difficult mask

[DrBrown]

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The question may seem redundant but here is the situation.

30 y/o female, alcoholic, no other medical history. Scheduled for elective incisional hernia repair (from C/S site) NPO. Slightly overweight. "Never been put to sleep" MP-2, good thyromental distance, good neck mobility, ie based on exam-"easy to inutbate." Everything else is normal. Surgeon wants a general with paralysis. Push 2mg versed, 100 fent, 200 mg propofol- can NOT mask ventillate-at all. Tried repositioning, oral airway-NOTHING. I am a senior resident and I have masked thousands of people- I do not think it was technique. WHAT is YOUR next step? SUX? ROC? LMA? WAKE UP? Take a peek with DL? Seriously this raised a big philisophical question and I would appreciate the input from the more experienced folks.

 

[huktonfonix]

Assuming preoxygenation, I would take a quick look by DL followed by an LMA if DL is unsuccessful. Unless of course you think that this is laryngospasm, in which case a small dose of succinylcholine may be beneficial. I would also check to make sure the oral aiway is appropriately sized and placed and not adding to the obstruction. An equipment malfunction might also be considered.

 

[snowman8]

Assuming preoxygenation, I would take a quick look by DL followed by an LMA if DL is unsuccessful. Unless of course you think that this is laryngospasm, in which case a small dose of succinylcholine may be beneficial. I would also check to make sure the oral aiway is appropriately sized and placed and not adding to the obstruction. An equipment malfunction might also be considered.

I Agree. The question is what to do if you cant intubate or place an LMA. Is it chest wall rigidity from the narcotic? Many would say give a dose of Sux and that will a lot of the time help with mask ventilation and intubation. Altough you are burning bridges. I probably wouldn't push the sux unless the pt is decompensating. I would wait for the pt to start spont. ventilation as long they are stable. If unstable and sux doesn't work...jet vent and prepare for surgical airway!

 

[Planktonmd]

The question may seem redundant but here is the situation.

30 y/o female, alcoholic, no other medical history. Scheduled for elective incisional hernia repair (from C/S site) NPO. Slightly overweight. "Never been put to sleep" MP-2, good thyromental distance, good neck mobility, ie based on exam-"easy to inutbate." Everything else is normal. Surgeon wants a general with paralysis. Push 2mg versed, 100 fent, 200 mg propofol- can NOT mask ventillate-at all. Tried repositioning, oral airway-NOTHING. I am a senior resident and I have masked thousands of people- I do not think it was technique. WHAT is YOUR next step? SUX? ROC? LMA? WAKE UP? Take a peek with DL? Seriously this raised a big philisophical question and I would appreciate the input from the more experienced folks.

If I think a patient is going to be easy to intubate, as the case with your patient, I push the muscle relaxant upfront so I don't have to go through philosophical questions like yours.
Think about it: Every time you can't mask ventilate a patient you are tempted to give a muscle relaxant to see if that will help, then why not do it initially?
If you wait you will waste precious time and limit your options.
If you anticipate a difficult intubation then from the beginning do something different.
In the unlikely event that I find myself in the situation you mentioned I would stick an LMA in and try to ventilate.

 

[powermd]

If I think a patient is going to be easy to intubate, as the case with your patient, I push the muscle relaxant upfront so I don't have to go through philosophical questions like yours.
Think about it: Every time you can't mask ventilate a patient you are tempted to give a muscle relaxant to see if that will help, then why not do it initially?
If you wait you will waste precious time and limit your options.
If you anticipate a difficult intubation then from the beginning do something different.
In the unlikely event that I find myself in the situation you mentioned I would stick an LMA in and try to ventilate.

I gotta go with Plankton here. When I am pushing the drugs, I give fent, lido, prop, plus at least a small dose of sux (like 20 mg) up front. Makes them much easier to mask. Also addresses the question of laryngospasm. Very, very few people are going to be can't intubate, can't ventilate- the odds are overwhelmingly on your side for an easy looking airway.

