EP case

[Noyac]

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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.

Well there you go.

 

[drmwvr]

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.

Routinely do TAVR's with precedex with very good results. By itself, not so much, but who gives anything by itself? Very modest pre op sedation and 5-15 of ketamine, it's pretty smooth. And the dose needs to be appropriate.

 

[22go]

We do the majority of these with Precedex +/- ketamine. The key with Precedex is you have to give a full load. Occasionally we still add a little ketamine if they start to move a little. I just normally remind them its a sign of life.

Our new ventilators have a PSVpro mode which is a really nice Bipap mode. If I am really worried, I put strap behind their head, attach the mask and oral airway, and you are good to go. Dial in a little positive inspiratory pressure and add a little peep for end-expiratory pressure.

I never use nasal airways in EP/Cath lab or whenever giving heparin. I have been burned too many times. Bloody airway in BMI 50 is not fun. Been there, done that.

If you were really concerned, you could do as mentioned earlier with a low dose Remifentanil infusion. Turn it off, and it's gone. Add a little Narcan, and the patient is WIDE awake.

If it was the scariest airway ever, I would have just intubated from the start.

 

[acidbase1]

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.

If I’m that worried then ketamine + versed + fentanyl go in and take a looksie

 

[Arch Guillotti]

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

If you are doing an awake intubation, what are you so concerned about?

 

[Noyac]

If you are doing an awake intubation, what are you so concerned about?

Ok, I’ll play. Because somehow you have decided to challenge me.
I have had more than a few cases that I did awake Intubations on that I wasn’t sure it was going to be possible. Actually, many of these cases are on this site. And many people, including yourself possibly, have responded with, have ENT at the bedside.
The first one that comes to my mind was the one I had last year when an alcoholic tried to stop drinking for a new job. He seized of course and bit nearly through and though his tongue. This was a problem for the EMT’s when they arrived because the blood was everywhere. But it was a much greater problem for our ER who immediately called me when they heard the call come in. When this bull necked obese delirious pt arrived in the ER he was struggling to breath around his swollen tongue which was pumping out blood like a trochanter in the aorta. But he was maintaining his airway sort of. And to my dismay, the ER never thought to call ENT or even general surgery (which would have been nearly fruitless since I’ve never seen one of them perform and emergent airway in a reasonable amount of time). So I looking at the worst possible situation for FOB. And the surgeon they called was a dentist/OMF. I’m f’ed. I did this intubation wide awake. I could go on but you get the point I hope.

Look, I know you are a smart guy, Arch. But why you chose me to challenge after all these years is beyond me.

I’m not like Blade. Blade is super chill. None of the characters here phase him. I on the other hand, will respond.

 

[anbuitachi]

Ok, I’ll play. Because somehow you have decided to challenge me.
I have had more than a few cases that I did awake Intubations on that I wasn’t sure it was going to be possible. Actually, many of these cases are on this site. And many people, including yourself possibly, have responded with, have ENT at the bedside.
The first one that comes to my mind was the one I had last year when an alcoholic tried to stop drinking for a new job. He seized of course and bit nearly through and though his tongue. This was a problem for the EMT’s when they arrived because the blood was everywhere. But it was a much greater problem for our ER who immediately called me when they heard the call come in. When this bull necked obese delirious pt arrived in the ER he was struggling to breath around his swollen tongue which was pumping out blood like a trochanter in the aorta. But he was maintaining his airway sort of. And to my dismay, the ER never thought to call ENT or even general surgery (which would have been nearly fruitless since I’ve never seen one of them perform and emergent airway in a reasonable amount of time). So I looking at the worst possible situation for FOB. And the surgeon they called was a dentist/OMF. I’m f’ed. I did this intubation wide awake. I could go on but you get the point I hope.

Look, I know you are a smart guy, Arch. But why you chose me to challenge after all these years is beyond me.

I’m not like Blade. Blade is super chill. None of the characters here phase him. I on the other hand, will respond.

Awake DL?

