Difficult Airway

[militarymd]

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A guy comes to our OR for ACD/F. He is otherwise healthy. Airway exam shows limited range of motion in the cervical spine, and marginal mouth opening.

He reports that 2 prior anesthetics, before his neck symptons, in the past 2 years resulted in him being told by 2 separate anesthesiologists that he was difficult to intubate.

He is kind of "thick" in the neck, but appears to be mask ventilateable.

How would everyone get this guy anesthetized for his surgery?

 

[jetproppilot]

A guy comes to our OR for ACD/F. He is otherwise healthy. Airway exam shows limited range of motion in the cervical spine, and marginal mouth opening.

He reports that 2 prior anesthetics, before his neck symptons, in the past 2 years resulted in him being told by 2 separate anesthesiologists that he was difficult to intubate.

He is kind of "thick" in the neck, but appears to be mask ventilateable.

How would everyone get this guy anesthetized for his surgery?

Glycopyrrolate .2 mg IV in holding.

midazolam 2-5 mg IV, to the OR, 02 at max, sevoflurane inhaled induction, once he's asleep put in a big nasal airway coated with lidocaine jelly with epi, keep him breathing on his own, once he's deep enough, take the mask off, take out the nasal airway, place the 7.0 ETT through the now-anesthetized nasal mucosa into the oropharynx (not too far though), snake the pedi bronchoscope through the ETT, look for the moving white things, steer your scope through them like you're playing X-box, bury it, push the ETT over your buried bronchoscope. Piece of cake.

 

[Disse]

Reconfirm airway exam, dig for as many details as you can about his previous difficult intubations (..trach scar?..) and ask the standard OSA questions ("Do you snore? Are you tired throughout the day? blah blah blah).

If there is the suspicion of OSA is high or present proceed with awake FOB.
Premedicate, as one of my attendings likes to say, early and often. Many folks who think they wouldn't never tolerate an awake intubation do surprisingly well once the orange & blue have started. If you're really concerned about this guy obstructing you can use precedex, start the gtt early or bolus if not as much time. The stuff works wonders.

Also, don't forget the antisialagogue--EARLY!!!! This can make or break a difficult FOB.

Of course, premedication is only half the battle. Topicalize, topicalize, topicalize.. and don't use that benzocaine spray stuff. 4% lido by those cheapo atomizers & "paint" the oropharynx with the cherry flavored lido gel. For the trachea can either perform a transtracheal block (my preferred), or inject 4% lido through the FOB onto the cords when visualized (not my favorite as they can cough, you can lose the view and if it was tough to get there once its nice not to have to have to get there again).


If no suspicion of OSA consider proceeding with intubation post induction. Again, if you're afraid they may obstruct you can do an inhalational induction and take over their respirations. Once you have confirmed that you can mask ventilate you can administer your NMB agent and proceed with an asleep FOB (this guy doesn't have a history or worry for mediastinal mass so worries of compression post NMB don't seem to be in the picture...of course, you don't necessarily need NMB if the patient is nice and deep).

Outside of these options there are the FAST Trac LMAs--can do these either awake or asleep as well and with or without FOB guidance.

Lastly, have a good assistant who knows how to do jaw thrust--nothing worse than not being able to see anything because all the tissues are collapsed.

 

[jetproppilot]

A guy comes to our OR for ACD/F. He is otherwise healthy. Airway exam shows limited range of motion in the cervical spine, and marginal mouth opening.

He reports that 2 prior anesthetics, before his neck symptons, in the past 2 years resulted in him being told by 2 separate anesthesiologists that he was difficult to intubate.

He is kind of "thick" in the neck, but appears to be mask ventilateable.

How would everyone get this guy anesthetized for his surgery?

OR, dude, if you don't wanna go through all that crap, propofol/sux, and take a look. Chances are you can at least get a boojie (sic?) in and thread the tube over it. Worse case scenerio you cant get the boojie in, ventilate 'til the sux wears off, crack the sevo, get him breathing again (easier to fiberoptic when the cords are moving as you know), and put the scope through the moving white things.

Easier than the above idea, and will probably work.


OR, put a fast-trach LMA in and put the tube through it. Technically more difficult than is publisized in my opinion, but you can always put the scope in the LMA if you have problems threading the tube through the LMA.

 

[Disse]

OR, dude, if you don't wanna go through all that crap, propofol/sux, and take a look. Chances are you can at least get a boojie (sic?) in and thread the tube over it. Worse case scenerio you cant get the boojie in, ventilate 'til the sux wears off, crack the sevo, get him breathing again (easier to fiberoptic when the cords are moving as you know), and put the scope through the moving white things.

Easier than the above idea, and will probably work.


OR, put a fast-trach LMA in and put the tube through it. Technically more difficult than is publisized in my opinion, but you can always put the scope in the LMA if you have problems threading the tube through the LMA.

