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Direct Laryngoscopy

Direct Laryngoscopy

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Case I recently had. I figure this how the oral board clinical scenarios might be like

60M with hematuria in need cysto poss TUR-B. Booked as emergency, GU team tried irrigating catheter on the floor, but unable to clear out blots

PMHx Renal transplant 25 yrs ago, CAD with CABG X4 3 months ago, Squamous cell carcinoma of the pharynx, S/P palate reconstruction with flap POD #14, PE in the past, dianosed with DVT 1 week ago

PSHx: as above
All: PCN, compazine, Ampicillin
Meds: Zetia, Coumadin (last took 3 days prior), ecotrin, Metoprolol, plavix, prednisone, prograf, uroxatral

Labs:
chem: 130/5.2, 100/22, 40/2.28
CBC: 17>9.4/29.8<462
INR:1.6
EKG Sinus rhythm HR 93

PE:
69Kg, 177cm
V/S 128/76, P 87, R16, T 98
good dentition, poor mouth opening (poor effort), flap(graft) in place with sutures in place, MP4, TM 6cm, good neck mobility.

Pt is explicitly refusing awake fiberoptic intubation. What options do we have? How would you proceed
 
In addition to coumadin, the patient is also on plavix. No spinal.

If you are feeling lucky and you have a good urologist the patient will get a MAC for a diagnostic cysto only.

If the urologist says that it unacceptable, Strongly recommend to the patient that he go for the awake fiberoptic. If he still doesn't bite, Tell him to look at the bed that he is currently in. Tell him that by him tying your hands, that this is the bed that he will probably die in.
 
If this is just a palate reconstruction, i.e. roof of the mouth, and the tongue base/hypopharynx are disease free, I would convince the patient to let me topicalize and take a (very) gentle awake Glidescope look.

If view, pt can go to sleep. I suspect there will be a view.

If no view, pt gets to decide between awake fiber or awake trach. When he decides on the fiber, do that.

Details of surgical procedure and details of intubation for said procedure would be helpful.
 
I think we often forget that not long ago, relatively speaking, alotta cases were done with

MASK VENTILATION (jwk help me out here brah)

Yep.

This is a case where you wanna

K.I.S.S.

Keep It Simple, Stupid.

I'd emulate my anesthesia elders...

I'D FLIP IN AN LMA which essentially is the modern way to mask ventilate someone, plus it's easier.

I love regional and would love to do it here but with an INR=1.6...

BZZZZZZZZT I'M SORRY thats a no go.

Think about it, Homies...you've got a dude that needs surgery that has 2 week old suture lines in his mouth. The less hard stuff you put in there, the better off he's gonna be.

LMA ALL THE WAY

damn I could be a rapper... any you guy's have Lil Wayne's cell number? He's FROM here you know...
 
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I'm thinking an LMA is a lot of semirigid plastic resting right on that surgical site.

I tend to think the ETT would be less traumatic once in.

But without having the actual patient in front of us to evaluate, it's hard to say.
 
Jet beat me to it...

LMA.

As stated neuraxial would have been nice but, INR and plavix mean no go.

People here are thinking general. GREAT. But does this pt need a tube???

If it was same case with no airway issues, I feel most would put in an LMA as pt is not an aspiration risk.

So why are there so many wanting a tube here, and why are so many wanting to do it awake?
--Because of fear of the can't ventilate, can't intubate scenario.
This scenario should always be a concern to every anesthesiologist.

But let's review
Given the history is this pt going to be difficult to intubate with standard DL? Likely..
Difficult intubation with Glidescope? Possibly.
--My answers to above were mainly because of small mouth opening

NOW is this pt going to be difficult to ventilate?? IMO. No.
--The big worry with this is practitioners sometimes feel that you never really know until you try mask ventilation. BUT...
--Is pt edentulous, big bearded, have retrognathia, super fat neck? From what I gathered...NO
--Can pt open mouth enough to stick an oral airway in?? From what I gathered yes.
--Can pt open mouth enough to stick an LMA in?? From what I gathered likely.

--Also it sounds like pt has no problems breathing while supine. For me sometimes it is a concern if pt's are dyspneic while supine when considering LMA b/c I prefer to maintain pt's spontaneously breathing while on LMA, but if need be you could place pt on vent with LMA.

So pt breathes fine when he is supine. Pt has no classic physical exam traits that would lead me to believe that pt would be difficult to mask ventilate. I sense I could easily get an oral airway in. I feel I could get an LMA in. So I induce and put in the LMA.

