Case Question

[btbam]

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I'm doing a short preop rotation now for my AA program, and thought this might be a semi-interesting case discussion.

I was not preopping this pt, but the nurse comes over and asks the NP and I to come talk to her. I am probably forgetting some details, but think I got the relevant ones.

68 y/o AA woman coming in for a D+C next week. She is obese ~110kg, hypertensive, ECG/labs are normal, takes Protonix daily, uses CPAP at home, sleep at 45 degree angle in a chair at home every night. She told the first nurse, "When I had surgery 20-25 years ago the anesthesiologist couldn't put the tube in me when I was asleep, so they had to wake me up". I confirm with her that they actually performed an awake fiberoptic and do my own airway assessment which confirms almost every predictor of a difficult airway.

My question is what would be the best way to proceed with this case? Even though a D+C is a short procedure, I feel like doing a MAC on this woman would be a nightmare as you need her flat with legs in lithotomy...LMA seems out of the question due to reflux/daily proton pump inhibitor. If you tube her, would glidescope + difficult airway cart in room be the best strategy? I don't know exactly when the glidescope came into use, but it definitely wasn't around 20 years ago right? Thanks for the input.

 

[IlDestriero]

Elective surgery, hx of difficult airway 20 years and 20kg ago= elective awake fiber, or a spinal. The 45 degree angle and CPAP are concerning as well and would probably lead me to go with the fiber. She probably won't handle 20 min on her back. You'd have to ask.

 

[Idiopathic]

i dont think its terribly cavalier to say spinal, lidocaine or otherwise, even though its usually bad form to run away from a difficult airway with a regional technique. for this, i think your risk of high spinal is zero. now, what if that doesnt work or if she refused she has to get awake FOI. id be a little curious about that reflux as it sounds like the worst ive ever come across.

 

[nap$ter]

no spinal from me. safest route is to control the airway from the get-go.

awake fob (ie no sedation or stingy like the grinch systemic sedation), hand stroking reassurance, 4%lido, all done at 45 degrees.

after tube is in and she's asleep, document direct laryngoscopy and glidescope views.

 

[Bertelman]

What exactly happens when she lies flat?

 

[ssmallz]

What exactly happens when she lies flat?

To me thats the most important question when evaluating here GERD. Can she lie flat w/out heartburn? Does the heartburn wake her up at night? If a pts GERD is well controlled w/daily protonix then the GERD is not a contraindication to an LMA IMO

do my own airway assessment which confirms almost every predictor of a difficult airway

Please give more details in the airway exam. Whats the mouth opening like? Neck motion? MP etc. Is this a difficult intubation or a difficult ventilation problem? If this pt is a typical obese pt w/good neck ROM and mouth opening but poor MP then I think putting her to sleep and using a glidescope is certainly a reasonable way to proceed if you feel you can ventilate adequately.

 

[nap$ter]

To me thats the most important question when evaluating here GERD. Can she lie flat w/out heartburn? Does the heartburn wake her up at night? If a pts GERD is well controlled w/daily protonix then the GERD is not a contraindication to an LMA IMO

agreed that controlled gerd is not a rigid contraindication to an LMA.

but what about the difficult airway history? what would you do if the LMA didn't work? (and i have met a few patients that for whatever reason could not ventilate through any form of LMA).

sounds like this lady has classic predictors for difficult mask and difficult intubation...

 

[btbam]

To me thats the most important question when evaluating here GERD. Can she lie flat w/out heartburn? Does the heartburn wake her up at night? If a pts GERD is well controlled w/daily protonix then the GERD is not a contraindication to an LMA IMO



Please give more details in the airway exam. Whats the mouth opening like? Neck motion? MP etc. Is this a difficult intubation or a difficult ventilation problem? If this pt is a typical obese pt w/good neck ROM and mouth opening but poor MP then I think putting her to sleep and using a glidescope is certainly a reasonable way to proceed if you feel you can ventilate adequately.

