Happy Holidays SDN Anesthesiologists #Case_05

[DrAmir0078]

Dear All,
I hope you are doing well, it has been a year since my last post where I told you about passing my 1st year residency exam (like ABA) here in Iraq where I am now a third year resident in Anesthesia and Intensive Care / Iraqi Board. It has been a tough year for all of us, and for me since Covid hits Iraq, we worked very hard to contain the crisis especially with a weak and devastated health system, it wasn't easy at all, we have lost so many doctors in Iraq and well known Anesthesiologists too unfortunately, because of covid, and for me I had contracted the infection last August, and it wasn't that severe too.
I started my third year residency back in October in another teaching center in Baghdad, and day after day, I am realizing how different my approach in dealing with the cases, and as you remember, I had shared my cases especially in late 2018 and through 2019; and I hope I can say I am back with my backpack of interested cases to me at least, and looking always for an answer from a different perspective.
My New Case - I believe case #5 on SDN:
10 days ago, I had a shift to run the ORs of the emergency cases - not OBGYN (it is usually a 24 hour shift at our medical city), anyway - a neuro team approached me to tell me about a case they need to replace her VP shunt because of blocking issue, and they request to have a reserved OR room, because it was full house, and I asked them about the case and here is the summary from the neurosurgeon : 30 years old female with a current GCS of 10, had an OP of VP shunt 2 weeks ago, because of a brain tumor, and she was kept at the ward for observation.
The patient arrived to the OR to examine her, she was skinny like 55 Kg, (x 2.2 = 121 Ib), and yes, she was GCS of 10 - 11, with barely closed mouth, like contracted jaw and neck muscles, and I couldn't even open her mouth and wouldn't try the jaw thrust, and I got the consent for the anesthesia (consent of death complications), her vitals was upper normal, except a bit tachycardia.
Interestingly, I had with me a PGY1 resident and she was in her first weeks of residency and you know they keep ask valuable questions and sometime those questions based on logical prediction while I believe Anesthesia is unpredictable and sometime Logic means Guidelines !
I anticipated difficult intubation scenario, and I was ready, I had some Sevoflurane, and I started preoxygenation for 5 minutes, then I opened Sevo for another 3 minutes with a tight mask, and gave her propofol a sleeping dose and it was around 100 mg (10 ml slowly) and the jaw relaxed a bit, and I came with my laryngoscope and I saw the vocal cords shining like a star, and the resident said "did you see them?", I said "yes", she said "Lets give her muscle relaxants", I said "Okay, we may but (started to think about this logic, since you have seen the vocal cord proceed with MR as usual, and my heart was aching I don't know why) - Okay give her MR doctor", we only have rocuronium (C/I succinylcholine because of ICP).
Well, after 1 minute, she became very relaxed and I opened her mouth, her tongue disappeared - fallen down in her throat like, and I don't have Magill forceps handy, but with my fingers and laryngoscope manipulation was able to see the field and intubated her, I was relieved guys to be honest!
The operation went smooth and another problem was how to awake a GCS of 10 like?, and the patient at the end of the operation was taking full breath (end Tv was great) and she was like biting on the ETT (she had excised premolars and fortunately was creating a nice gap for the ETT - without it she was biting the ETT for sure) - and her eye muscles and especially the corrugator supercilii was functioning to tell me "EXTUBATE", and I did honestly and tried to do suction and barely from the premolars area. The patient was well and the same voice of mumbling like, and just like I received her prior!
I maintained the Operation with Isoflurane, analgesics and set the RR 16 (for ICP), and at the end of the operation, I shifted her to SIMV-PC and then PSPro modes !
My question, what is your opinion about the whole process? Any comment? Will you do an inhalational technique?
Love to hear from you friends !
Sincerely,
Amir

 

[GassYous]

If it works it works. From what you said, I'd maybe opt for an awake nasal fiberoptic with ent close by.

Welcome back.

 

[DrAmir0078]

If it works it works. From what you said, I'd maybe opt for an awake nasal fiberoptic with ent close by.