If you're going to put them asleep priot to intubation why not simply do a FOB from the start (i.e. induce, mask, FOB)? Its quick, easy and no worries about torque on the neck?

In my limited experience, while the whole propofol/sux take a look thing usually works, when it doesn't it seems to add a whole lot more stress than necessary especially since there are so many other options (that, despite longwinded posts, don't take all that much more time to do).

 

[supahfresh]

Jet,

Is the glycopyrrolate only to decrease secretions? How much in advance to you have to give it?

also, once you anesthetize the nostril, how big ett can you stick up someone's nose?

 

[zippy2u]

Just do an awake nasal fiberoptic and don't burn your bridges. Robinul 0.1mg (don't need to get his heart rate up).1 mg of versed and 1 ml of fentanyl Trantracheal with 22G IV needle using 3 ml of 4% lido and make pt. cough. Get a 5 cc syringe and place 4 cc of 4% lido and 1cc of 1% phenylephrine and shake. Attach atomizer and gently anesthetize and vasoconstrict the nasal passages. 7.0 ETT is loaded and not placed in the nose-- only the FOB. I want no chance for blood. Right nare. Insert until see rings and slide lubricated ETT in. Confirm ET CO2 and bang with Dip. I did one last week with a guy who had trismus due to infection. Start to finish --5 minutes. Ole Zip don't play, the CRNA was impressed to say the least. ----Zippy

 

[jetproppilot]

Jet,

Is the glycopyrrolate only to decrease secretions? How much in advance to you have to give it?

also, once you anesthetize the nostril, how big ett can you stick up someone's nose?

Yeah dude, the glycopyrrolate really makes a difference...the less spit on the end of your scope means you'll see better with less suctioning needed. I've always given .2mg....Zippy Lighter (thats pretty funny, huh?) said to give .1mg...cant really argue with that. Just give SOME 15-20 minutes before your procedure.

Typically after pulling the nasal airway you can get a 7.0 in...a good trick is to soften up the ETT by placing it in a warm bottle of sterile water/saline 10 minutes or so B4 you need it. Theres usually those 1 liter bottles in the warmer somewhere in the OR where the blankets are warmed. Works well to soften the tube which means less chance of a nosebleed.

Using precedex or a sevo mask induction you can get great fiberoptic intubation conditions without all the hassle of laryngeal/transtracheal blocks. I've done many both ways....both work, its just that the precedex or sevo inhalation induction is less hassle. But always remember in anesthesia theres usually no correct way....as long as it works and the patient does fine (as eloquently said by Military previously), THAT was the right way.

 

[rn29306]

Just do an awake nasal fiberoptic and don't burn your bridges. Robinul 0.1mg (don't need to get his heart rate up).1 mg of versed and 1 ml of fentanyl Trantracheal with 22G IV needle using 3 ml of 4% lido and make pt. cough. Get a 5 cc syringe and place 4 cc of 4% lido and 1cc of 1% phenylephrine and shake. Attach atomizer and gently anesthetize and vasoconstrict the nasal passages. 7.0 ETT is loaded and not placed in the nose-- only the FOB. I want no chance for blood. Right nare. Insert until see rings and slide lubricated ETT in. Confirm ET CO2 and bang with Dip. I did one last week with a guy who had trismus due to infection. Start to finish --5 minutes. Ole Zip don't play, the CRNA was impressed to say the least. ----Zippy

Has the old trick of using 4mls of 4% nebulized lido fallen out of view in light of the atomizer? I understand that at least with the atomizer you can do lido + phenylephrine but have any of you had any luck or perhaps not so good luck with a lido neb + and phenylephrine gtts in the intended nose? Perhaps you might get the phenyl further back in the nasopharynx and also maybe get better absorption by the tissues given the relatively larger surface area that the atomizer provides.

 

[militarymd]

One of my associates went ahead and induced GA with Propofol 200 mg/ Fentanyl 200mcg/ and sux 200mg.

Able to mask ventilate, but failed intubation after 3 DLs...a/w now bloody and mask is difficult, and sux has worn off.

What would you guys do now?

 

[Disse]

One of my associates went ahead and induced GA with Propofol 200 mg/ Fentanyl 200mcg/ and sux 200mg.

Able to mask ventilate, but failed intubation after 3 DLs...a/w now bloody and mask is difficult, and sux has worn off.

What would you guys do now?

Depending on availability of equipment/help:
A) If mask ventilation is still adequate could either suction very well and attempt a FOB (if not comfortable with the scope... this isn't the time to try).

OR

B) Attempt Fast Trac LMA. Again, this would depend on comfort/experience but advantage would be in should (possibly) help with ventilating the patient until the airway is truly secured (again, if an FOB is available this could be of benefit).

Of course, the board answer would most likely be wake the patient up, reevaluate needs/options and proceed from there.

 

[jetproppilot]

One of my associates went ahead and induced GA with Propofol 200 mg/ Fentanyl 200mcg/ and sux 200mg.

