EP case

[caligas]

44 y.o. Female for a-flutter ablation with a good, fast EP doc (1-1.5 hrs). BMI 50, mallanpati 4. Well controlled GERD. No other comorbidities, says she can lay flat. ep lab is far from main OR.

Plan?

If your answer is precedex (mine was), what do you do when patient starts thrashing 30 minutes in?

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[chocomorsel]

Retrograde intubation!!! Woohoo!!

 

[chocomorsel]

For real though, AFOBI.

 

[chocomorsel]

Too fat for an LMA.

 

[ambiturner]

are they actively ablating or at a point where you can pause? I agree with avoiding an LMA, could try some ketamine but there's a chance that makes things worse

 

[caligas]

are they actively ablating or at a point where you can pause? I agree with avoiding an LMA, could try some ketamine but there's a chance that makes things worse

Yes, ablating, and yes, gave some ketamine and it worked, done about 20 minutes later.

AFOI from beginning may be the correct “board” answer, since if the ketamine had not worked I could have been in trouble (probably would have been stuck with slipping in an LMA so as to maintain spontaneous vent.)

 

[ambiturner]

Yes, ablating, and yes, gave some ketamine and it worked, done about 20 minutes later.

AFOI from beginning may be the correct “board” answer, since if the ketamine had not worked I could have been in trouble (probably would have been stuck with slipping in an LMA so as to maintain spontaneous vent.)

nice - good case to think about and most residencies don't seem to do enough of these marginal type patients that need MAC for GI, EP, etc., even though these are all over the place in actual practice. i was nowhere near prepared because solo attendings and CRNAs did them all at my program.

 

[Noyac]

I can think of at least 3-4 good ways to do this.

 

[Noyac]

I can think of at least 3-4 good ways to do this.

And precedex isn’t one of them.

 

[Urzuz]

Prop/roc/tube, AFOI if actually concerned (MP4 and BMI have lost all meaning to me).

Don't know what all the discussion is about, seems fairly straightforward. Precedex is definitely NOT the answer, on boards or in real life.

 

[narcusprince]

This sounds very simple but what about midazolam for anxiolysis and fentanyl for pain control. What you want is a controlled state without disinhibition. Bring him in 2 of versed and prn fentanyl when they access the groin and during ablation. I don’t ever do any of these cases. How stimulating is the procedure?

 

[caligas]

Prop/roc/tube, AFOI if actually concerned (MP4 and BMI have lost all meaning to me).

Don't know what all the discussion is about, seems fairly straightforward. Precedex is definitely NOT the answer, on boards or in real life.

Truly scary looking airway, like the first I've seen in years that really scared me. Probably good justification for an AFOI, but got away with the MAC.

 

[Twiggidy]

Too fat for an LMA.

not necessarily

 

[Twiggidy]

I can think of at least 3-4 good ways to do this.

yep. and to be quite honest one answer is give little to nothing. A flutter ablation is usually on the right side and sometimes the right patient can get through it with a bit of fentanyl here and there. if little won't do it then you usually head down the road of "a lot" with obese patients and then at that point you manage the airway. in reality, Obese MP 4 isn't always the scariest airway (knock on wood) just like sometimes the little old skinny old lady may have a nightmare airway. once you're at airway management phase, see if he's deep enough to breath with an oral airway and maybe a propofol infusion. if not, put a #5 LMA in and see what you get with him still breathing. while doing these options have one of the cath nurses or somebody at least get the glidescope. FOB intubation is a great skill to have and yes, it's usually the correct board answer, but I also believe that we can tube about 90% or more people no matter how large with a glidescope. i mean, the advent of the glidescope is the reason we're called to less airways nowadays.

Obese patient in the Cath lab is a Monday where I am. It's even more fun when they want to do an echo exam on top of it. that goes back to what another person post on this thread, that is, in today's world, obese patient needing "sedation" for a cath, gi, etc procedure is becoming more and more the norm and people coming out of residency need to learn to handle these cases.

 

[anbuitachi]

Prop infusion low dose, ketamine.

 

[urge]

Patient for a-flutter ablation with a good, fast EP doc (1-1.5 hrs). BMI 50, mallanpati 4. Well controlled GERD. No other comorbidities, says he can lay flat. ep lab is far from main OR.

Plan?

If your answer is precedex (mine was), what do you do when patient starts thrashing 30 minutes in?

Big MAC with your choice of CPAP, oral airway, or an LMA while spontaneously breathing.