 

[DrBrown]

the attd pushed roc. I would have pushed sux or just taken a peak with DL...If it looked easy with a quick peak I would have pushed sux. If it looked iffy I would have either woken up pt or done LMA. This of course brings up the debate..The attd felt once you've pushed that much propofol fent and versed you are committed, ie the pt would be hypoxic before they would "wake up" from what you have given them. If you go by that logic then all the pateints should get non depolarizer along with the induction agents, unless of course you are doing RSI for full stomach or they are an antcipated difficult airway....in which case you'd do something awake. I have been taught more commonly to push induction doses and then make sure you can bag before you paralyze. Or, if you can bag but it is suboptimal-maybe give some sux to improve the situation. I know it is rare to get the can't intubate/can't vent but it does happen, and it is the UNanticipated ones (such as this) in which a person could get burned. Thank you for the replies,,,keep them coming

 

[jetproppilot]

If I think a patient is going to be easy to intubate, as the case with your patient, I push the muscle relaxant upfront so I don't have to go through philosophical questions like yours.

BINGO.

Plank busts a cap into another academic anesthesia dogma.

 

[Arch Guillotti]

I have always thought that it was kinda dumb to push the induction agent and then give a test ventilation prior to giving paralytic. 99.9% of the time if there is any trouble ventilating/mask seal, etc. we push paralytic to loosen things up and relax the patient. In the meanwhile you have wasted some potentially valuable time. Pushing the paralytic up front makes your first shot the best shot. I wouldn't push a non-depolarizer up front in someone I really thought that I might have a problem with. Either it would be an awake intubation or a rapid sequence in which you could theoretically bail out of once the prop/sux wore off. I have personally not witnessed this before, but I know of at least two cases where a pt. has been induced then could not be intubated and there was difficulty ventilating them. Subsequently they were woken up, topicalized and fiberoptically intubated. One of the attendings involved is pretty sharp so I can't fault him. The other case involved an attending who is either the dumbest sumbitch ever or has steel balls. I haven't figured out which one yet. I heard that he expected to have difficulty with the airway and even told the pt. that they might have to wake him up if the induction failed. Which it did. Of note, both failed cases involved DL's by either SRNA's and/or not too experienced CRNA's that muddied up the waters a bit.

To answer the OP's original question, I would have given sux. I expect I'll be pushing quite a bit of that next year since it will be my first year out and sphincter tone will be pretty high.

 

[Arch Guillotti]

I gotta go with Plankton here. When I am pushing the drugs, I give fent, lido, prop, plus at least a small dose of sux (like 20 mg) up front. Makes them much easier to mask. Also addresses the question of laryngospasm. Very, very few people are going to be can't intubate, can't ventilate- the odds are overwhelmingly on your side for an easy looking airway.

Interesting. So you give them a little sux, ventilate and then push the non-depolarizer?

 

[drccw]

I keep seeing the words.

Pent. Sux. Tube.

Think about it. RSI if you believe in it- don't ventilate....
Yet there are some people out there who preach "test ventilate... before relaxant.."

To me all inductions are "rapid sequence"
narcotic. hypnotic. relaxant. ventilate while relaxant kicks in... or turn the vent on pressure control while you wait and shoot the ****.... some people call that lazy.. i call that using teh anesthesia machine to its full capabilities...

Test ventilating is wasting time that muscle relaxant could be kicking in....

i'm not a 20 of Sux fan either... it's half-a$$ing it.... give them a good intubating dose...

if I am really worried about an airway.. someone who I think will be difficult to ventilate (note that that is different from difficult to intubate)... I put away pent sux tube and awake fiber. The only people who get the asleep fiber are people that the spine surgeon says "I am worried about his c-spine.. be gentle with your intubation..."

 

[jetproppilot]

Test ventilating is wasting time that muscle relaxant could be kicking in....
"

Again, this is very true, and yet our residency education continues to teach our residents to ventilate before paralyzing indiscriminately.

I'd really like to see some powerful academic Chair STEP UP TO THE MIKE WITH MICATIN with the many, many myths that every resident emerges with, since they were taught that way.

That would eliminate the inevitable private practice transition.....which involves shedding myths.

Another transition that happens....happens because anesthesia is really a surgical subspecialty, not a medical one.

No, we're not surgeons.....I don't mean that.....what I mean is

if you arent deft with your hands, THATS A PROBLEM.

That should be stressed in residency more.....more emphasis on becoming deft with your hands.....being told.....dude, it took you ten minutes to put in that IJ....lemme show you a better way so you can become more efficient.....

.....Residency Dude, it took you twenty minutes to put in that epidural....lets go through what you did so we can make you better....

In other words, hand deftness isnt constructively criticized enough in residency.

Myths are propegated.

Your cancellation rate will be too high initially, since thats how you were taught.

OR management/efficiency isnt even talked about.