 

[deleted59964]

Ok, I’ll play. Because somehow you have decided to challenge me.
I have had more than a few cases that I did awake Intubations on that I wasn’t sure it was going to be possible. Actually, many of these cases are on this site. And many people, including yourself possibly, have responded with, have ENT at the bedside.
The first one that comes to my mind was the one I had last year when an alcoholic tried to stop drinking for a new job. He seized of course and bit nearly through and though his tongue. This was a problem for the EMT’s when they arrived because the blood was everywhere. But it was a much greater problem for our ER who immediately called me when they heard the call come in. When this bull necked obese delirious pt arrived in the ER he was struggling to breath around his swollen tongue which was pumping out blood like a trochanter in the aorta. But he was maintaining his airway sort of. And to my dismay, the ER never thought to call ENT or even general surgery (which would have been nearly fruitless since I’ve never seen one of them perform and emergent airway in a reasonable amount of time). So I looking at the worst possible situation for FOB. And the surgeon they called was a dentist/OMF. I’m f’ed. I did this intubation wide awake. I could go on but you get the point I hope.

Look, I know you are a smart guy, Arch. But why you chose me to challenge after all these years is beyond me.

I’m not like Blade. Blade is super chill. None of the characters here phase him. I on the other hand, will respond.

Put a cannula and wire through the cricothyroid membrane ... feel the stress dissipate

 

[deleted171991]

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

Respectfully, you don't need to put them through AFOI to find out what's inside their throat. You just need to know you can intubate them if necessary.

There is a simple way to do that. You have them gargle some lidocaine 4% until their pharynx becomes numb, or whatever method tickles your fancy, then you take an awake look with a glidescope or your favorite device. Then you KNOW what's inside their throats. It takes me less than 5 minutes. Peace of mind? Priceless.

The other solution is to become a master of Supreme LMAs, and always have some on you. You can ventilate some pretty big dudes through that device. I-gel is close, but not the same. Still, inducing any loss of airway reflexes, without a realistic plan of securing the airway, borders on malpractice. And one can't have a realistic plan if one doesn't know that particular airway (e.g. Mallampati 4 without further exploration).

I am not judging you here. I am just a Monday morning-quarterback who is sharing with you his way of skinning the cat. I am sure you have learned a lot from this case, even without us wiseguys.

 

[Twiggidy]

Ok, I’ll play. Because somehow you have decided to challenge me.
I have had more than a few cases that I did awake Intubations on that I wasn’t sure it was going to be possible. Actually, many of these cases are on this site. And many people, including yourself possibly, have responded with, have ENT at the bedside.
The first one that comes to my mind was the one I had last year when an alcoholic tried to stop drinking for a new job. He seized of course and bit nearly through and though his tongue. This was a problem for the EMT’s when they arrived because the blood was everywhere. But it was a much greater problem for our ER who immediately called me when they heard the call come in. When this bull necked obese delirious pt arrived in the ER he was struggling to breath around his swollen tongue which was pumping out blood like a trochanter in the aorta. But he was maintaining his airway sort of. And to my dismay, the ER never thought to call ENT or even general surgery (which would have been nearly fruitless since I’ve never seen one of them perform and emergent airway in a reasonable amount of time). So I looking at the worst possible situation for FOB. And the surgeon they called was a dentist/OMF. I’m f’ed. I did this intubation wide awake. I could go on but you get the point I hope.

Look, I know you are a smart guy, Arch. But why you chose me to challenge after all these years is beyond me.

I’m not like Blade. Blade is super chill. None of the characters here phase him. I on the other hand, will respond.

ER put you in a bad spot with not reasonable backup. I may have had that person hold out and manage the airway in the OR with a surgeon

 

[Lecithin5]

Respectfully, you don't need to put them through AFOI to find out what's inside their throat. You just need to know you can intubate them if necessary.

There is a simple way to do that. You have them gargle some lidocaine 4% until their pharynx becomes numb, or whatever method tickles your fancy, then you take an awake look with a glidescope or your favorite device. Then you KNOW what's inside their throats. It takes me less than 5 minutes. Peace of mind? Priceless.

The other solution is to become a master of Supreme LMAs, and always have some on you. You can ventilate some pretty big dudes through that device. I-gel is close, but not the same. Still, inducing any loss of airway reflexes, without a realistic plan of securing the airway, borders on malpractice. And one can't have a realistic plan if one doesn't know that particular airway (e.g. Mallampati 4 without further exploration).

