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Once again, great discussion from everyone. I will try to summarize what went down.
When I met the pt in pre-op he was sitting somewhat semirecumbent and his voice was hoarse. He was pleasant and anxious to get going. He stated that his breathing was better after the steroids but his wife said that today was not as good as the past few days. She was very concerned. She felt like he was not going to do well.
I had him brought to the PACU where I gave him OV glyco and a lido neb. Then I followed with a viscous lido swish and swallow.
In the room I set up the pedi FOIscope with a 6.0 flex tip ETT. And a glidescope #4 with a 6.0 ETT. I also setup my extremely airway tools. A 14g IV catheter with a 3c syringe and a ETT connector for jet ventilation. But because of the tense rutty feel of his neck and trachea I didn’t want to stick this in there at any point. I brought the lot back to the OR and he was getting real nervous. I had Remi ready to go. ENT was standing at his side and trach set was ready.
Monitors on and in a semi recumbent position I gave him 1mg of versed. This is when the **** started to get real. He was out and I couldn’t mask him. But if I shouted his name he would open his eyes. So I told him to take a breath and he would give a halfass effort. Now I could assist him and all was better. Sats never dropped. I then decided I wanted to know where his trachea was so I inserted a 25g needle with 4% lido where I thought his trachea was and I go air, thanks god, but it was deep and not normal. Transtracheal injection complete and I topicalized his nares as well with plans to go through one but that never happened. ENT and I thought maybe a quick peek with the GS would be a good idea at this time. It wasn’t. I very carefully inserted the GS and barely used and force and we could see nothing on the screen but edema. And now there was blood in the posterior pharynx. I came out and assisted his breathing again and he was coming around a little more as well. Eyes are opening off and on without prompting him.
We thought about going to the trach now but I was worried about the difficulty of that and I had never done an awake trach with this ENT before. I was not easy to relinquish control of this situation. This turned out to be the correct move. I grabbed the FOI scope which had the screen display and slowly worked my way down the back of his mouth. Blood was present and kept smearing my screen but I found the epiglottis which was the appearance of a pediatric epiglottis. It was narrow, curved and very very stiff. I snaked my way past it and there was nothing behind it except for a fold of tissue. We agreed that this must be the glottis opening and I put the lens right in it. Screen was black and I gently applied pressure. I could feel the scope moving down but it was extremely tight and I was concerned that he couldn’t breath much less that I couldn’t get a 6.0 tube to follow. At this point he truly could not breath which caused him to cough mildly. That was just what I needed. When he coughed the scope advanced some and the second time he coughed I made it past the obstruction and the carina was in site. We couldn’t believe it. Now the tube was meeting resistance and the same thing happened. About two gentle coughs and I was in. I confirmed ETCO2 and off the sleep he went.
ENT started the case with the right thyroidectomy for tissue and it was a bloody f’n mess and took at least an hour and a half. She then asked me if we could do a trial extubation and I said no way. There was no way I was gettting back in that trachea in an emergency and she knew there was no way she was doing a trach in an emergency so she agreed to trach him right then. That took another 45 min I believe. It most complicated one I’ve been a part of for sure. Bloody, distorted and tight.
The best part of the story was when I went out to tell his wife what we did she stood up and hugged me and said “I love you”. I’ve never had that happen before.
In hindsite, I’m not sure what I would do in this situation again. I guess I would approach it the same way. Maybe no glidescope look though. And zero sedation but I’m still not sure why he was so sensitive. I would probably having him sitting more upright and I would stand in front of him while passing through the nose with him awake. That my usual approach anyway. But once I gave him the versed, I could no longer go that route with him sitting upright.
He went home 5days later after 2-3 days in ICU. And is starting treatment for Bcell lymphoma.
Thanks everyone for participating in this case. Fire away!!!
When I met the pt in pre-op he was sitting somewhat semirecumbent and his voice was hoarse. He was pleasant and anxious to get going. He stated that his breathing was better after the steroids but his wife said that today was not as good as the past few days. She was very concerned. She felt like he was not going to do well.
I had him brought to the PACU where I gave him OV glyco and a lido neb. Then I followed with a viscous lido swish and swallow.
In the room I set up the pedi FOIscope with a 6.0 flex tip ETT. And a glidescope #4 with a 6.0 ETT. I also setup my extremely airway tools. A 14g IV catheter with a 3c syringe and a ETT connector for jet ventilation. But because of the tense rutty feel of his neck and trachea I didn’t want to stick this in there at any point. I brought the lot back to the OR and he was getting real nervous. I had Remi ready to go. ENT was standing at his side and trach set was ready.
Monitors on and in a semi recumbent position I gave him 1mg of versed. This is when the **** started to get real. He was out and I couldn’t mask him. But if I shouted his name he would open his eyes. So I told him to take a breath and he would give a halfass effort. Now I could assist him and all was better. Sats never dropped. I then decided I wanted to know where his trachea was so I inserted a 25g needle with 4% lido where I thought his trachea was and I go air, thanks god, but it was deep and not normal. Transtracheal injection complete and I topicalized his nares as well with plans to go through one but that never happened. ENT and I thought maybe a quick peek with the GS would be a good idea at this time. It wasn’t. I very carefully inserted the GS and barely used and force and we could see nothing on the screen but edema. And now there was blood in the posterior pharynx. I came out and assisted his breathing again and he was coming around a little more as well. Eyes are opening off and on without prompting him.
We thought about going to the trach now but I was worried about the difficulty of that and I had never done an awake trach with this ENT before. I was not easy to relinquish control of this situation. This turned out to be the correct move. I grabbed the FOI scope which had the screen display and slowly worked my way down the back of his mouth. Blood was present and kept smearing my screen but I found the epiglottis which was the appearance of a pediatric epiglottis. It was narrow, curved and very very stiff. I snaked my way past it and there was nothing behind it except for a fold of tissue. We agreed that this must be the glottis opening and I put the lens right in it. Screen was black and I gently applied pressure. I could feel the scope moving down but it was extremely tight and I was concerned that he couldn’t breath much less that I couldn’t get a 6.0 tube to follow. At this point he truly could not breath which caused him to cough mildly. That was just what I needed. When he coughed the scope advanced some and the second time he coughed I made it past the obstruction and the carina was in site. We couldn’t believe it. Now the tube was meeting resistance and the same thing happened. About two gentle coughs and I was in. I confirmed ETCO2 and off the sleep he went.
ENT started the case with the right thyroidectomy for tissue and it was a bloody f’n mess and took at least an hour and a half. She then asked me if we could do a trial extubation and I said no way. There was no way I was gettting back in that trachea in an emergency and she knew there was no way she was doing a trach in an emergency so she agreed to trach him right then. That took another 45 min I believe. It most complicated one I’ve been a part of for sure. Bloody, distorted and tight.
The best part of the story was when I went out to tell his wife what we did she stood up and hugged me and said “I love you”. I’ve never had that happen before.
In hindsite, I’m not sure what I would do in this situation again. I guess I would approach it the same way. Maybe no glidescope look though. And zero sedation but I’m still not sure why he was so sensitive. I would probably having him sitting more upright and I would stand in front of him while passing through the nose with him awake. That my usual approach anyway. But once I gave him the versed, I could no longer go that route with him sitting upright.
He went home 5days later after 2-3 days in ICU. And is starting treatment for Bcell lymphoma.
Thanks everyone for participating in this case. Fire away!!!
