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GassYous

GassYous

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40 yo bmi 40 for dental procedure. History of developmental delay, seizures, htn, hld, osa, asthma, cardiac murmur. What else do you want to know?
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GassYous said:
40 yo bmi 40 for dental procedure. History of developmental delay, seizures, htn, hld, osa, asthma, cardiac murmur. What else do you want to know?
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My usual approach to adult mentally disabled dental is:

IM Ketamine
IV Placement
IV Versed, glyco
Facemask and Pulse ox in holding while waiting with IV dripping
Go into room
Prop, Roc, Nasal Tube
Glidescope if needed.

This guy will probably need nebs in his facemask after extubation.

Precedex drips are nice for these cases in addition to sevo.

Of course the cardiac murmur would have had to have been appropriately investigated or I would want some reliable history of decent exercise tolerance before proceeding if the murmur history is vague. A sedentary bmi>40 guy with a completely uninvestigated murmur for a dental procedure i would cancel
 
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Has the patient's murmur been investigated, or is it new? That's the only loose end I see regarding the history, other than making sure the other chronic problems have been addressed.

As far as the approach, it can vary. Who is accompanying the patient, and how well does that person know them? Caregivers can be an invaluable resource to find out things that have worked well in the past vs things that have not. Intellectually disabled adults frequently have been sedated and/or anesthetized numerous times before. Why re-invent the wheel if you don't have to.

Many ways to get an IV in and get the case done: IM ketamine, PO ketamine, PO benzo du jour + EMLA cream, PO benzo + nitrous, PO clonidine, inhalation induction (not for the BMI 40 adult with OSA the OP mentioned, but some of these patients are skinny), and the list goes on. Once the IV is in, induce and put in a nasal rae tube however suits you.
 
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I imagine we will eventually be told this patient has a syndrome with notable septal defect(s) and inducible R->L shunting. Am I warm?
 
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Infective endo from his yucky toothies?
 
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EKG/Echo would be nice. Also any syndrome?
Seizures/htn/asthma controlled? Meds? Hows the airway? Retrognathic/high narrow arched palate/ thick neck/limited mouth opening? Nasal patency?
Drooler?
IV access?
How cooperative? Verbal?
 
Autistic. Nonverbal. Murmur was as a child. Unable to hear it in preop. No cardiac workup. Patient has had dental procedures in the past but not at this institution. Patient is uncooperative with the airway exam. Nasal patency looks good.

Case is booked for the main OR. The preop nurse was able to get iv access without any major issues. I usually save the im ketamine for those who can't tolerate the iv. I like to give 1-2 / kg which is probably low but it seems to work ok to chill them out.

No inhalers but on bblocker and ace.

Caregivers at bedside, says he has no limitations in exercise tolerance. I think it's safe to proceed.

Needs a little coaxing to get him to lay back in bed but we get to the OR without incident. Monitors go on and bp is 120/80. IV induction with prop, roc and nasal intubation. How do you do the intubation?
 
McGrath is great for nasal intubation. Low profile which allows room for Magills if needed.
 
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Any complications or difficulty with previous anaesthetics?
 
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GassYous said:
Autistic. Nonverbal. Murmur was as a child. Unable to hear it in preop. No cardiac workup. Patient has had dental procedures in the past but not at this institution. Patient is uncooperative with the airway exam. Nasal patency looks good.

Case is booked for the main OR. The preop nurse was able to get iv access without any major issues. I usually save the im ketamine for those who can't tolerate the iv. I like to give 1-2 / kg which is probably low but it seems to work ok to chill them out.

No inhalers but on bblocker and ace.

Caregivers at bedside, says he has no limitations in exercise tolerance. I think it's safe to proceed.

Needs a little coaxing to get him to lay back in bed but we get to the OR without incident. Monitors go on and bp is 120/80. IV induction with prop, roc and nasal intubation. How do you do the intubation?
Click to expand...
is there something interesting that occurs here? if so the audience is ready for the twist..
 
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Ace inhibitor was held, no ecg. Does not tolerate a mask. I decided to induce, then mask then proceed with nasal intubation with mcgrath and magills. I just put the mask near his face for some blowby while I pushed meds.