Welcome back.

Interesting
Nasal fiberoptic, would be a great option - but will you use inhalational like me + propofol ? and then you try the fiberoptic ? Do you advise me next time to call the ENT at the bedside?

Thanks brother ....

 

[Sleeplessbordernights]

First year resident in Mexico here, I’d probably use a VL with standard induction with fent, prop and roc

 

[FFP]

Why was a 55 kg patient considered probably difficult intubation AND ventilation, and in need of some form of look before giving muscle relaxant (unless she was not NPO, in which case inhalational induction was a BAD idea)? It's not like any of the jaw muscles are smooth muscle. Suppose difficult ventilation is expected, why give propofol and stop spontaneous ventilation, in such a patient, especially with the increased ICP? I am afraid what you did was NOT an inhalational technique, it was a cowboy one.

Also, why would a patient be biting on the ETT, if she had the proper bite block in place? And why would one care about what the eye muscle "says" about extubation? If the patient is breathing well with no support and she has airway reflexes, the tube should come out at the end of the surgery (given that she was not a difficult intubation).

I'm sorry to have to be tough on you, but you are a PGY-3, so you (and your attending) should have much better plans by now. For example, if you're concerned about the airway, but not so much about the ICP, let her breath sevo until you can take a look and spray some lido on the cords, then muscle relax her and pass the tube. If you think she can tolerate being manipulated a bit, and you have time, prep her nose and take a look with a fiberoptic (with the ETT-loaded), including some lidocaine sprays through the side port, until you can pass the fiberoptic through her vocal cords, then induce her with propofol and pass the tube. Or, if you are not afraid that you won't be able to ventilate her, take a FO look or not pre-induction, and just induce her with high dose roc (that's what I would have done, as long as I had a FO at bedside).

P.S. I am glad that you found me funny. Proves that my work here was/is a waste of time, as expected. Nothing I said is hard to do in a developing country (except not having a fiberoptic available - even then, why the propofol?).

 

[Arch Guillotti]

If it works it works. From what you said, I'd maybe opt for an awake nasal fiberoptic with ent close by.

Welcome back.

No way. No reason to believe she will be hard to ventilate.

 

[DrAmir0078]

Why was a 55 kg patient considered probably difficult intubation, and in need of some form of look before giving muscle relaxant (unless she was not NPO, in which case inhalational induction was a BAD idea)? It's not like any of the jaw muscles are smooth muscle.

Why would a patient be biting on the ETT, if she had the proper bite block in place?

ٍI considered it because of that contracted jaw, she was clinging her teeth, It is not the 55 kg issue ! I couldn't asses Mallampati like too !
She had already an NG tube in place and I did suction prior !
I don't have a bite block ! (I am in Iraq), may be we have to invent sometimes like what we do in the ICU
cheers

 

[DrAmir0078]

First year resident in Mexico here, I’d probably use a VL with standard induction with fent, prop and roc

We have a VL, but it was in locker ! lol ...

 

[chocomorsel]

Why was a 55 kg patient considered probably difficult intubation AND ventilation, and in need of some form of look before giving muscle relaxant (unless she was not NPO, in which case inhalational induction was a BAD idea)? It's not like any of the jaw muscles are smooth muscle.

Why would a patient be biting on the ETT, if she had the proper bite block in place?

Cue the dingus response. Some resident comes here to ask a question and gets this response? From you? No way!!!!

 

[coffeebythelake]

Not concerned about spiking ICP from bucking during DL? I would RSI with rocuronium. If truly worried about ability to intubate then induce w ketamkne, keep spontaneous breathing, and look then give paralytic

 

[DrAmir0078]

Not concerned about spiking ICP from bucking during DL? I would RSI with rocuronium. If truly worried about ability to intubate then induce w ketamkne, keep spontaneous breathing, and look then give paralytic

I did what you have mentioned, I used propofol instead of Ketamine (I worried about ICP !) and looked it up and it was fine and I could do tube, but I gave MR and the issue was her tongue fallen down on her throat !
Can you elaborate this about using agents that can provoke the ICP, as I know we prohibit use Ketamine, Sux (MR) like because it increases the ICP ! is this a myth or what ?