I am not judging you here. I am just a Monday morning-quarterback who is sharing with you his way of skinning the cat. I am sure you have learned a lot from this case, even without us wiseguys.

Interesting- anyone else have success with gargling lidocaine and taking a look with a glidescope? This could be a game changer...

 

[Noyac]

Awake DL?

He couldn’t tolerate anything touching his tongue. It was so swollen and tight from the hematoma that it was excruciatingly painful. I had to go nasally.

 

[Noyac]

Interesting- anyone else have success with gargling lidocaine and taking a look with a glidescope? This could be a game changer...

I use it all the time. It works well. But in my case above, nothing worked very well because everything was covered with blood and the topical lidocaine couldn’t penetrate the mucosa. Even the trachea was covered in blood and the transtracheal injection wasn’t as effective as usual.

 

[facted]

Interesting- anyone else have success with gargling lidocaine and taking a look with a glidescope? This could be a game changer...

Yes, can also give 2 or 3 ml prop to stun after the lido. Works very well.

 

[deleted162650]

The other solution is to become a master of Supreme LMAs

I'm gonna vehemently disagree with this. If you're gonna be a master of any (insert name of any fancy-pants designer)LMA, then it better be one you can intubate through. That's my main gripe with the Supremes. Intubating LMA's are such game-changers/life savers. The ability to continuously ventilate while sliding a tube through cords with or without a bronchoscope is uuuuuge.

Check out the Air-Q's.

 

[caligas]

I'm gonna vehemently disagree with this. If you're gonna be a master of any (insert name of any fancy-pants designer)LMA, then it better be one you can intubate through. That's my main gripe with the Supremes. Intubating LMA's are such game-changers/life savers. The ability to continuously ventilate while sliding a tube through cords with or without a bronchoscope is uuuuuge.

Check out the Air-Q's.

Do you like the Aintree? Extra steps but very easy to get into the trachea.

 

[deleted171991]

I'm gonna vehemently disagree with this. If you're gonna be a master of any (insert name of any fancy-pants designer)LMA, then it better be one you can intubate through. That's my main gripe with the Supremes. Intubating LMA's are such game-changers/life savers. The ability to continuously ventilate while sliding a tube through cords with or without a bronchoscope is uuuuuge.

Check out the Air-Q's.

Except the intubating LMA usually sucks at developing the positive pressures necessary to ventilate obese patients. It was good 30 years ago, when people were thinner.

I haven't had the chance to work with the Air-Q yet. Can one intubate through one of them?

 

[Arch Guillotti]

I haven't had the chance to work with the Air-Q yet. Can one intubate through one of them?

Yes

 

[deleted162650]

Except the intubating LMA usually sucks at developing the positive pressures necessary to ventilate obese patients. It was good 30 years ago, when people were thinner.

I haven't had the chance to work with the Air-Q yet. Can one intubate through one of them?

Ya, they were designed with that as a primary use. Wide barrel, no aperture bars, a little ramp that "kicks" the ETT anterior right through the cords, and the circuit adapter is even removable and attached by a little leash so you don't lose it.

They're not as soft and supple as a Unique though, so aren't my first choice for routine LMA cases. But, for a difficult airway or rescue situation they're like a sore penis - you can't beat it.

 

[deleted162650]

Do you like the Aintree? Extra steps but very easy to get into the trachea.

You mean the exchange catheters? I'd rather just put the tube through the LMA while ventilating the whole time via a broch elbow on the ETT.

 

[Arch Guillotti]

You mean the exchange catheters? I'd rather just put the tube through the LMA while ventilating the whole time via a broch elbow on the ETT.

I think the Aintree is easier although it is another step. Putting the tube through the LMA requires a pusher which I don’t really like using.

 

[AdmiralChz]

I think the Aintree is easier although it is another step. Putting the tube through the LMA requires a pusher which I don’t really like using.

We had some horrible ancient reusable intubating LMA (torture) device in residency that came with a pusher - FastTrach? I can't remember, but I do remember failing to get the airway every time. Then the attending would subsequently fail as well, I don't believe I personally saw it work (obviously anecdotal). Almost comically bad!