I sprayed some afrin in both nares and checked for patency with a q tip. Masked him with an oral airway. The q tip went easily so I placed a 7.0 nasal rae. I felt a little resistance but no more than usual. I visualized the end of the tube in the hypopharynx and looked for view with a mcgrath. Saw the epiglottis but couldn't see cords. It was dark and there was a little blood in the mouth. I positioned the tube with the foreceps and pushed the tube but there was no end tidal. So I pulled it out and all of a sudden there was a gush of blood coming from the right nares then the left. What now?
 
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GassYous said:
Ace inhibitor was held, no ecg. Does not tolerate a mask. I decided to induce, then mask then proceed with nasal intubation with mcgrath and magills. I just put the mask near his face for some blowby while I pushed meds.

I sprayed some afrin in both nares and checked for patency with a q tip. Masked him with an oral airway. The q tip went easily so I placed a 7.0 nasal rae. I felt a little resistance but no more than usual. I visualized the end of the tube in the hypopharynx and looked for view with a mcgrath. Saw the epiglottis but couldn't see cords. It was dark and there was a little blood in the mouth. I positioned the tube with the foreceps and pushed the tube but there was no end tidal. So I pulled it out and all of a sudden there was a gush of blood coming from the right nares then the left. What now?
Click to expand...
suction. mask ventilate. more afrin, glyco. attempt oral intubation with various devices...
 
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Trendelenberg. Suction. Have someone pinch the nose. LMA. Rev trendelenberg. Pack the nose/call ENT if available.
 
I would have left the tube in the nose but just pulled it into view in the pharynx. Make sure its not occluded/kinked. Can also ventilate through it as an NPA . Did you feel resistance when you bagged? Did you try BURP to improve your initial view?
 
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propadope said:
I would have left the tube in the nose but just pulled it into view in the pharynx. Make sure its not occluded/kinked. Can also ventilate through it as an NPA . Did you feel resistance when you bagged? Did you try BURP to improve your initial view?
Click to expand...

I only thought to do this as I pulled the tube out. Didn't feel resistance as I bagged when the tube was in but there just no end tidal. I had end tidal when I bagged him earlier through the facemask. I thought that I couldn't see because of the blood, not because I wasn't able to lift the epiglottis. I was wondering if it was bronchospasm because of the asthma but only thought of it after I pulled the tube.

At the time, I thought I had to either completely wake him up or put him to sleep and tube. First I sprayed basically the whole bottle of afrin in there and packed both nostrils. Got an lma ready. I thought that I already missed the intubation once and there was a lot of blood so I figured that the safest thing to do was to wake him up, especially since this case was elective. He got sugammadex and was bagged with an oral airway until he started breathing by himself.

Since he was not super cooperative before, I gave some precedex to chill him out and decadron for possible swelling. Still not tolerating the facemask well so did some blowby again. Sats were okay.

Called ENT, they will see him when they finish operating.
 
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Suction, Trendelenburg, put in an LMA to temporize the situation, flood the offending nostril with epi, and then take a hot second to think.

What about the airway was the problem? Was the patient not positioned well? Didn't wait long enough for the paralytic to work before attempting intubation? Trying to use a video scope that got some gunk on the camera? Or features that made the airway itself difficult (poor neck ROM, anterior airway, short chin, etc.)? Or just bad luck and the patient had an unanticipated difficult airway?

One suggestion would be fiberoptic intubation through the LMA, assuming it seated well when placed. Then you tell the dentist to live with the oral tube, and can deal with the nose with either packing vs. ENT consult depending on if the bleeding stops with epi and packing or not.

Absolutely nothing wrong with reversing NMB, and aborting the case though if that's what you thought was in the patient's best interest. He's alive to come back another day.
 
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UnbentLaryngoscope said:
Suction, Trendelenburg, put in an LMA to temporize the situation, flood the offending nostril with epi, and then take a hot second to think.

What about the airway was the problem? Was the patient not positioned well? Didn't wait long enough for the paralytic to work before attempting intubation? Trying to use a video scope that got some gunk on the camera? Or features that made the airway itself difficult (poor neck ROM, anterior airway, short chin, etc.)? Or just bad luck and the patient had an unanticipated difficult airway?

One suggestion would be fiberoptic intubation through the LMA, assuming it seated well when placed. Then you tell the dentist to live with the oral tube, and can deal with the nose with either packing vs. ENT consult depending on if the bleeding stops with epi and packing or not.

Absolutely nothing wrong with reversing NMB, and aborting the case though if that's what you thought was in the patient's best interest. He's alive to come back another day.
Click to expand...