Probably didn't investigate the GERD as much as I should have, but again I'm just a student and she wasn't my patient. The impression I got was that she essentially cannot lay flat, mostly due to obstructing not sure about the GERD. She did say her GERD bothered her most of the time and that she needed the Protonix daily.

Regarding the airway... poor mouth opening <2 fingers, limited extension, MP IV, macroglossia, short TMD.

 

[deleted9493]

There are just so many good ways to skin the awake fiberoptic 'cat' and do it well that if the notion arises in my mind that a patient may need it, I'm doing it.

Spinals can be amazing and simple but in a patient like this it can quickly become amazingly complicated.

 

[shopsteward]

Layperson here. I can, just about, understand a weight of 110kg.

Understanding a weight of 110kg in a person who has "poor mouth opening" is a little harder to process.

 

[ssmallz]

agreed that controlled gerd is not a rigid contraindication to an LMA.

but what about the difficult airway history? what would you do if the LMA didn't work? (and i have met a few patients that for whatever reason could not ventilate through any form of LMA).

sounds like this lady has classic predictors for difficult mask and difficult intubation...

All I heard was that she's a difficult intubation and she takes protonix daily. My suspicion for difficult ventilation was increased but I certainly need more information before I will say this is a difficult ventilation in need of an AFOI. If I felt this was a difficult intubation but reasonable ventilation (I.E. typical bariatric patient) I would have no problem inducing and attempting an LMA if the GERD was well controlled on meds. If the LMA failed I would intubate with a glidescope or other difficult intubation technique as long as mask ventilation is not an issue. In that situation I also believe that information can be gained by doing a basic DL even to just document the degree of difficulty b/c it can help with our extubation plan.

Given the additional information posted by btbam, I agree that an AFOI technique would be safest for this patient.

Btbam - no worries about the GERD thing. We all understand that you're a student and this forum is for learning not criticizing. Thanks for posting the case

 

[bentrider]

If reflux is controlled with medication would consider GA with Supreme LMA. I would also consider light MAC with paracervical block and tell patient she might remember block due to light sedation which would be safest way to give anesthesia.

 

[nap$ter]

All I heard was that she's a difficult intubation and she takes protonix daily. My suspicion for difficult ventilation was increased but I certainly need more information before I will say this is a difficult ventilation in need of an AFOI. If I felt this was a difficult intubation but reasonable ventilation (I.E. typical bariatric patient) I would have no problem inducing and attempting an LMA if the GERD was well controlled on meds. If the LMA failed I would intubate with a glidescope or other difficult intubation technique as long as mask ventilation is not an issue. In that situation I also believe that information can be gained by doing a basic DL even to just document the degree of difficulty b/c it can help with our extubation plan.

Given the additional information posted by btbam, I agree that an AFOI technique would be safest for this patient.

Btbam - no worries about the GERD thing. We all understand that you're a student and this forum is for learning not criticizing. Thanks for posting the case

if an aa student tells me a pt is a difficult intubation, on cpap, and has "all the exam predictors of a difficult airway", i assume they will be a difficult ventilation as well as a difficult intubation. students don't usually differentiate between the predictors for difficult ventilation and intubation.

i don't consider 110 kg to be quite bariatric - more like average.

i agree with your logic - if the pt is maskable but difficult intubation, she can go to sleep for airway management. however, I would hesitate to put an LMA into a pt known to be a difficult intubation, even if I believe we could mask. especially in the setting of "controlled" gerd. airways change with manipulation and anesthesia, and if you have burned or charred the bridge of spontaneous ventilation and lose the ability to ventilate you are hosed. it would suck to give a lady an emergent trach for a d and c.

the older i get the lower my threshold to go to awake fob - if done right it really is not traumatic. i have yet to regret it. but i have regretted a few LMA's.

 

[btbam]

if an aa student tells me a pt is a difficult intubation, on cpap, and has "all the exam predictors of a difficult airway", i assume they will be a difficult ventilation as well as a difficult intubation. students don't usually differentiate between the predictors for difficult ventilation and intubation.

