. And did you know, if you poke the patient in the eye with it, that can also be a Q.I. issue. Same with banging the patient on the head repeatedly with a laryngoscope. Point: know how to use an airway tool properly and safely, or don't use it at all.

 

[hoyden]

Had a very similar call to ED on a Sunday afternoon in July, except the pt wasn't pregnant ( thanks God!). Obese 45yo female who was transferred to the EDa from a nearby OSC after a cancelled surgery there - 2 anesthesiologists failed to intubate her there( plastic surgery scheduled), per HPI non-intubating LMA placed. ED doc tried to take a look with glydescope ( without removing the LMA) - couldn't see anything. Upon arrival - obese, non-responding female with an unfamiliar stick from a mouth, in a moderate respiratory distress(RR 22-28), tongue out of the mouth, overall face severely edematous, suspicion on angioneurotic edema after induction in the surgicenter.
Started to give decadron, lasix, calling in a surgeon who can do trach in 4-5 min ( we do not have ENT), while maintaining sats in low 90's, ABG tolerable.
Finally in 3 hours were all assembled and able to move to OR - pt woke up during that time, tongue became less edematous.
Planned to remove the LMA after arrival in the OR and see how she tolerates it ),with plan A( take a look with laryngoscope),B( glydescope),C(fastrach LMA/fiberoptic scope), D( bougie) and E ( scrubbed surgeon) ready to go if pt doesn't fly.
While replacing the monitors in the OR and moving pt to the OR table, pt desaturates - to 80s( bit that stick) - unable to ventilate - push prop - unable to ventilate - push sux - nothing to loose, but pt may loosen the grip - still unable to ventilate, desats to 60s - remove the LMA - ****- it is a combitube( was told repeatedly it is LMA) - MAC3 in, grade 2 view(!!!) -7 tube-ETCO2 + - pt stabilized/awakened - to ICU - extubated the next day.

 

[cchoukal]

I've used I-gels at the VA, they're great, but not the end all, IMHO.

We had a grand rounds last year on the extreme danger of exchanging tubes of any kind over exchangers, esp in this kind of situation. What are the experiences of the board?

There's some data on this and, as I recall, of all the failures of airway exchange catheters, all but one were because the users didn't know where their catheter was and it came out of the trachea. I've only used them a handful of times (aside from the aforementioned use in placing DLTs in the OR), and they've all gone fine.

Anesth Analg. 2007 Nov;105(5):1182-5.
BACKGROUND: The American Society of Anesthesiologists Task Force on the Management of the Difficult Airway regards the concept of an extubation strategy as a logical extension of the intubation process, although the literature does not provide a sufficient basis for evaluating the merits of an extubation strategy. Use of an airway exchange catheter (AEC) to maintain access to the airway has been reported on only a limited basis. METHODS: I reviewed an observational analysis of a prospectively collected difficult airway quality improvement database for patients who were extubated over an AEC for a known or presumed difficult airway primarily in the intensive care unit. The data were reviewed for time to reintubation, number of attempts to reintubate the trachea, method of securing the airway, incidence of hypoxemia during reintubation, and complications encountered during reestablishment of the airway. RESULTS: Fifty-one patients with an indwelling AEC failed their extubation trial. Forty-seven of 51 AEC patients were successfully reintubated over the AEC (92%), with 41 of 47 on the first attempt (87%). In three of the four AEC reintubation failures, the AEC was inadvertently removed from the glottis during the reintubation process, and one patient had significant laryngeal edema precluding endotracheal tube advancement. CONCLUSIONS: Maintaining continuous access to the airway postextubation via an AEC can be an important component of an extubation strategy in selected difficult airway patients. The indwelling AEC appears to increase the first-pass success rate in patients with known or suspected difficult airways and decrease the incidence of complications in patients intolerant of extubation and requiring tracheal

 

[Planktonmd]

Had a very similar call to ED on a Sunday afternoon in July, except the pt wasn't pregnant ( thanks God!). Obese 45yo female who was transferred to the EDa from a nearby OSC after a cancelled surgery there - 2 anesthesiologists failed to intubate her there( plastic surgery scheduled), per HPI non-intubating LMA placed. ED doc tried to take a look with glydescope ( without removing the LMA) - couldn't see anything. Upon arrival - obese, non-responding female with an unfamiliar stick from a mouth, in a moderate respiratory distress(RR 22-28), tongue out of the mouth, overall face severely edematous, suspicion on angioneurotic edema after induction in the surgicenter.
Started to give decadron, lasix, calling in a surgeon who can do trach in 4-5 min ( we do not have ENT), while maintaining sats in low 90's, ABG tolerable.
Finally in 3 hours were all assembled and able to move to OR - pt woke up during that time, tongue became less edematous.
Planned to remove the LMA after arrival in the OR and see how she tolerates it ),with plan A( take a look with laryngoscope),B( glydescope),C(fastrach LMA/fiberoptic scope), D( bougie) and E ( scrubbed surgeon) ready to go if pt doesn't fly.
While replacing the monitors in the OR and moving pt to the OR table, pt desaturates - to 80s( bit that stick) - unable to ventilate - push prop - unable to ventilate - push sux - nothing to loose, but pt may loosen the grip - still unable to ventilate, desats to 60s - remove the LMA - ****- it is a combitube( was told repeatedly it is LMA) - MAC3 in, grade 2 view(!!!) -7 tube-ETCO2 + - pt stabilized/awakened - to ICU - extubated the next day.