Able to mask ventilate, but failed intubation after 3 DLs...a/w now bloody and mask is difficult, and sux has worn off.

What would you guys do now?

Wake em up, dude. You are teetering on the perilous edge of losing an airway. Time to regroup. This is an elective case.

Sometimes you can look a cuppla times without traumatizing alotta stuff. Sometimes you look a cuppla times and blood/spit is everywhere. This is a dynamic business, bro. The Force was not with your partner on those intubation attempts. Nobody's fault, and nobody has done anything wrong.....yet. Like I posted previously, I probably would've done the same thing.

BUT IT IS AT THIS MOMENT IN TIME where the decision you make could literally be life and death. You're backed up in a corner. You've elected the induction-and-look option and it hasnt worked.

A good poker player knows when to hold 'em, and when to fold 'em.

Time to wake him up. Your opponent just got a flush on the river, and if you elect to proceed at this point, it may cost you everything.

 

[militarymd]

I got called into the room by the OR nurse...She said please come and help...so I did.

I said "wake the patient up"...they said..."we're trying"

The 4 CCs of fentanyl delayed the wake up significantly.....I took over the airway when I came in to the room.

The mask was difficult....Patient was rigid...and breathing maybe 4 times a minute....sats were in the low 80's than mid 70's....that's when I was told "we gave 4 cc's of fentanyl"....

I gave 0.2 mg of Narcan...to wake the dude up.

 

[militarymd]

So, here's my question to all you experienced practitioners out there.

Would any of you give 200 mcg of fentanyl to a patient with a potentially difficult to intubate a/w where you may have to wake the patient up?

When I sleep someone to "take a look" because I think I can do it, but am not 100% sure....I use no benzo...no narcotic...only an IV hypnotic (like propofol)....+/- on sux and look....If I don't see what I need, I wake the patient up....I take only 2 looks ...one mac/ one miller...and I call it a day.

 

[zippy2u]

Who's got time for the pt. to breathe nebulized 4% lido? Not Homey -- surgeon's tappin toes and rollin eyes! The throw away atomizer is like a 6 inch IV tubing doo hickey where one end you can attach a syringe. The other end atomizes the liquid you have in the syringe. You gradually insert the entire flexible tubing in the pt.'s nare as you continually inject the syringe, atomizing the 4% lido and 1% phenylephrine. The flexible atomizer can anesthetize and vasoconstrict the nasal passage in 1 minute. Zippy loves zippy tools! ---Zippy

 

[jetproppilot]

So, here's my question to all you experienced practitioners out there.

Would any of you give 200 mcg of fentanyl to a patient with a potentially difficult to intubate a/w where you may have to wake the patient up?

When I sleep someone to "take a look" because I think I can do it, but am not 100% sure....I use no benzo...no narcotic...only an IV hypnotic (like propofol)....+/- on sux and look....If I don't see what I need, I wake the patient up....I take only 2 looks ...one mac/ one miller...and I call it a day.

HA!!!!! VER, VERY important, frequently overlooked issue. ALL YOU BUDDING ALAN KAYE CHAIRMAN WANNABES OUT THERE, LISTEN UP!!!!

Congrats...you've IDed a difficult airway, and have elected to propofol/etom plus sux induction just in case. BUT DONT FORGET everything you give in the meantime, albeit normal for a GA, may defeat your purpose!!!!

SO, PAY ATTENTION TO THE BENZO/OPIOD ADMINISTRATION. Minimize or eliminate. That stuff will make your sux decision non influential. What good is using sux if you've saturated the opiod receptors with fentanyl so the pt doesnt breathe???

AND,,, (very important, grasshoppas),,, PAY ATTENTION TO YOUR SUX DOSE. Gotta difficult airway? Dont give alotta sux. Minimize your dose. Your goal is to render the pt motionless for a few quick seconds so your clinically superior skills can take a look. And if you dont like what you see, 100 mg will wear off faster than 200mg.
Remember this, dudes/dudettes.

 

[jetproppilot]

HA!!!!! VER, VERY important, frequently overlooked issue. ALL YOU BUDDING ALAN KAYE CHAIRMAN WANNABES OUT THERE, LISTEN UP!!!!

Congrats...you've IDed a difficult airway, and have elected to propofol/etom plus sux induction just in case. BUT DONT FORGET everything you give in the meantime, albeit normal for a GA, may defeat your purpose!!!!

SO, PAY ATTENTION TO THE BENZO/OPIOD ADMINISTRATION. Minimize or eliminate. That stuff will make your sux decision non influential. What good is using sux if you've saturated the opiod receptors with fentanyl so the pt doesnt breathe???

AND,,, (very important, grasshoppas),,, PAY ATTENTION TO YOUR SUX DOSE. Gotta difficult airway? Dont give alotta sux. Minimize your dose. Your goal is to render the pt motionless for a few quick seconds so your clinically superior skills can take a look. And if you dont like what you see, 100 mg will wear off faster than 200mg.
Remember this, dudes/dudettes.