Good point slavin and something I should have considered more carefully. I don't think ventilating her would have been particularly difficult. She had all her teeth and the majority of her "mass" was lower body. Any reason you guys wouldn't just start out with glidescope? I asked that in the original post cause I know that wasn't around 20 years ago and I assume they attempted normal DL and had to abort when they couldn't intubate.

If for whatever reason you didn't have a view with the glidescope, but could still easily mask then just whip out the FO right?

 

[Idiopathic]

depends on if the GERD is really that bad. 110kg certainly not too big to mask/attempt DL. If maskable and GERD is just ordinary, sleep followed by video laryngoscopy/glidescope

if its so bad that she cant lay flat, etc...then i dont think you should mask or consider an LMA.

also would caution against using an LMA in a patient to avoid securing a difficult airway.

 

[rsgillmd]

Layperson here. I can, just about, understand a weight of 110kg.

Understanding a weight of 110kg in a person who has "poor mouth opening" is a little harder to process.

🤣

 

[rsgillmd]

During most of residency I used to believe the "controlled GERD should be fine for LMA" theory, but as one of my attendings pointed out, you are controlling the symptoms, not the disease.

If someone tells me they only get GERD after they eat and it does not wake them up in the middle of the night, I would probably be fine with an LMA, but otherwise I tend to put a tube. But to each his own.

If I have been following the thread correctly, it sounds like this lady cannot lie flat because of trouble breathing, and has severe GERD. Based on the information given and assuming my exam was the same, and if a skilled surgeon was going to do the case (as opposed to a learning resident), and if I could ramp her enough to a tolerable position for her and the surgeon, I might consider a spinal or CSE (if I thought she would be too deep). Obviously leave her sitting for several minutes to establish a dense saddle block, and have difficult airway equipment (Glidescope/fiberoptic) in the room.

This is a D&C in lithotomy, not a cerclage where they also want trendelenburg. So if you establish a dense saddle block, she really should not get a high level.

I would not do paracervical block + MAC because you run the risk that MAC becomes non-intubated general.

 

[jennyboo]

1. If no GERD symptoms on an empty stomach, spinal vs LMA vs asleep Glidescope/FOI.

2. If severe GERD, awake FOI.

 

[Idiopathic]

my interpretation is that the GERD is so bad that she cant lay flat

my plans in order

1. spinal
2. awake FOI
.
.
.
.
.
.
.
.
10. LMA
11. MAC/room air general

 

[fakin' the funk]

If reflux is controlled with medication would consider GA with Supreme LMA.

Just to jump on the hatin'-on-Bentrider bandwagon...

An LMA in a 110kg person who cannot lay flat?

As in...spontaneous ventilation, supine, in a person under volatile GA...who can't lay flat anyway?

Or...

Positive pressure ventilation with a max Pinspired of 20 cm H2O?!

This is the plan?!

 

[Idiopathic]

Just to jump on the hatin'-on-Bentrider bandwagon...

An LMA in a 110kg person who cannot lay flat?

As in...spontaneous ventilation, supine, in a person under volatile GA...who can't lay flat anyway?

Or...

Positive pressure ventilation with a max Pinspired of 20 cm H2O?!

This is the plan?!

well if they cant lay flat because of upper airway obstruction, then maybe an LMA is not a terrible idea.

 

[TrustMe]

I'm thinking that the lady must have gotten in lithotomy and was semi-recumbent for the exam in her Gyn's office (assuming approx. 5 min.). So she has the potential to get in the same position for the D&C with the Gyn. able to get access to where they need. I would have a discussion with the Gyn. and the pt. and shoot for a spinal with the pt. semi-recumbent and tell the Gyn. that they have 10 min. before you start sitting the pt. up even more. I would also have the difficult airway stuff in the room just in case.

 

[RT2MD]

👍
Thanks for posting, it's always nice when a case gets posted where I can follow along with everything that is said. Thanks to all who contributed, as well.