Do you know why the 2 anesthesiologists at the other place failed to intubate her?
They most likely did some kind of half ass induction because they were concerned about the airway.
My experience is that a significant percentage of failed intubtions is caused by crappy induction and insufficient muscle relaxation by people who have no real plan of how to handle marginal airways.
In my opinion if you decide to induce GA before intubation then you do it right other wise do a real awake intubation.
And by the way, the reason why you were successful at intubating her is most likely because you had a good anesthetic on board combined with hypoxia (which is a great muscle relaxant by itself).

 

[hoyden]

Do you know why the 2 anesthesiologists at the other place failed to intubate her?
They most likely did some kind of half ass induction because they were concerned about the airway.
My experience is that a significant percentage of failed intubtions is caused by crappy induction and insufficient muscle relaxation by people who have no real plan of how to handle marginal airways.
In my opinion if you decide to induce GA before intubation then you do it right other wise do a real awake intubation.
And by the way, the reason why you were successful at intubating her is most likely because you had a good anesthetic on board combined with hypoxia (which is a great muscle relaxant by itself).

As I have been told both by ED doc and one of the OPS center anesthesiologists - they could not pass the ETT - they were able to see the vc and could not pass the tube!!!! Their induction was - versed pre-op, propofol and sux. Since there was a question of angioneurotic edema, these exact drugs were somewhat scary, but, on the other hand - if she is already going down the road and I need her to relax quickly( because she was biting that tube, sticking from her mouth with all her teeth) - that was the choice. Of course, she would relax soon anyway, without any drugs, with obvious sequelae...
I was able to intubate her because 1)I was lucky 2) as you've said 3) I've used smaller tube ( I posted 7, but I think it was actually 6, as I recall now) 4) in 3 hours of treatment and waiting either for ENT or GS to come her edema was not so bad.

 

[Planktonmd]

As I have been told both by ED doc and one of the OPS center anesthesiologists - they could not pass the ETT - they were able to see the vc and could not pass the tube!!!! Their induction was - versed pre-op, propofol and sux. Since there was a question of angioneurotic edema, these exact drugs were somewhat scary, but, on the other hand - if she is already going down the road and I need her to relax quickly( because she was biting that tube, sticking from her mouth with all her teeth) - that was the choice. Of course, she would relax soon anyway, without any drugs, with obvious sequelae...
I was able to intubate her because 1)I was lucky 2) as you've said 3) I've used smaller tube ( I posted 7, but I think it was actually 6, as I recall now) 4) in 3 hours of treatment and waiting either for ENT or GS to come her edema was not so bad.

This patient was going for an elective surgery as I understood, why do you think she had "angioneurotic edema"?
Was that a reaction to some medication?
If this was a reaction to a medication, have you ever heard of angioedema that causes difficulty inserting a tube without visible edema of the epiglottis or the larynx?
When people can not intubate they tend to come up with some strange explanations for why they could not do it.

 

[hoyden]

This patient was going for an elective surgery as I understood, why do you think she had "angioneurotic edema"?
Was that a reaction to some medication?
If this was a reaction to a medication, have you ever heard of angioedema that causes difficulty inserting a tube without visible edema of the epiglottis or the larynx?
When people can not intubate they tend to come up with some strange explanations for why they could not do it.

Her tongue, lips, eyelids and face overall were swollen like in angioedema. It is hard to define whichever was first - edema which caused the difficulty to pass the tube or inability to pass the tube and then the other symptoms. I encountered the pt who was severely edematous with no apparent reason for that( she wasn't fluid overloaded per notes).
The other concern was - the surgicenter anesthesiologists tried to wake her up( the case was canceled after failed intubation and placement of the Combitube) - apparently they spent about 3 hours trying to do so - and also failed - then decided to admit her to the nearby hospital. Pt didn't have any particular previous medical history except obesity and HTN. Personally, I do not think she was edematous upon their attempt of intubation, she, probably, became swollen after it. Angioneurotic edema does not have to be immediate in development after the trigger injection.

 

[Planktonmd]

Her tongue, lips, eyelids and face overall were swollen like in angioedema. It is hard to define whichever was first - edema which caused the difficulty to pass the tube or inability to pass the tube and then the other symptoms. I encountered the pt who was severely edematous with no apparent reason for that( she wasn't fluid overloaded per notes).
The other concern was - the surgicenter anesthesiologists tried to wake her up( the case was canceled after failed intubation and placement of the Combitube) - apparently they spent about 3 hours trying to do so - and also failed - then decided to admit her to the nearby hospital. Pt didn't have any particular previous medical history except obesity and HTN. Personally, I do not think she was edematous upon their attempt of intubation, she, probably, became swollen after it. Angioneurotic edema does not have to be immediate in development after the trigger injection.