 

[coffeebythelake]

I did what you have mentioned, I used propofol instead of Ketamine (I worried about ICP !) and looked it up and it was fine and I could do tube, but I gave MR and the issue was her tongue fallen down on her throat !
Can you elaborate this about using agents that can provoke the ICP, as I know we prohibit use Ketamine, Sux (MR) like because it increases the ICP ! is this a myth or what ?

Suxx causes a brief small increase in ICP but reliably provides muscle relaxation within 45 seconds. The alternative is to do high dose rocuronium which takes a little longer and does not cause any increase in ICP (i prefer this, but also recognize that formulations of roc differ in its potency). Ketamine was initially believed to be bad for head injury and ICP concerns but more recent studies show it is safe. In either case, it is much less likely to cause problem than a huge spike on ICP from coughing and bucking

 

[DrAmir0078]

I'm sorry, OP, but you are a PGY-3, you (and your lazy-ass absent attending) should have much better plans by now.

You are a bit what a bully or narcissistic I believe ! lol
That was my own plan, and with what available tools dude !

 

[DrAmir0078]

Suxx causes a brief small increase in ICP but reliably provides muscle relaxation within 45 seconds. The alternative is to do high dose rocuronium which takes a little longer and does not cause any increase in ICP (i prefer this, but also recognize that formulations of roc differ in its potency). Ketamine was initially believed to be bad for head injury and ICP concerns but more recent studies show it is safe. In either case, it is much less likely to cause problem than a huge spike on ICP from coughing and bucking

Thanks a lot for explanation ...

Do you recall a link about it !

Next time, I will use Ketamine (and Sux too) ... I adore them !

 

[DrAmir0078]

'm sorry, OP, but you are a PGY-3, so you (and your attending) should have much better plans by now. For example, if you're concerned about the airway, but not so much about the ICP, let her breath sevo until you can take a look and spray some lido on the cords, then muscle relax her and pass the tube. If you think she can tolerate being manipulated a bit, and you have time, prep her nose and take a look with a fiberoptic (with the ETT-loaded), including some lidocaine sprays through the side port, until you can pass the fiberoptic through her vocal cords, then induce her with propofol and pass the tube. Or, if you are not afraid that you won't be able to ventilate her, take a FO look or not pre-induction, and just induce her as usual.

P.S. I am glad that you found me funny. Proves that my work here was/is a waste of time. Good luck!

I did that, did you read the thread ?
I preoxygenate for 5 minutes
Sevo for 3 minutes on 4% (2 MAC)
I gave propofol
Then I looked it up and I saw the cords very easily, I would intubate her, but I gave MR and then I went back to see her tongue for some reason, and I haven't seen such case, her tongue fallen relaxed down ... I had to manipulate with my finger and guide my laryngoscope and I intubated her with ease !

Fiberoptic stuff, we don't have it, only at Baghdad Medical City and it is not for emergency use, for only special cases for elective, it very expensive and you know ... we are working in a field of limited resources and I believe you appreciate that !

I didn't find it funny, but since you said "you (and your lazy-ass absent attending)", I have to laugh with emoji response and not to be angry at all, you don't know our struggle, and you are talking with insult, and I am talking with respect !

Good Luck too

 

[chocomorsel]

You are a bit what a bully or narcissistic I believe ! lol
That was my own plan, and with what available tools dude !

No, he insists he's really a sweet, sweet, teddy bear in real life.

 

[FFP]

.

You are a bit what a bully or narcissistic I believe ! lol
That was my own plan, and with what available tools dude !