 

[deleted162650]

I think the Aintree is easier although it is another step. Putting the tube through the LMA requires a pusher which I don’t really like using.

You don't need the special pusher. You can just use another ETT that's 1 full size smaller i.e. use a 6.0 to push a 7.0.

We had some horrible ancient reusable intubating LMA (torture) device in residency that came with a pusher - FastTrach? I can't remember, but I do remember failing to get the airway every time. Then the attending would subsequently fail as well, I don't believe I personally saw it work (obviously anecdotal). Almost comically bad!

Ya, the FasTrach is/was a POS. No comparison to the AirQ's.

 

[Arch Guillotti]

You don't need the special pusher. You can just use another ETT that's 1 full size smaller i.e. use a 6.0 to push a 7.0.

I know, I still like the Aintree better.

 

[deleted162650]

I know, I still like the Aintree better.

To each their own. The only other point I'll add is that by going the Aintree route, you lose the ability to ventilate continuously.

 

[caligas]

To each their own.

So true, I actually like the fastrach, usually works blindly without FOS, but can use FOS if needed

 

[Arch Guillotti]

To each their own. The only other point I'll add is that by going the Aintree route, you lose the ability to ventilate continuously.

The Aintree allows you to ventilate although it may not be ideal. If you do it right, there is almost zero risk of losing the airway whereas if you intubate fiberoptically through the fast trach lma there seems to be a chance of screwing up the exchange with whatever pusher you use.

 

[drmwvr]

The Aintree allows you to ventilate although it may not be ideal. If you do it right, there is almost zero risk of losing the airway whereas if you intubate fiberoptically through the fast trach lma there seems to be a chance of screwing up the exchange with whatever pusher you use.

Yes. One can jet ventilate through an Aintree all day long.

 

[Arch Guillotti]

Ok, I’ll play. Because somehow you have decided to challenge me.
I have had more than a few cases that I did awake Intubations on that I wasn’t sure it was going to be possible. Actually, many of these cases are on this site. And many people, including yourself possibly, have responded with, have ENT at the bedside.
The first one that comes to my mind was the one I had last year when an alcoholic tried to stop drinking for a new job. He seized of course and bit nearly through and though his tongue. This was a problem for the EMT’s when they arrived because the blood was everywhere. But it was a much greater problem for our ER who immediately called me when they heard the call come in. When this bull necked obese delirious pt arrived in the ER he was struggling to breath around his swollen tongue which was pumping out blood like a trochanter in the aorta. But he was maintaining his airway sort of. And to my dismay, the ER never thought to call ENT or even general surgery (which would have been nearly fruitless since I’ve never seen one of them perform and emergent airway in a reasonable amount of time). So I looking at the worst possible situation for FOB. And the surgeon they called was a dentist/OMF. I’m f’ed. I did this intubation wide awake. I could go on but you get the point I hope.

Look, I know you are a smart guy, Arch. But why you chose me to challenge after all these years is beyond me.

I’m not like Blade. Blade is super chill. None of the characters here phase him. I on the other hand, will respond.

lol I will bite on this one even though I know better🙂

Why are you so offended that I choose to "challenge" you? You are a board certified anesthesiologist, you didn't make it through oral boards by just coasting along.

You aren't the only one that has seen crappy airways or been called to clean up somebody else's mess.

I think the idea of putting a catheter in someone's trachea sounds great but I also think the reality is much different.

Are you really going to jet ventilate someone in the ER? Who's going to secure the airway while you ventilate? Because if you let someone else jet the patient will probably pop a lung and get a pneumothorax. Do you bring the jet and hook it up to the wall beforehand?

Along the same lines, have you ever performed a retrograde wire intubation? I have been on this board close to 20 years and have yet to hear a credible report of one being performed. What wire are you going to use? Are you going to have it available if things go awry?

I have no doubt you are an excellent anesthesiologist but my point is that while it may sound cool to place a catheter in the trachea, the reality is that functionally it will serve very little use. If you are that far down the airway algorithm then you might as well perform a surgical airway.

By the way, nice call on GSP. That guy is a beast!