Interesting!

 

[jd1572]

So if you extubate someone over an airway exchange catheter (AEC), how long do you leave the AEC in the patient after you take the ETT out? I imagine it would be uncomfortable to be sitting in the ICU with the AEC coming out of your mouth?

There's some data on this and, as I recall, of all the failures of airway exchange catheters, all but one were because the users didn't know where their catheter was and it came out of the trachea. I've only used them a handful of times (aside from the aforementioned use in placing DLTs in the OR), and they've all gone fine.

Anesth Analg. 2007 Nov;105(5):1182-5.
BACKGROUND: The American Society of Anesthesiologists Task Force on the Management of the Difficult Airway regards the concept of an extubation strategy as a logical extension of the intubation process, although the literature does not provide a sufficient basis for evaluating the merits of an extubation strategy. Use of an airway exchange catheter (AEC) to maintain access to the airway has been reported on only a limited basis. METHODS: I reviewed an observational analysis of a prospectively collected difficult airway quality improvement database for patients who were extubated over an AEC for a known or presumed difficult airway primarily in the intensive care unit. The data were reviewed for time to reintubation, number of attempts to reintubate the trachea, method of securing the airway, incidence of hypoxemia during reintubation, and complications encountered during reestablishment of the airway. RESULTS: Fifty-one patients with an indwelling AEC failed their extubation trial. Forty-seven of 51 AEC patients were successfully reintubated over the AEC (92%), with 41 of 47 on the first attempt (87%). In three of the four AEC reintubation failures, the AEC was inadvertently removed from the glottis during the reintubation process, and one patient had significant laryngeal edema precluding endotracheal tube advancement. CONCLUSIONS: Maintaining continuous access to the airway postextubation via an AEC can be an important component of an extubation strategy in selected difficult airway patients. The indwelling AEC appears to increase the first-pass success rate in patients with known or suspected difficult airways and decrease the incidence of complications in patients intolerant of extubation and requiring tracheal

 

[i want out]

So if you extubate someone over an airway exchange catheter (AEC), how long do you leave the AEC in the patient after you take the ETT out? I imagine it would be uncomfortable to be sitting in the ICU with the AEC coming out of your mouth?

not nearly as uncomfortable as being dead.

I have only used an AEC once, and the pt kept it for a couple hours.

I do know of one case where an ENT had recently done a reanastomosis of a tracheostomy. Pt was taken back to OR for removal of ETT after surgery. Done over Fiber optic scope with idea that replacing tube would be possible if needed.

scope inserted, tube pulled back over scope, and airway inspected, decision made to place tube back in. Anesthesiology resident trys, and feels resistance. Faculty anesthesiologist trys and feels resistance. ENT jams tube back in, and pt spends next few weeks in unit blowing bubbles out neck from rip in newly put back together trach with not above bed to keep sedated and don't let move. Ends up getting fresh new trach several weeks later because there wasn't enough tissue left to keep trying to put trachea back together.

 

[cchoukal]

So if you extubate someone over an airway exchange catheter (AEC), how long do you leave the AEC in the patient after you take the ETT out? I imagine it would be uncomfortable to be sitting in the ICU with the AEC coming out of your mouth?

As opposed to an endotracheal tube coming out of your mouth? It's no worse, probably better in that it's smaller. The duration of the AEC depends on the patient's trajectory. If they look great after an hour, I'd probably pull it. If not, I'd follow.

 

[coprolalia]

I haven't checked this forum for a while but today I did and I saw this thread and It made me think that there is hope for this forum after all!
My only rule in anesthesia is "keep it simple and do what you do best every time".
So, as a private practice anesthesiologist who is used to not having much of a backup and operating solo here is how I see it:
I am good at intubating people and I am good at placing LMA's, so in a situation like this this is exactly what I am going to do (intubate or place LMA):
1- Put her to sleep (Propofol + Sux), take the crappy combitube out and try to intubate with DL then Glidescope, most likely this will succeeed but if it doesn't (very unlikely) I am going to plan # 2
2- Place an LMA in then do a Fiberoptic intubation through it while they are doing the C section in the OR.
This might not be what you want to say on your oral boards but this is what makes sense in my hands.
Keep in mind that I can intubate a gravid ant with clift palate anytime of the day so if you are not that good then do what others have said.

AND I QUOTE...

I am done with this BS, and I don't have any clinical contribution to a pseudo clinical thread that is composed of random google search results.
I am actually done with this whole stupid forum and I do regret every minute I wasted on it.
Good Bye.

Pfft... sheesh... hah... 🙄

Go back to the above thread (where you wrote this forum off) and look-see what I said later in the same. Pretty much sums it up.

-copro

 

[Planktonmd]

AND I QUOTE...



Pfft... sheesh... hah... 🙄

Go back to the above thread (where you wrote this forum off) and look-see what I said later in the same. Pretty much sums it up.

-copro

There must be a good reason you feel so threatened by my presence on this forum!
Do I make you feel stupid?
Do I trigger some childhood abuse memories in you?
I am going to stay as long as I feel it bothers you, so get over it.
And now why don't you tell us how you really feel?