 

[sleepallday]

BMI 50? pshhhht

Thats like every other patient i see at my place. As long as he has a decent mouth opening, I would ramp up, use a glidescope and do the case under GA. Personally, I've always felt that inter-incisor distance is a better predicator of a difficult airway.

 

[sheeed]

depends on how the weight is distributed for a lot of these patients. I'd probably tube the patient from the beginning, you can optimize the positioning and intubating conditions prior to the patient being draped and being mid procedur. Last thing I want to do in EP, is urgently call for a glidescope that's two floors down, with a morbidly obese patient not in optimal position.

 

[sheeed]

BMI 50? pshhhht

Thats like every other patient i see at my place. As long as he has a decent mouth opening, I would ramp up, use a glidescope and do the case under GA. Personally, I've always felt that inter-incisor distance is a better predicator of a difficult airway.

BMI 50? pshhhht

Thats like every other patient i see at my place. As long as he has a decent mouth opening, I would ramp up, use a glidescope and do the case under GA. Personally, I've always felt that inter-incisor distance is a better predicator of a difficult airway.

Same thing here. I'm guessing depending on where you practice, BMI of 50+ might not be so common. I'd lean towards GA to start, he has you're probably not gonna be able to ramp up the patient once the procedure has started.

 

[Laryngophed]

depends on how the weight is distributed for a lot of these patients.

I'm with you here. You can be obese, just don't do it above your clavicles and it is usually okay.

 

[caligas]

I don’t think I communicated my concern very well: this airway was SCARY. Airways almost never scare me anymore but this one did. Could not visualize soft palate, prominent teeth, thickest neck you can imagine. So really the question is do you put them through AFOI (probably not simple in this case, anybody on SDN would have it done in 90 seconds but others might find it challenging) and hold everything up in this off site location or do you risk getting into serious trouble in the middle of the case without having secured the airway to begin with. Neither answer is perfect.

In defense of the precedex, it worked great....until it didn’t

 

[WholeLottaGame7]

I don’t think I communicated my concern very well: this airway was SCARY. Airways almost never scare me anymore but this one did. Could not visualize soft palate, prominent teeth, thickest neck you can imagine. So really the question is do you put them through AFOI (probably not simple in this case, anybody on SDN would have it done in 90 seconds but others might find it challenging) and hold everything up in this off site location or do you risk getting into serious trouble in the middle of the case without having secured the airway to begin with. Neither answer is perfect.

Spinal? Would never fly for our EP cases but if yours are 90min...

 

[caligas]

Spinal? Would never fly for our EP cases but if yours are 90min...

Maybe, at least it would keep them from moving their legs, just have to hold their arms down

 

[WholeLottaGame7]

Maybe, at least it would keep them from moving their legs, just have to hold their arms down

Give her a couple turkey legs to work on?

 

[chocomorsel]

not necessarily

This is America. Fatties get tubed in my book. Unless it's a really short case. As in 10 minutes. Then I can give them sedation. My malpractice is not the lotto.

 

[deleted162650]

So really the question is do you put them through AFOI (probably not simple in this case, anybody on SDN would have it done in 90 seconds but others might find it challenging) and hold everything up in this off site location or do you risk getting into serious trouble in the middle of the case without having secured the airway to begin with. Neither answer is perfect.

But one is a lot more perfect than the other

 

[Noyac]

In defense of the precedex, it worked great....until it didn’t

That’s the issue with precedex. It isn’t reliable enough for me. I have had cases that it flat out didn’t work for. It is just an adjuvant. Not a primary anesthetic.

 

[deleted162650]

That’s the issue with precedex. It isn’t reliable enough for me. I have had cases that it flat out didn’t work for. It is just an adjuvant. Not a primary anesthetic.

I've said it before - it's a great sedative for people who didn't need a sedative in the first place.

 

[Twiggidy]

This is America. Fatties get tubed in my book. Unless it's a really short case. As in 10 minutes. Then I can give them sedation. My malpractice is not the lotto.