AND YET ALOT IS EXPECTED OF YOU ON THE JULY FIRST FOLLOWING YOUR GRADUATION!

Current academic system needs to be modified.

We could be turning out better, faster, stronger residents who LEAP into private practice instead of crawl.

 

[powermd]

Interesting. So you give them a little sux, ventilate and then push the non-depolarizer?

No, small dose of sux with prop, ventilate, then push the rest of the sux.
The small dose of sux would wear off with the propofol if masking were truly difficult. This is an aging habit of mine, and I'm starting to accept the idea that RSI (with or without ventilation) is right for all tube cases, with the exception of the anticipated difficult airways.

 

[Dinkyconductor]

I have always thought that it was kinda dumb to push the induction agent and then give a test ventilation prior to giving paralytic. 99.9% of the time if there is any trouble ventilating/mask seal, etc. we push paralytic to loosen things up and relax the patient. In the meanwhile you have wasted some potentially valuable time.

My algorithm (in someone who seems like a pretty straightforward airway) is propofol - try to ventilate - if can ventilate, give roc, if can't, give sux and ventilate/intubate.

Nothing wrong with giving muscle relaxant up front, but this is why I mask ventilate prior to muscle relaxant - determines whether I give sux or roc.

 

[Arch Guillotti]

My algorithm (in someone who seems like a pretty straightforward airway) is propofol - try to ventilate - if can ventilate, give roc, if can't, give sux and ventilate/intubate.

Nothing wrong with giving muscle relaxant up front, but this is why I mask ventilate prior to muscle relaxant - determines whether I give sux or roc.

That makes sense to me. What doesn't make sense is giving a test ventilation with the thought in your mind that you are going to wake the pt. up if there is difficulty ventilating.

 

[urge]

took you ten minutes to put in that IJ...

took you twenty minutes to put in that epidural....

10 and 20 min are not too bad for said procedures from prep time to tape time(assuming you will also chart for the epidural).

How will you teach speed?

Speed comes from doing many of them.

 

[yes2drugs]

Pardon the intrusion. I read with interest this post. An old attending (now retired) I had in Conn. had a technique that some of you all might find interesting.

In non RSI situations he had me give propofol, lidocaine and fentanyl. Usually 130-150, 50 and 150 or so. Mask them. Any sign of not being totally chilled out, more fentanyl. DL and once I told him that tube was through cords, he gave the Vec or Panc depending on case. This is how he avoided trouble up front. He also believed NMB promoted reflux/aspiration. On the back end, no reversal until pt initiates spont vent. He felt these rules in his OR kept his CRNAs/SRNAs from screwing him or the patient pharmacologically. You thought long and hard before giving nmb or opiate.

 

[Planktonmd]

Pardon the intrusion. I read with interest this post. An old attending (now retired) I had in Conn. had a technique that some of you all might find interesting.

In non RSI situations he had me give propofol, lidocaine and fentanyl. Usually 130-150, 50 and 150 or so. Mask them. Any sign of not being totally chilled out, more fentanyl. DL and once I told him that tube was through cords, he gave the Vec or Panc depending on case. This is how he avoided trouble up front. He also believed NMB promoted reflux/aspiration. On the back end, no reversal until pt initiates spont vent. He felt these rules in his OR kept his CRNAs/SRNAs from screwing him or the patient pharmacologically. You thought long and hard before giving nmb or opiate.

The reason Why the majority of people in this business give muscle relaxants before intubation is because muscle relaxants give you better intubation conditions and could make a borderline airway easier and the intubation less traumatic.
I am not sure that skipping the muscle relaxant from the induction process would provide any advantage in terms of safety, especially if your response to difficult ventilation is going to be: let's give more Fentanyl.

 

[drccw]

intrusion
Pardon the intrusion. I read with interest this post. An old attending (now retired) I had in Conn. had a technique that some of you all might find interesting.

In non RSI situations he had me give propofol, lidocaine and fentanyl. Usually 130-150, 50 and 150 or so. Mask them. Any sign of not being totally chilled out, more fentanyl. DL and once I told him that tube was through cords, he gave the Vec or Panc depending on case. This is how he avoided trouble up front. He also believed NMB promoted reflux/aspiration. On the back end, no reversal until pt initiates spont vent. He felt these rules in his OR kept his CRNAs/SRNAs from screwing him or the patient pharmacologically. You thought long and hard before giving nmb or opiate.