I am a little quick to intubate and I usually have the tube in once they stop breathing spontaneously but I bagged this guy a bit because he didn't let me preox. I think that I got some blood on the mcgrath camera when it was going in which made it hard to see anything other than the epiglottis. I felt pressured because I put him to sleep without preoxygenating and he was big. I didn't want him desatting/coding which happened once after an esophageal intubation in a sick patient during residency. One thing I noticed is that his pressure shot up to the 200s/100s during intubation which contributed to the bleeding.

I've done a few fiberoptic intubations through igels and it is not easy even in totally controlled situations with another anesthesiologist right there. I'm not sure I could pull it off by myself in this kind of patient.

Anyway the ENT comes by later in the day and says that because the patient won't even let him get close to his face, this needs to be done in the OR with general. The nose has been oozing all day. Plan?
 
GassYous said:
I only thought to do this as I pulled the tube out. Didn't feel resistance as I bagged when the tube was in but there just no end tidal. I had end tidal when I bagged him earlier through the facemask. I thought that I couldn't see because of the blood, not because I wasn't able to lift the epiglottis. I was wondering if it was bronchospasm because of the asthma but only thought of it after I pulled the tube.

At the time, I thought I had to either completely wake him up or put him to sleep and tube. First I sprayed basically the whole bottle of afrin in there and packed both nostrils. Got an lma ready. I thought that I already missed the intubation once and there was a lot of blood so I figured that the safest thing to do was to wake him up, especially since this case was elective. He got sugammadex and was bagged with an oral airway until he started breathing by himself.

Since he was not super cooperative before, I gave some precedex to chill him out and decadron for possible swelling. Still not tolerating the facemask well so did some blowby again. Sats were okay.

Called ENT, they will see him when they finish operating.
Click to expand...
I wonder if you would have gotten a view suctioning and wiping the McGrath blade or even DL. Thats a bad situation with a potential difficult airway and a bleed. Was the bleed anterior or posterior? Also was the tube thermosoftened?
 
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GassYous said:
I am a little quick to intubate and I usually have the tube in once they stop breathing spontaneously but I bagged this guy a bit because he didn't let me preox. I think that I got some blood on the mcgrath camera when it was going in which made it hard to see anything other than the epiglottis. I felt pressured because I put him to sleep without preoxygenating and he was big. I didn't want him desatting/coding which happened once after an esophageal intubation in a sick patient during residency. One thing I noticed is that his pressure shot up to the 200s/100s during intubation which contributed to the bleeding.

I've done a few fiberoptic intubations through igels and it is not easy even in totally controlled situations with another anesthesiologist right there. I'm not sure I could pull it off by myself in this kind of patient.

Anyway the ENT comes by later in the day and says that because the patient won't even let him get close to his face, this needs to be done in the OR with general. The nose has been oozing all day. Plan?
Click to expand...

If you feel in your gut that gunk on the camera was really the issue (plus time pressure, and memories of prior bad airways), have a go at this airway with DL plus or minus a bougie. But give yourself every advantage. Make your first attempt the best.

--Patient wouldn't allow adequate preoxygenation, and he's obese. -- Give the prop and stick in an LMA right away. Use the LMA to ventilate the patient with 100% O2 while you get him in the perfect position to intubate. Make a ramp under him, etc.
--You're a little quick to intubate (I can be, too). -- Let the machine ventilate the patient via the LMA while your paralytic takes full effect, by the clock (depending on when the patient got sugammadex you may want to use sux or cis). There's no rush if your ventilating and oxygenating well.
--Patient got hypertensive during laryngoscopy attempts previously -- get the patient deep on volatile before you start
--Once everything is picture perfect, take the LMA out, suction and intubate by direct laryngoscopy

If your gut says maybe it wasn't just gunk on the camera, maybe this was an unanticipated difficult airway, that's different. On the bright side you also know from earlier in the day that you are able to mask ventilate the patient.

--don't start the case until you know someone is available to assist you, gather all of the difficult airway toys.
--start a propofol infusion, low and slow, so as not to abolish spontaneous respiration. Eventually, you will be able to put the mask on the patient's face to give O2, and preoxygenate for the next part. You can take over ventilation with the face mask if needed. Mark the cricothyroid space.
--go from there with whichever tools you like. DL, bougie, Glidescope, fiber, intubating LMA... the sky's the limit

Also, don't forget to call the tooth fairy back to get in on the fun!
 