This is true. No anesthesiologists will ever fault you for putting a breathing tube in someone, but given that LMA does sit in the difficult airway algorithm and if the A flutter is truly only an hour with a good private practice EP (which they can be), doing a test shot at the beginning with an LMA doesn't hurt. But maybe I'm a bit more cowboy because I'm a big guy with big hands and can mask ventilate most patients until a glide arrives. (Full disclosure, our lab has a glidescope so it doesn't take long. If it were further away maybe I'd have a more conservative approach)

 

[Noyac]

This is true. No anesthesiologists will ever fault you for putting a breathing tube in someone, but given that LMA does sit in the difficult airway algorithm and if the A flutter is truly only an hour with a good private practice EP (which they can be), doing a test shot at the beginning with an LMA doesn't hurt. But maybe I'm a bit more cowboy because I'm a big guy with big hands and can mask ventilate most patients until a glide arrives. (Full disclosure, our lab has a glidescope so it doesn't take long. If it were further away maybe I'd have a more conservative approach)

I thought the same thing when I first read this. But for some reason I think I would have tubed him or would have done the case with mild sedation and a lot of it’s “ok”. I would have tried some gentle ketafol, enough to keep him conversive if I tried to talk to him. Another way, possibly could have done a remi infusion alone or with very very little sedation. If these didn’t work then AFOI. It would only take another 90sec, right.

I would have an LMA ready to go if I tried the sedation technique. I don’t hesitate to place LMA’s in fatties. I love them. But sometimes they are belly breathers and just beg for a tube. All that belly breathing can really frustrate whom ever is trying to work. This will only take longer to complete the task which is the last thing you want. Make the procedure as simple as possible for the surgeon/proceduralist so that it is as fast as possible for you.

 

[acidbase1]

Prop/roc/tube, AFOI if actually concerned (MP4 and BMI have lost all meaning to me).

Don't know what all the discussion is about, seems fairly straightforward. Precedex is definitely NOT the answer, on boards or in real life.

This was my first thought. Why not GETA? I did a ton of fattys in the EP lab. Glidescope worked like a charm every time. Why get cute?

One caveate, put in bite blocks for defibrillation. One guy bit through his tongue . Had to keep him intubated over night

 

[acidbase1]

This is America. Fatties get tubed in my book. Unless it's a really short case. As in 10 minutes. Then I can give them sedation. My malpractice is not the lotto.

Three things I never regret in life. 1) going to the gym 2) going to church 3) putting in a tube

 

[Twiggidy]

I thought the same thing when I first read this. But for some reason I think I would have tubed him or would have done the case with mild sedation and a lot of it’s “ok”. I would have tried some gentle ketafol, enough to keep him conversive if I tried to talk to him. Another way, possibly could have done a remi infusion alone or with very very little sedation. If these didn’t work then AFOI. It would only take another 90sec, right.

I would have an LMA ready to go if I tried the sedation technique. I don’t hesitate to place LMA’s in fatties. I love them. But sometimes they are belly breathers and just beg for a tube. All that belly breathing can really frustrate whom ever is trying to work. This will only take longer to complete the task which is the last thing you want. Make the procedure as simple as possible for the surgeon/proceduralist so that it is as fast as possible for you.

The belly breathing is a good point.

 

[OB1🤙]

Easiest prop/roc/tube/SDN ever.

 

[caligas]

LOVE the glide scope but I have seen a couple patients where it was not easy even with multiple experienced users, correct blade size, etc.

The possibility of “can’t intubate can’t ventilate” still exists in the post-racism/post-glide scope era.

 

[Twiggidy]

LOVE the glide scope but I have seen a couple patients where it was not easy even with multiple experienced users, correct blade size, etc.

The possibility of “can’t intubate can’t ventilate” still exists in the post-racism/post-glide scope era.

it’s pretty rare though. so much so that i have to remind myself to practice with the fiber optic when we have. stagger cases since i almost never use it. ive had maybe one “oops i crapped my pants” moment with the glide

if we seriously want to save the field of anesthesia.....ban the glidescope. it’ll raise the bar dramatically

 

[sheeed]

LOVE the glide scope but I have seen a couple patients where it was not easy even with multiple experienced users, correct blade size, etc.

The possibility of “can’t intubate can’t ventilate” still exists in the post-racism/post-glide scope era.

Agreed. There have been patients similar to what you've described where we had the glidescope blade in then had to basically snake the ET tube in on one of the portable fiber optic scopes. Would probably not want to do that in EP by myself tho

 

[anbuitachi]

When was the last time any one here has done a needle cric?

 

[bigdan]

OP -

Under my care, I would likely have started this case with an intubation, and, if required, everyone would have waited for me to safely do an AFOI. With each detail you described, it sounded worse and worse. I'm interested as to why you didn't choose intubation right off the bat.