I've done a lot of intubations without NMB....
2 groups of patients...
kids and dead people...

this induction method is half a$$ing it again.....
wishful thinking and it eventually will catch up with you.... this isnt avoiding trouble, it's creating trouble-> did he have many instances of dental damage when patients protested a Mac 3 in their mouth? If this was such an old attending; did he do the same with pentothal? or try doing that with etomidate as well.... I look at our practice as being a couple of components....
amnesia
analgesia
akinesia

all 3 I think are integral to our practice... while you dont need a NMB to achieve all three; you might need either 1) a whole lot of hypnotic or gas or 2) a whole lot of narcotic...

 

[yes2drugs]

He certainly was old (73maybe) I only worked with him for a year. He was the only person who did this in our group of 34 or so CRNAs and 12 docs. I actually give prop, mask, relax, tube. I believe first shot should be best shot. Have stylet in tube, stack pt, lube tube and stylet etc. (you can always back it out some before putting it in if not needed). We almost never used NMB in kids. Especially, no sux in kids if possible.
I owe this doc a debt however. He taught me to tube without relaxant and not to use it as a crutch during the case.

 

[goodoc]

Tubing without relaxent is hardly a "trick" get almost anyone deep enough and you can, as for muscle relaqxent as a crutch I suppose you could view almost any drug as a "crutch".

 

[yes2drugs]

I wish more docs I have worked with had your attitude. I once had a case where the patient said that it took a while for the muscle relaxant to wear off. She had a good airway. I suggested to my doc "why not just tube her without relaxant?" The case was an ortho extremity procedure. "oh No!. The case will last an hour and a half. 30 of Roc will wear off by then". WRONG! extra hour in the OR. NMBs not a crutch? I can't count the times I have been relieved and I tell them "Pt has 4 twitches" No need for NMB in the case. They immediately reach for the ROC. They must be afraid of the pt moving etc.

I am outside the forum for CRNAs so I apologize. I just thought y'all might want to hear how an old Korean anesthesiologist skinned his cats. Promotes thought and makes us look at why we do what we do.

 

[Planktonmd]

I wish more docs I have worked with had your attitude. I once had a case where the patient said that it took a while for the muscle relaxant to wear off. She had a good airway. I suggested to my doc "why not just tube her without relaxant?" The case was an ortho extremity procedure. "oh No!. The case will last an hour and a half. 30 of Roc will wear off by then". WRONG! extra hour in the OR. NMBs not a crutch? I can't count the times I have been relieved and I tell them "Pt has 4 twitches" No need for NMB in the case. They immediately reach for the ROC. They must be afraid of the pt moving etc.

I am outside the forum for CRNAs so I apologize. I just thought y'all might want to hear how an old Korean anesthesiologist skinned his cats. Promotes thought and makes us look at why we do what we do.

I agree with you on the muscle relaxants being overutilized during maintenance of anesthesia by many inexperienced people.
Muscle relaxants can make a crappy anesthetic look good.
The cases where you truly need muscle relaxants are not that common if you know how to give general anesthesia.

 

[coprolalia]

I've gotten to the point where I keep 'em deep and keep 'em narcotized. If you blow them down to 32mmHg of ETCO2, they won't breathe or move. If they have good lungs, everyone breathes when the ETCO2 hits 50-55.

Muscle relaxation is WAY overused. And, it is a rare day for me where someone ain't breathing at the end of the case. I do use muscle relaxation 'til the end on the kidney transplants (mostly because the surgeon bitches like a 4-year-old who just had his lollipop taken away if he sees the abdominal muscles ripple a little on the TV screen). I had one Jedi master anesthesiologist who slapped my hand early on, though, for overusing relaxation. It was a lesson that stuck, and he's been proven right time and time again.

Rarely reverse, despite it being "hospital policy". Last stitch in. Drapes down. I'm pulling the tube. They don't puke or complain in the PACU either, which has won the nurses over for me.

Maybe I just yield "the force" already...

-copro

 

[blotto geltaco]

Rarely reverse, despite it being "hospital policy". Last stitch in. Drapes down. I'm pulling the tube. They don't puke or complain in the PACU either, which has won the nurses over for me.

Maybe I just yield "the force" already...

-copro

You must be the BEST RESIDENT EVER!

 

[coprolalia]

You must be the BEST RESIDENT EVER!

You know what? I hadn't thought of it before, but I guess you're right. I am. Thanks for noticing.

-copro