Nice reminder to a commonly committed clinical mistake. Minimize benzos/opiods in a difficult airway, and minimize your sux dose, so the dude will start breathing again if you have a problem.

Nice post, Chi. 👍

 

[militarymd]

Nice reminder to a commonly committed clinical mistake. Minimize benzos/opiods in a difficult airway, and minimize your sux dose, so the dude will start breathing again if you have a problem.

Nice post, Chi. 👍

Thanks....

I think I may have to have an educational session with my associate.

 

[jetproppilot]

One of my associates went ahead and induced GA with Propofol 200 mg/ Fentanyl 200mcg/ and sux 200mg.

Able to mask ventilate, but failed intubation after 3 DLs...a/w now bloody and mask is difficult, and sux has worn off.

What would you guys do now?

Uh, dude, I noticed you said one of my "associates" instead of one of my "partners". Freudian subliminal slip? I think not. You're obviously pissed off that your "associates" are holding you back from the holy grail of anesthesia....satisfied/safe patients, happy surgeons, and a high 6 figure income for you.

We need to hook up, bro. We could bring down the house of this business together. Throw in UT, you-the-Force-ninja-warrior, and me-the florida-cracka, and we'd be retired in 2015. 😀

 

[jetproppilot]

Uh, dude, I noticed you said one of my "associates" instead of one of my "partners". Freudian subliminal slip? I think not. You're obviously pissed off that your "associates" are holding you back from the holy grail of anesthesia....satisfied/safe patients, happy surgeons, and a high 6 figure income for you.

We need to hook up, bro. We could bring down the house of this business together. Throw in UT, you-the-Force-ninja-warrior, and me-the florida-cracka, and we'd be retired in 2015. 😀

Reminds me how important the THREE A's of anesthesia are:

1) Amicability: good personality, leaves home problems at home, keeps the environment light with staff and surgeons alike
2) Availability: Minimize obstructionalism. Instead of saying "whats wrong here? GEEZ....the sodium is low....I don't know...", SAY TO YOURSELF, WHAT CAN I DO TO GET THIS CASE DONE???? IS THIS NEBULOUS LAB CRAP IN AN ASYMPTOMATIC PATIENT REALLY IMPORTANT???

Surgeon calls the OR at 5:30 pm..."Hey Jet...just saw Ms Migilllicutty in my office and I really need to do something..." You say, "GREAT, DUDE. I'm SENDING FOR YOUR PATIENT NOW. I'LL SEE YOU WHEN YOU GET HERE. LATER, DUDE."

....Instead of, "GEEZ, DUDE, DO you really have to do it tonite? Did you order a cbc/chem 7/pt-ptt/fibrinogen level/BMP/echo/heart cath? I'll do the case when hell freezes over and all those useless labs are posted."

3)ABILITY: see above posts for the ABILITY to practice PRIVATE-PRACTICE-MINIMAL-OBSTRUCTIONALISM-ANESTHESIA. Get the cases done. Quick. Tell the surgeon you're ready whenever they are. Talk about porsches/sportbikes/etc in the OR instead of complaining about the dude posting a 6pm case.
Yes, you reserve the right to cancel/delay if it doesnt look good. But believe me, folks, it is RARE that a case cant be done likkity split. Lose the obstructionalist stance and you'll gain with more cases/satisfied surgeons...and you can do it SAFELY.

Believe me. Youll be happy, the surgeons will be happy, the OR staff will be happy, and you'll have to open another bank account.

 

[militarymd]

Reminds me how important the THREE A's of anesthesia are:

1) Amicability: good personality, leaves home problems at home, keeps the environment light with staff and surgeons alike
2) Availability: Minimize obstructionalism. Instead of saying "whats wrong here? GEEZ....the sodium is low....I don't know...", SAY TO YOURSELF, WHAT CAN I DO TO GET THIS CASE DONE???? IS THIS NEBULOUS LAB CRAP IN AN ASYMPTOMATIC PATIENT REALLY IMPORTANT???

Surgeon calls the OR at 5:30 pm..."Hey Jet...just saw Ms Migilllicutty in my office and I really need to do something..." You say, "GREAT, DUDE. I'm SENDING FOR YOUR PATIENT NOW. I'LL SEE YOU WHEN YOU GET HERE. LATER, DUDE."

....Instead of, "GEEZ, DUDE, DO you really have to do it tonite? Did you order a cbc/chem 7/pt-ptt/fibrinogen level/BMP/echo/heart cath? I'll do the case when hell freezes over and all those useless labs are posted."

3)ABILITY: see above posts for the ABILITY to practice PRIVATE-PRACTICE-MINIMAL-OBSTRUCTIONALISM-ANESTHESIA. Get the cases done. Quick. Tell the surgeon you're ready whenever they are. Talk about porsches/sportbikes/etc in the OR instead of complaining about the dude posting a 6pm case.
Yes, you reserve the right to cancel/delay if it doesnt look good. But believe me, folks, it is RARE that a case cant be done likkity split. Lose the obstructionalist stance and you'll gain with more cases/satisfied surgeons...and you can do it SAFELY.