I put my tubes in the warm water bottles before I place them. Seems like most people like to use 6.5 nasal tubes. I chose a 7.0 ett because he is a big guy. Maybe that was a mistake.

I think the timing for sugammadex doesn't matter that much. You can intubate with roc an hour after a patient gets sugammadex and probably even earlier.

I did basically what the above post recommended. Bougie ready, partner in the room. Video scopes, DL, Fiberoptic all prepped. 2 suctions. ENT right there. I gave some precedex and decided to start with the glide. Prop and roc in, able to mask ventilate with an oral airway (thank god). I was a little worried about the masking blasting blood all over the place but the otolaryngologist said it shouldn't be an issue. Got a grade 2 b view and slid an 8.0 right in.

By the time this all happened the original proceduralist was long gone. But we fixed his nose.

Apparently some people like to put a red rubber over the end of the tube or do serial dilations with nasal airways before placing the nasal rae.
 
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GassYous said:
I put my tubes in the warm water bottles before I place them. Seems like most people like to use 6.5 nasal tubes. I chose a 7.0 ett because he is a big guy. Maybe that was a mistake.

I think the timing for sugammadex doesn't matter that much. You can intubate with roc an hour after a patient gets sugammadex and probably even earlier.

I did basically what the above post recommended. Bougie ready, partner in the room. Video scopes, DL, Fiberoptic all prepped. 2 suctions. ENT right there. I gave some precedex and decided to start with the glide. Prop and roc in, able to mask ventilate with an oral airway (thank god). I was a little worried about the masking blasting blood all over the place but the otolaryngologist said it shouldn't be an issue. Got a grade 2 b view and slid an 8.0 right in.

By the time this all happened the original proceduralist was long gone. But we fixed his nose.

Apparently some people like to put a red rubber over the end of the tube or do serial dilations with nasal airways before placing the nasal rae.
Click to expand...
How tall was he? Problem with nasal RAEs is if you go down in size it might not be long enough.
 
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GassYous said:
I put my tubes in the warm water bottles before I place them. Seems like most people like to use 6.5 nasal tubes. I chose a 7.0 ett because he is a big guy. Maybe that was a mistake.

I think the timing for sugammadex doesn't matter that much. You can intubate with roc an hour after a patient gets sugammadex and probably even earlier.

I did basically what the above post recommended. Bougie ready, partner in the room. Video scopes, DL, Fiberoptic all prepped. 2 suctions. ENT right there. I gave some precedex and decided to start with the glide. Prop and roc in, able to mask ventilate with an oral airway (thank god). I was a little worried about the masking blasting blood all over the place but the otolaryngologist said it shouldn't be an issue. Got a grade 2 b view and slid an 8.0 right in.

By the time this all happened the original proceduralist was long gone. But we fixed his nose.

Apparently some people like to put a red rubber over the end of the tube or do serial dilations with nasal airways before placing the nasal rae.
Click to expand...
Red rubber definitely helps if you are meeting any resistance. I like to try without it first but if I meet any significant amount of resistance, I'm leading the tube with a red rubber hooked to it.
 
I’m unfamiliar with the red rubber technique (nasal intubation isn’t a very frequent part of my current practice). Anyone care to explain the details? What kind of catheter are you using exactly, what are you doing with it, and how does it help navigate past a resistance?
 
Red rubber is not going to help if there is bony resistance. Neither is serial dilation which is not advised
 
Been there. Now my patients get afrin in preop. After induction attempt lido lubed 28fr nasal airway then one attempt with warm nasal RAE. If no go and unable to pass with resistance at either step then straight to oral tube. The dentist can deal with it. One good iatrogenic turbinectomy requiring rhino rocket, admission, and subsequent cautery by ENT under GA is what it took. Never again.
 
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Hork Bajir said:
I’m unfamiliar with the red rubber technique (nasal intubation isn’t a very frequent part of my current practice). Anyone care to explain the details? What kind of catheter are you using exactly, what are you doing with it, and how does it help navigate past a resistance?
Click to expand...
12-14Fr red rubber catheter. Stretch the larger end over the tip of the ETT so that they are attached and not too easy to pull apart, lubricate the nare, pass the red rubber catheter.

Use magill forceps to grab the catheter from the oropharynx and pull the red rubber catheter while gently pushing the nasal tube. Should go pretty easily. "Should" being the optimal word.
 