Also let me add that the pt refused awake intubation. I understand that those that are advaocating that awake intubation is the only way to go are going to say that pt is not making an informed decision so his refusal is moot, but is awake intubation the only way to go?
 
excalibur said:
Jet beat me to it...

LMA.

As stated neuraxial would have been nice but, INR and plavix mean no go.

People here are thinking general. GREAT. But does this pt need a tube???

If it was same case with no airway issues, I feel most would put in an LMA as pt is not an aspiration risk.

So why are there so many wanting a tube here, and why are so many wanting to do it awake?
[/I]
Click to expand...

Your guess is as good as mine.

Tube not needed here.
 
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I did (semi-purposely) failed to mentioned that the pt stated he never had an awake fiber optic intubation in the past and this was also the second graft that was placed. According the pt, the first graft "failed". Pt had a old scar to his forearm, where he stated they used for the first graft and a large scar on his neck where I supposed the flap? (Second graft) was done.

Pt wasn't the greatest historian and his prior surgeries were done at other institutions. Admittedly when he he mentioned that I was hesitant to place an LMA.
 
HumidifiedMoistureExchange said:
I did (semi-purposely) failed to mentioned that the pt stated he never had an awake fiber optic intubation in the past and this was also the second graft that was placed. According the pt, the first graft "failed". Pt had a old scar to his forearm, where he stated they used for the first graft and a large scar on his neck where I supposed the flap? (Second graft) was done.

Pt wasn't the greatest historian and his prior surgeries were done at other institutions. Admittedly when he he mentioned that I was hesitant to place an LMA.
Click to expand...

Why?

I don't see how/why this changes anything. Not many patients have had an awake FOTI. Do you think an LMA would damage the graft? I'm not aware so it's a genuine question.
 
Last edited:
jetproppilot said:
I think we often forget that not long ago, relatively speaking, alotta cases were done with

MASK VENTILATION (jwk help me out here brah)

Yep.

This is a case where you wanna

K.I.S.S.

Keep It Simple, Stupid.

I'd emulate my anesthesia elders...

I'D FLIP IN AN LMA which essentially is the modern way to mask ventilate someone, plus it's easier.

I love regional and would love to do it here but with an INR=1.6...

BZZZZZZZZT I'M SORRY thats a no go.

Think about it, Homies...you've got a dude that needs surgery that has 2 week old suture lines in his mouth. The less hard stuff you put in there, the better off he's gonna be.

LMA ALL THE WAY

damn I could be a rapper... any you guy's have Lil Wayne's cell number? He's FROM here you know...
Click to expand...

I've come to realize that the KISS philosophy is often very applicable to anesthesia. I know many who try to go all fancy but often times less is more, especially with sick patients.
 
Doctor4Life1769 said:
I've come to realize that the KISS philosophy is often very applicable to anesthesia. I know many who try to go all fancy but often times less is more, especially with sick patients.
Click to expand...

Indeed.

We start out our careers as anesthesiologists figuring out what drugs we can do

WITH

and as we progress in our careers as anesthesiologists, we figure out that

Less Is More so we strive to do cases simpler and easier,


WITHOUT the complexity we were taught.

When we're in training as residents, most often our attendings make this biz look very complicated....looking back, I don't know why man. Yeah, we're doctors practicing a trade that involves SKILL and KNOWLEDGE...but

Academic Attendings That Teach Residents Have A Tendency To Make Things Complicated.

K.I.S.S.

That's what I want you to remember.

It'll make you look like a

ROKKSTARR.
 
I would tell the surgeon to do local for the cysto. They do it all the time in their office. They tried to irrigate the foley and failed. They don't necessarily need to do a TURBT.

MAC is a possibility, but not something I would be pushing for. Just in case it goes bad and becomes an airway emergency.

Inhaled sevo/nitrous maybe, but same airway concern.

Tube could be reasonable if only the palate was involved. I would have to call the surgeon who did the reconstruction before attempting that. The surgeon might even come and do the intubation/trach if they are really concerned.

Glidescope intubation maybe, but there are a good number of reports on palate trauma with it. Look it up. I have personally seen one.

LMA definetely no. That thing will invariably bang against the palate.


My final answer is call the ENT and go from there.
 
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Talk to surgeon

Not an emergency

The surgeon might say that this case "needs" to happen because the patient is bleeding. But they need to medically control his bleeding first. The patient is on warfarin and clopidogrel. Transfuse FFP and PLT and prepare to transfuse RBCs.