Believe me. Youll be happy, the surgeons will be happy, the OR staff will be happy, and you'll have to open another bank account.

You read my mind 👍

 

[militarymd]

Thanks....

I think I may have to have an educational session with my employee.

let me rephrase

 

[Noyac]

All the above ideas are good in the right hands. Personally, I like the Fastrach LMA's but with any question of ability to ventilate I go with the awake FOB. However, the Bullard is another great tool at our disposal (especially in cervical cases).

 

[Monty Python]

...... the THREE A's of anesthesia are:

1) Amicability:
2) Availability:
3) ABILITY: .

The four A's of anesthesia, from the surgeon's perspective when something goes wrong in the OR or post-op.

A ssess
A ct
A ccuse A nesthesia

 

[Tenesma]

whatever happend to the awake DL??? I used to do those all the time... If I can DL the guy (if he cooperates) and I see part of cords, then go to sleep then intubate.... otherwise it is an awake intubation

another thing you can do is do a quick nasal laryngoscopy w/ a pedi wand - if the path looks wide open and clear... put him to sleep

 

[militarymd]

whatever happend to the awake DL??? I used to do those all the time... If I can DL the guy (if he cooperates) and I see part of cords, then go to sleep then intubate.... otherwise it is an awake intubation

another thing you can do is do a quick nasal laryngoscopy w/ a pedi wand - if the path looks wide open and clear... put him to sleep

I believe it went out the door when the LMAs of various types came in the door.

 

[jetproppilot]

whatever happend to the awake DL??? I used to do those all the time... If I can DL the guy (if he cooperates) and I see part of cords, then go to sleep then intubate.... otherwise it is an awake intubation

another thing you can do is do a quick nasal laryngoscopy w/ a pedi wand - if the path looks wide open and clear... put him to sleep

Bottom line here is, uh, and call this cocky if you wish but, if someone comes to our institution with a "difficult intubation" history, unless I know the laryngoscopist, I take it with a grain of salt. Laryngoscopy prowess is so varied that someone not deft with the Miller 2 could fail X 2-3 attempts, and the pt is from-then-on labeled "difficult intubation".

Case in point...dude came to our facility last week...labeled "difficult intubation" by previous laryngoscopists...yeah, he had a small chin, but other than that, he opened wide, Mal 2.

No opiods, 1 mg midaz, propofol 150mg, sux 100mg....Yvette the Srna smoked it with a Miller 3 blade.

I dont think a hx of difficult intubation means automatic awake intubation. There are very, very few people out there that my team and I cannot intubate. If someone I know who is a great laryngoscopist, say on Mitch L. CRNA's level, or my level, or a cuppla my partner's level, than yes, I'll walk the line. Otherwise you're getting induced with a "wake up quick" induction, just in case.

 

[joshmir]

to the council-

now at the CA-1 level, I have yet to see someone fully reversed with narcan. i've heard it can be an unpretty sight, with significant co-morbidities.

in someone with an anticipated difficult airway, and you are dosing propofol/etom +sux for a "quick look", is there *any* significant advantage to adding some fentanyl that can be reversed?

pros/cons of adding a little breathing-down-sevo to the mix? i'm sure it will "get 'm deeper" for the quick look, and be less of an impediment to the return of respirations...

I'm asking this b/c I'm wondering if reversable fentanyl or sevo can allow you to get away with giving less propofol+sux...

(and i'm assuming that if tachycardia/hypertension could possibly be very detrimental, you'd be doing it awake...)

thanks...

 

[2ndyear]

Does anyone use cocaine for the nares? I've used the 4% liquid twice (on patients of course) and it seems to provide pretty good vasoconstriction, anesthetic, and likely a little buzz.

My other question: What is wrong with just some propofol, intubating LMA, and scope through the LMA? Is this a bad deal on an anticipated difficult airway if you can't ventilate through the LMA? Just seems real fast and avoids a lot of the topicalizing stuff.

 

[Worldtraveler]

I recently used 40mg of sux during induction of an average adult which provided enough muscle relaxation (although a little slower to take effect) as as an example of the potency of sux. I agree that large doses of sux are rarely needed.

 

[Noyac]

I recently used 40mg of sux during induction of an average adult which provided enough muscle relaxation (although a little slower to take effect) as as an example of the potency of sux. I agree that large doses of sux are rarely needed.

There are some reports out there that low dose sux causes more myalgia then the larger doses. But its been a really long time since I have had anyone complain of myalgia. Mostly cause I rarely use sux.