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DocMcCoy said:
Been there. Now my patients get afrin in preop. After induction attempt lido lubed 28fr nasal airway then one attempt with warm nasal RAE. If no go and unable to pass with resistance at either step then straight to oral tube. The dentist can deal with it. One good iatrogenic turbinectomy requiring rhino rocket, admission, and subsequent cautery by ENT under GA is what it took. Never again.
Click to expand...

Agree if in doubt just oral tube. The only reason for nasal intubation for dental work is for surgical convenience.
 
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DocMcCoy said:
Been there. Now my patients get afrin in preop. After induction attempt lido lubed 28fr nasal airway then one attempt with warm nasal RAE. If no go and unable to pass with resistance at either step then straight to oral tube. The dentist can deal with it. One good iatrogenic turbinectomy requiring rhino rocket, admission, and subsequent cautery by ENT under GA is what it took. Never again.
Click to expand...

Yep. Never again. I will do the same. I tried going on the other side but stopped as soon as I hit a little resistance. It didn't look so bad on the scope but there was a little trauma. I think most of the blood came from the other side.
 
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An oral RAE might be preferable to an oral ETT depending on whats being done. Usually there is not much treatment on the lower incisors. That way you don’t have to tape the tube off to the side and switch it midway if they are working on both sides of the mouth.
I think it is reasonable to try nasal but don’t hesitate to go oral.
Sometimes you need a little bit of finessing to get through the nasal cavity with rotation, backing out and readvancing.
Bonus: If the patient has a panoramic radiograph you can actually see if one side is more patent than the other or if they are occluded. I had one patient the other day that was blocked on both sides on the Xray and went straight to oral
 
repititionition said:
not advised by whom? (serious q)

I've been told (but have not ever confirmed myself) that MLTs do not soften nearly as much with heat. True?
Click to expand...
I don’t think its been studied much so for what its worth

Adamson DN, Theisen FC, Barrett KC. Effect of mechanical dilation on nasotracheal intubation. J Oral Maxillofac Surg. 1988 May;46(5):372-5. doi: 10.1016/0278-2391(88)90220-0. PMID: 3163370.
 
GassYous said:
I've done a few fiberoptic intubations through igels and it is not easy even in totally controlled situations with another anesthesiologist right there. I'm not sure I could pull it off by myself in this kind of patient.

Anyway the ENT comes by later in the day and says that because the patient won't even let him get close to his face, this needs to be done in the OR with general. The nose has been oozing all day. Plan?
Click to expand...
Fiberoptic intubation through an LMA is easy 99% of the time. You just have to do it a few times. If you don't do it perfectly and have good help there is a good chance it will turn into a mess though.
 
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“After topical anesthesia and application of vasoconstrictor, some practitioners advocate usage of a device to “dilate” the tissue, commonly a nasal airway. The necessity of dilation before intubation is a topic of debate in the anesthesiology community. Currently, there are no PubMed indexed papers showing benefit from this practice, only increased complications from repeated instrumentation of delicate structures. As of the time of this article’s writing "dilation" is not a recommended practice.”

Nasotracheal Intubation - StatPearls - NCBI Bookshelf

www.ncbi.nlm.nih.gov
 
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propadope said:
“After topical anesthesia and application of vasoconstrictor, some practitioners advocate usage of a device to “dilate” the tissue, commonly a nasal airway. The necessity of dilation before intubation is a topic of debate in the anesthesiology community. Currently, there are no PubMed indexed papers showing benefit from this practice, only increased complications from repeated instrumentation of delicate structures. As of the time of this article’s writing "dilation" is not a recommended practice.”

Nasotracheal Intubation - StatPearls - NCBI Bookshelf

www.ncbi.nlm.nih.gov
Click to expand...

I don't know if it is that controversial. Nasal airways are generally much softer material than the ETT plastic even if it has been thermosoftened. Do you know anyone who doesn't dilate?
 
Does anyone really believe these soft and easily compressible nasopharyngeal airways are dilating anything? I could see checking for nasal patency... I haven't "dilated" since residency, nor does anyone where I work currently, though it's 100% peds.
 
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coffeebythelake said:
I don't know if it is that controversial. Nasal airways are generally much softer material than the ETT plastic even if it has been thermosoftened. Do you know anyone who doesn't dilate?
Click to expand...
I don’t know anyone who does
 
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