I've been in practice as an attending for ~26 months. I have developed a pretty good rapport with most of our surgeons/proceduralists, and work to be efficient and facilitate patient care/work flow. That's my capital. Fortunately, those few times I need more time, I spend the aforementioned capital by saying "I'm sorry, (whichever surgeon), the only safe way for me to do this is with (insert time consuming but essential procedure here). This will take me a few extra minutes". I don't ask permission and, if asked about it, I say the patient requires it for safety. Once a surgeon turned around and left, but that's the worst I've gotten. As Chocomorsel deftly noted, this is my malpractice (and license) - and the PATIENT'S LIFE, BY THE WAY!!! - at risk. Why chance it?

I admit I had not considered that I am simply too unskilled to effectively get sick fat patients through a sedation case. That could certainly be true. But until the pulse ox alarms, only one or two people in the room know that something is wrong with the patient's airway or breathing. I supervise rooms with CRNAs and residents. With an ETT in place and vent on, Airway and Breathing are covered, and almost everyone can identify hypotension. Any story that sounds anything like "This is the worst airway I've ever need, it terrified me, I'm far away from any help, and the case involves catheters in the patient's heart" puts placement of an ETT high on my list.

I'm perhaps too conservative. I RARELY use LMAs. If I retire as being branded too conservative or overly safe, I can live with that.

 

[facted]

Remi infusion at .05-.1 mcg/kg/min. Can titrate small amounts of midaz (0.5mg at a time). No prop, ketamine, or fent if you use remi mac. They will stare into space and not have a care in the world. Most importantly, they are always awake and can follow commands. In addition, you have ready reversal (narcan) if you need it, though I've never had to pull out the narcan during a remi mac. When you change infusion rates, gotta wait a bit.

 

[deleted162650]

A couple pearls for the residents out there:

1) Don't try to run away from a scary airway with regional or MAC. Eventually you're gonna get burned

2) A good anesthetic plan doesn't include the phrase

got away with

 

[facted]

1) Don't try to run away from a scary airway with regional or MAC. Eventually you're gonna get burned

There's a difference between running away from something and trying to avoid it. I would DEFINITELY recommend trying to avoid a scary airway if alternate techniques can get you through the case. With that being said, you clearly should be prepared to deal with that airway if the need arises.

 

[Twiggidy]

OP -

I supervise rooms with CRNAs and residents.

totally separate issue

 

[Twiggidy]

There's a difference between running away from something and trying to avoid it. I would DEFINITELY recommend trying to avoid a scary airway if alternate techniques can get you through the case. With that being said, you clearly should be prepared to deal with that airway if the need arises.

scary is very subjective especially when dealing with a room full of anesthesiologists. one person’s ‘scary airway. i need all hands on deck’ is another person’s ‘Wednesday’. if you’re personally sitting a case, have a bit of confidence in yourself, your skills, and your training. if you’re supervising, yes, i think conservative is the way to go

 

[deleted162650]

There's a difference between running away from something and trying to avoid it. I would DEFINITELY recommend trying to avoid a scary airway if alternate techniques can get you through the case. With that being said, you clearly should be prepared to deal with that airway if the need arises.

The OP said that this was the first airway he'd seen in a long time that scared him. That's not one I want to have to dick with in the middle of the case. Attack it at the beginning, stay outta trouble, and make your life a whole lot less stressful for the next 1-2 hours.

 

[Noyac]

When was the last time any one here has done a needle cric?

I have done a version of it. I do a transtracheal injection on all of my awakes and if I am super concerned then I will slide an angiocath 18 or16g in just to be able to either jet ventilate, hook the circuit to (3cc syringe with 7.0 tube connector, screw syringe to angiocath and put the circuit on the connector then close the pop off) or do a retrograde wire.

 

[Arch Guillotti]

I have done a version of it. I do a transtracheal injection on all of my awakes and if I am super concerned then I will slide an angiocath 18 or16g in just to be able to either jet ventilate, hook the circuit to (3cc syringe with 7.0 tube connector, screw syringe to angiocath and put the circuit on the connector then close the pop off) or do a retrograde wire.

How do you decide if the angiocath will go up or down? Jet ventilation and a retrograde wire require the angiocath to be pointed in different directions.

 

[Noyac]

How do you decide if the angiocath will go up or down? Jet ventilation and a retrograde wire require the angiocath to be pointed in different directions.

It depends on what I plan to do with the cath. I’m sure it is nonsense to you though.

 

[sevoflurane]

We frequently drop a probe to look at the left atrial appendage before ablation. So my go to is prop/roc/tube 90% of the time.

 

[sevoflurane]

It depends on what I plan to do with the cath. I’m sure it is nonsense to you though.

Yeah... I've done both jet and retrograde (not on the same patient though). It's pretty easy to know which way the catheter is pointing.