Get ENT on board

I kind of like the idea of mask GA, not sure how I feel rubbing an LMA on a 14-day-old highly vascular surgical site
 
So this guy had a freshly reconstructed palate and the roof of his mouth was approximately at the level of his incisors (maybe 1cm higher), so for me an LMA was out the question.

My plan was glide scope and the "academic" attending I was working with told the patient his only option was awake fiber-optic, and when the pt refused, he subsequently said cancel the case or remove him from that room.

Next attending agreed with my plan. We had the fiber-optic on standby in the room. Tubed the pt via glide scope. Case proceeded. Surgeons evacuated approx 1 liter in clots, pt extubated, and trasferred PACU.

Jet I see your point on the academic way of complicating things but, I believe there is a very thin line from being a rock star and a cowboy, at the pts expense. I felt an LMA for a fresh (low lying) palate reconstruction would have been dicey at best and may have put the pt at increased risk. But I do appreciate your input from someone in the real world. Maybe my perspective may have been different if I was out in PP.
 
HumidifiedMoistureExchange said:
So this guy had a freshly reconstructed palate and the roof of his mouth was approximately at the level of his incisors (maybe 1cm higher), so for me an LMA was out the question.

My plan was glide scope and the "academic" attending I was working with told the patient his only option was awake fiber-optic, and when the pt refused, he subsequently said cancel the case or remove him from that room.

Next attending agreed with my plan. We had the fiber-optic on standby in the room. Tubed the pt via glide scope. Case proceeded. Surgeons evacuated approx 1 liter in clots, pt extubated, and trasferred PACU.

Jet I see your point on the academic way of complicating things but, I believe there is a very thin line from being a rock star and a cowboy, at the pts expense. I felt an LMA for a fresh (low lying) palate reconstruction would have been dicey at best and may have put the pt at increased risk. But I do appreciate your input from someone in the real world. Maybe my perspective may have been different if I was out in PP.
Click to expand...


Sounds like a the case could have been done under local.
 
I have to ask.

Does it take bigger balls to make a big fuss and cancel the case, or to go cowboy on this case?

I would say your first attending has the biggest pair.
 
This is a great case for Ketamine + Propofol infusion
Don't give anything else: No Midaz no Fentanyl... nothing
Take him to cysto room and let him position himself.
Start with a loading dose of Ketamine (50mg) than run your Propofol/ Ketamine mixture at a low rate.
You can use additional bolus doses of Ketamine if needed.
Very simple technique and can be used for almost any surgery you might think of.
 
Planktonmd said:
This is a great case for Ketamine + Propofol infusion
Don't give anything else: No Midaz no Fentanyl... nothing
Take him to cysto room and let him position himself.
Start with a loading dose of Ketamine (50mg) than run your Propofol/ Ketamine mixture at a low rate.
You can use additional bolus doses of Ketamine if needed.
Very simple technique and can be used for almost any surgery you might think of.
Click to expand...

Did you learn this from Barry and his minimally invasive anesthesia?
 
I'm still trying to work through the process of formulating anesthetic plans on simple let alone complex pt's, but is there any reason this couldn't be done with MAC assuming you knew it was just gonna be the washout?
 
vector2 said:
I'm still trying to work through the process of formulating anesthetic plans on simple let alone complex pt's, but is there any reason this couldn't be done with MAC assuming you knew it was just gonna be the washout?
Click to expand...

Some surgeons are rough and a simple "MAC" will not be enough.
 
urge said:
Sounds like a the case could have been done under local.
Click to expand...

As a new attending I am quickly learning the value of good communication with surgical staff. One of my first really sick pts as an attending was a GU pt. 80 y/o with metastatic prostate CA. COPD on home O2, IDDM, dementia, malnutrition, worsening cardiomyopathy (EF generously estimated at 10%, which is down from 20% 3 months ago). Worsening renal fxn (creat 2.8), dude basically looked like a talking corpse. Cardiology thinks renal function is obstructive from disease and urologist thinks it is cardiac mediated renal dysfunction (I agreed with the urologist) as the guy has a stent in place. Regardless, he has been a pt of urologist for many years so he agrees to change out stent to officially rule out obstruction. Learned a lot of this from talking to urology staff. Told him to give us couple minute notice before putting in cystoscope. 0.5mg/kg of ketamine and a reassuring "little bit of pressure" were all the dude got and urologist understood and was okay when pt moved a little. Little communication goes a long ways with most (not all) colleagues.
 
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