 

[jetproppilot]

to the council-

now at the CA-1 level, I have yet to see someone fully reversed with narcan. i've heard it can be an unpretty sight, with significant co-morbidities.

in someone with an anticipated difficult airway, and you are dosing propofol/etom +sux for a "quick look", is there *any* significant advantage to adding some fentanyl that can be reversed?

pros/cons of adding a little breathing-down-sevo to the mix? i'm sure it will "get 'm deeper" for the quick look, and be less of an impediment to the return of respirations...

I'm asking this b/c I'm wondering if reversable fentanyl or sevo can allow you to get away with giving less propofol+sux...

(and i'm assuming that if tachycardia/hypertension could possibly be very detrimental, you'd be doing it awake...)

thanks...

Youll make your life easier by avoiding/minimizing opiods in this scenerio.

Use esmolol/labetolol if you need to attenuate hemodynamic response to laryngoscopy.

You mentioned sevo. Great trick.

Actually you good do the whole procedure with sevo. Do an inhalation induction (just like a kid), get'em deep, take a look....works great for planned fiberoptics..since the cords continue to move, and moving cords make it easier to see where you're at. Same concept with dexmetatomidine.

 

[jetproppilot]

.

 

[VolatileAgent]

Use esmolol/labetolol if you need to attenuate hemodynamic response to laryngoscopy.

yeah, i don't know why this isn't more routinely done. you see old/sick patients get 100mcg (or more) of fentanyl pre-induction and then you're chasing their bp with pressors for the first 40 minutes of the case. a little pre-induction squirt of esmolol is a great trick.

 

[Planktonmd]

One of my associates went ahead and induced GA with Propofol 200 mg/ Fentanyl 200mcg/ and sux 200mg.

Able to mask ventilate, but failed intubation after 3 DLs...a/w now bloody and mask is difficult, and sux has worn off.

What would you guys do now?

At this point wake him up, do it another day AWAKE FIBEROPTIC.




This guy is awake fiberoptic intubation in my book.

 

[VentdependenT]

Glycopyrrolate .2 mg IV in holding.

midazolam 2-5 mg IV, to the OR, 02 at max, sevoflurane inhaled induction, once he's asleep put in a big nasal airway coated with lidocaine jelly with epi, keep him breathing on his own, once he's deep enough, take the mask off, take out the nasal airway, place the 7.0 ETT through the now-anesthetized nasal mucosa into the oropharynx (not too far though), snake the pedi bronchoscope through the ETT, look for the moving white things, steer your scope through them like you're playing X-box, bury it, push the ETT over your buried bronchoscope. Piece of cake.

Why not just go awake my man? Like the zippster said, transtracheal 4% 5ml, nasal neosynephrine/cocaine plegets lido 4% atomizer, 2 versed, 1 fentanyl.

Masking down the patient with sevo do you worry bout laryngospasm in this guy if he's too light when you start worken the tube in?

Would any of you just start off with an awake ORAL FOI? This would have been my first choice. The surgeon can kiss my ASS if it takes an additional 5 minutes. I'll do the case, but I aint losing the airway.

Thanks for the clinical bit about fentanyl/benzo use in a difficult airway when you choose to go to sleep. Push LIDO IV if you wanna blunt response to laryngoscopy. Give the fentanyl later. Thanks again MIL!

 

[VentdependenT]

Wake em up, dude. You are teetering on the perilous edge of losing an airway. Time to regroup. This is an elective case.

Sometimes you can look a cuppla times without traumatizing alotta stuff. Sometimes you look a cuppla times and blood/spit is everywhere. This is a dynamic business, bro. The Force was not with your partner on those intubation attempts. Nobody's fault, and nobody has done anything wrong.....yet. Like I posted previously, I probably would've done the same thing.

BUT IT IS AT THIS MOMENT IN TIME where the decision you make could literally be life and death. You're backed up in a corner. You've elected the induction-and-look option and it hasnt worked.

A good poker player knows when to hold 'em, and when to fold 'em.

Time to wake him up. Your opponent just got a flush on the river, and if you elect to proceed at this point, it may cost you everything.

There it is boys and girls. The bottom line.

Thanks Jet.

Sometimes we (myself DEFINITELY included) can get so caught up in trying to nail the intubation that we forget this is not only an option but a valid pathway to follow in the ASA difficult airway algorythm (spel?). Now that this dude's tough to ventilate you could slap in an LMA and try to bag him through that until he wakes up.

Another option could be a FastTrach but I've had limited success with that device.

But further attemts at intubation will most likely FAIL at this time and will worsen airway edema compounding the ventilation difficulty. The airway is all juicy now and the fiberoptic wont do JACK for you now.

 

[Pooh & Annie]

There it is boys and girls. The bottom line.

Thanks Jet.

Sometimes we (myself DEFINITELY included) can get so caught up in trying to nail the intubation that we forget this is not only an option but a valid pathway to follow in the ASA difficult airway algorythm (spel?). Now that this dude's tough to ventilate you could slap in an LMA and try to bag him through that until he wakes up.

Another option could be a FastTrach but I've had limited success with that device.

But further attemts at intubation will most likely FAIL at this time and will worsen airway edema compounding the ventilation difficulty. The airway is all juicy now and the fiberoptic wont do JACK for you now.

I hope I always have the cajones to do the right thing and call it quits when that's the rght way to go. I bet this is tough for private practice guys when they're starting out, especially because of concerns that they'll get the bad rep from their partners and the surgeons. (Although killing the pt will probably earn an even worse rep).

 

[Noyac]

I hope I always have the cajones to do the right thing and call it quits when that's the rght way to go. I bet this is tough for private practice guys when they're starting out, especially because of concerns that they'll get the bad rep from their partners and the surgeons. (Although killing the pt will probably earn an even worse rep).

Your right, it is a tough situation to be in as a new grad. It can cause some doubt among your peers that may take time to change. But if you are solid and have the skill you will change this doubt. Remember, you can always call in your partners to give you a hand and help with your decision. they will probably attempt the airway and if successful then great if not then you don't look s bad. And everyone has a point in time when they can't accomplish a task for one reason or another while someone else seems to be able to get it done. Don't worry about it cause if you are around long enough you will return the favor.

 

[Dejavu]

First, someone mentioned an impatient surgeon breathing down your neck. Is he going to be standing behind you in court, admitting that he pressured you into acting hastily? I don't think so. Tell him to go breathe out in the hallway and let you do your job.

Secondly, I agree with the poster who said you have to take a history of difficult intubation with a grain of salt, but when two different people report difficulties, the story gains credibility.

Here at Mayo, this guy has his airway anesthetised slowly, sedated and gets an awake fiberoptic. It is the gold standard of airway management after all and you don't want to hear plaintiff's attorney say "So, doctor, tell the jury why, knowing full well the pt's history of difficult intubations, you recklessly went ahead and put him to sleep and hoped for the best instead of using the safest possible approach."

Also, for you about to take the oral boards, I would bet the better answer is not "put him to sleep and see what happens". I would answer, given the history, that an awake fiberoptic is the safest approach. Otherwise, the examiners will take you down many streets you don't want to go down.

 

[Frank Rizzo]

Glycopyrrolate .2 mg IV in holding.

midazolam 2-5 mg IV, to the OR, 02 at max, sevoflurane inhaled induction, once he's asleep put in a big nasal airway coated with lidocaine jelly with epi, keep him breathing on his own, once he's deep enough, take the mask off, take out the nasal airway, place the 7.0 ETT through the now-anesthetized nasal mucosa into the oropharynx (not too far though), snake the pedi bronchoscope through the ETT, look for the moving white things, steer your scope through them like you're playing X-box, bury it, push the ETT over your buried bronchoscope. Piece of cake.

I had a similar case a few weeks ago, and did it almost the same way. Two differences, one small, one big: 1. I also pretreated with some Afrin. 2. Did it awake. I didn't want to take the risk of putting him down first. Used some versed to get him to the point of not caring, added some atomized nasal 4% lido and some lido jelly on the nasal trumpet then placed the tube to oropharynx, drove the scope home, and slide the ETT down the scope the rest of the way

 

[Frank Rizzo]

Nevermind, read a little further and seen Zippy beat me to it, awake FOI, atomizer, and all. Good stuff.

 

[2ndyear]

Maybe you all know this one, but it was new to me:
Take whatever sized nasal trumpet you are going to use, now cut it lengthwise (from proximal to distal). Lube it with lido jelly, place it, scope goes in and there you are, no messing up the turbinates or anything and you're positioned nicely in the pharynx. Then it just slides out and over the bronchoscope and you can proceed below the cords, place the tube and so on.

 

[GasMan72]

Just do an awake nasal fiberoptic and don't burn your bridges. Robinul 0.1mg (don't need to get his heart rate up).1 mg of versed and 1 ml of fentanyl Trantracheal with 22G IV needle using 3 ml of 4% lido and make pt. cough. Get a 5 cc syringe and place 4 cc of 4% lido and 1cc of 1% phenylephrine and shake. Attach atomizer and gently anesthetize and vasoconstrict the nasal passages. 7.0 ETT is loaded and not placed in the nose-- only the FOB. I want no chance for blood. Right nare. Insert until see rings and slide lubricated ETT in. Confirm ET CO2 and bang with Dip. I did one last week with a guy who had trismus due to infection. Start to finish --5 minutes. Ole Zip don't play, the CRNA was impressed to say the least. ----Zippy

This reminds me of an M and M from a couple months ago. Big guy (BMI>50) comes to ER for SOB. Has hx of OSA. Gets roomed, put on O2 by NC, ER doc walks away. Med student goes to get a full history 10 minutes later and the guy is unresponsive. O2 sat still around 92, he's breathing and has a pulse, but will not wake up. Long story short, the ER residents try to intubate and can't. He starts desatting even on 100% non rebreather, down to O2 sats of like 80. The ER calls ENT!!!! for a nasal fiberoptic approach! No one knows why the didn't Anesthesia. The ENT 2nd year resident comes down and is able to finally get the guy tubed, but it takes forever and he continued to desat and he died a few days later. Now mind you, he prolly would have died regardless, but why call ENT when Gas is on and has done plenty of fiberoptic intubations? No one had a good answer for why the wrong service was called. And the guy was only 35 or so....

But I guess with a bad outcome likely, it's better just to have your name off the chart.

EJ

 

[Planktonmd]

This reminds me of an M and M from a couple months ago. Big guy (BMI>50) comes to ER for SOB. Has hx of OSA. Gets roomed, put on O2 by NC, ER doc walks away. Med student goes to get a full history 10 minutes later and the guy is unresponsive. O2 sat still around 92, he's breathing and has a pulse, but will not wake up. Long story short, the ER residents try to intubate and can't. He starts desatting even on 100% non rebreather, down to O2 sats of like 80. The ER calls ENT!!!! for a nasal fiberoptic approach! No one knows why the didn't Anesthesia. The ENT 2nd year resident comes down and is able to finally get the guy tubed, but it takes forever and he continued to desat and he died a few days later. Now mind you, he prolly would have died regardless, but why call ENT when Gas is on and has done plenty of fiberoptic intubations? No one had a good answer for why the wrong service was called. And the guy was only 35 or so....

But I guess with a bad outcome likely, it's better just to have your name off the chart.

EJ

Many ER guys are being taught that they are as good as anesthesiologists at managing airways and they feel insulted if they have to call anesthesia.
So this is probably why they called ENT.
It's funny but it's true.

 

[Fah-Q]

He starts desatting even on 100% non rebreather, down to O2 sats of like 80. The ER calls ENT!!!! for a nasal fiberoptic approach! No one knows why the didn't Anesthesia. The ENT 2nd year resident comes down and is able to finally get the guy tubed, but it takes forever and he continued to desat and he died a few days later. Now mind you, he prolly would have died regardless, but why call ENT when Gas is on and has done plenty of fiberoptic intubations? No one had a good answer for why the wrong service was called. And the guy was only 35 or so....
EJ

The ENT resident should have known to call anesthesia as soon as he/she realized they were not involved yet. I'm an ENT resident and had a similar situation once. When I realized nobody had called anesthesia yet I was simply shocked. The steam coming from my ears let the ICU jokers know I would sure appreciate anesthesia being there with the handy airway cart.

 

[Carm]

The cavalier attitude that many providers have that have done enough airways to be "proficient" but not enough to see how things can go badly in a hurry is interesting.

Both IM and ER at my institution act like it is an insult if anesthesia is standing by to either assist or be ready to take over one of their airways.

When I respond to code blue the medicine team is usually already there (they are much closer to the floor) and inevitably one of the IM residents is standing at the head of the bed. This is fine. In fact most of us (anesthesia residents) are OK with them taking a look if the patient appears to be a reasonable candidate.

They are usually pretty jittery just because they have not had as much experience. I try to make sure the nurse get things ready like free flowing IV, suction, mask and all the equipment we will need. Basically just offer helpful assistance in a way that does not seem patronizing. If they even look like they are having a difficult time (first tip-off is waving the blade around in the right hand) I will bump them and secure airway.

It always surprises me when one of the aggressive (is that possible) IM residents who is already at the head of the bed yells "We don't need you. we've got the airway" when we walk in the room. This is just inexperience in my opinion. I have probably done several hundred tubes by this point in my CA-1 year, but am always a little more settled when I see a sleepy eyed upper level or staff leaning against the doorway when I go to intubate an emergent airway.

I would think that you would want an expert in the background when you are doing something that you are not trained to do. I can see if the anesthesia doctors are being douche bags about the whole thing, but I for the life of me can't seem to find the source of this righteous indignation when we arrive to help secure airways.

 

[Arch Guillotti]

It always surprises me when one of the aggressive (is that possible) IM residents who is already at the head of the bed yells "We don't need you. we've got the airway" when we walk in the room.

I have had this happen a few times before. One of the times the pts. sats did not get better, his color was terrible and his stomach was blowing up and the ventilation sounded like crap. Dude, come on.

 

[VentdependenT]

I like it when the RT has been moving ZERO air despite pumping the ambu bag frantically because he/she was never taught how to friggen mask a patient or even put in a damn oral airway.

You can push on the chest all ya want but if you aint moving air whats the point.

 

[Arch Guillotti]

I like it when the RT has been moving ZERO air despite pumping the ambu bag frantically because he/she was never taught how to friggen mask a patient or even put in a damn oral airway.

You can push on the chest all ya want but if you aint moving air whats the point.

The RT's that I seem to run into all the time seem to think that the best way of masking someone is to smush it down on the persons face as tight as they can.