I think I am not the narcissist here. I actually tend to have a plan B and plan C in situations like this, and my residents would be able to present and argue them, unlike you. My suggestion to you is to either change your defensive attitude, especially with people who have zero obligations to you, or be prepared not to shine in this profession.

tl;dr: Sevo plus propofol is NOT an inhalational induction, if that's what you wanted. And you got lucky the patient did not buck or vomit during your first DL. Good luck!

P.S. My makeshift soft bite block (which most American anesthesiologists tend to use): take some 5 by 5 cm pieces of gauze, roll 3-4 up together until they are much thicker than your ETT, tape the roll, place it next to the ETT (preferably between the molars, so it will stop the bite). Next time a young patient does not bite on the tube during emergence, you'll appreciate its value.

 

[SaltyDog]

I don't have a bite block ! (I am in Iraq)

Rolled up gauze with a little tape. Pretty sure you have some lying around.

 

[DrAmir0078]

Rolled up gauze with a little tape. Pretty sure you have some lying around.

Yes, it is easy, we used it in the ICU and even we put a syringe and even in the OR we use the guedel airways Oropharyngeal airways !
What's up Dr SaltyDog?
I didn't do it in this case!
Next time, will put gauzes

 

[DrAmir0078]

.

I think I am not the narcissist here. I actually tend to have a plan B and plan C in situations like this, and my residents would be able to present and argue them, unlike you. My suggestion to you is to either change your defensive attitude, especially with people who have zero obligations to you, or be prepared not to shine in this profession.

tl;dr: Sevo plus propofol is NOT an inhalational induction, if that's what you wanted. And you got lucky the patient did not buck or vomit during your first DL. Good luck!

P.S. My makeshift soft bite block (which most American anesthesiologists tend to use): take some 5 by 5 cm pieces of gauze, roll 3-4 up together until they are the the diameter of a bigger cigar, tape the roll, place it next to the ETT (preferably between the molars, so it will stop the bite). Next time a young patient does not bite on the tube during emergence, you'll appreciate its value.

Ok you are not narcissistic, good for you !
I will change my behavior next time when somebody use A S S word with me ... come on, you deleted it (you felt the error of using such words !)
Anway I do respect you whatsoever, but we are learning !
My Plan A was Sevo, and it didn't actually bring her jaw down ! and I moved with Propofol then it worked ... I understand what inhalational induction only ! and I used the propofol for a purpose !
No one is in defense, but everybody have to respect !

 

[DrAmir0078]

No, he insists he's really a sweet, sweet, teddy bear in real life.

I don't know ... he is very smart and I like talking to smart people too like him !

 

[FFP]

I did that, did you read the thread ?
I preoxygenate for 5 minutes
Sevo for 3 minutes on 4% (2 MAC)
I gave propofol
Then I looked it up and I saw the cords very easily, I would intubate her, but I gave MR and then I went back to see her tongue for some reason, and I haven't seen such case, her tongue fallen relaxed down ... I had to manipulate with my finger and guide my laryngoscope and I intubated her with ease !

Fiberoptic stuff, we don't have it, only at Baghdad Medical City and it is not for emergency use, for only special cases for elective, it very expensive and you know ... we are working in a field of limited resources and I believe you appreciate that !

I didn't find it funny, but since you said "you (and your lazy-ass absent attending)", I have to laugh with emoji response and not to be angry at all, you don't know our struggle, and you are talking with insult, and I am talking with respect !

Good Luck too

"Narcissist and bully" must be how people talk when they are respectful.

There is more than one way to do things in anesthesia, but sevo plus propofol would have been pretty low on my list (I've seen enough oh-crap moments after propofol, especially when maintaining pCO2 is important, and difficult ventilation is expected). More likely sevo plus ketamine, if I wanted to proceed faster than just with a pure sevo induction.

But, if I had had few/poor airway instruments, I would have definitely had ENT at bedside, scrubbed and draped for an emergent crycothyroidomy, in case I fail. All they need is sterile gloves, a disinfectant, some local anesthetic, a knife, something to hold the trachea open with and an ETT. Also, I would have inserted an awake arterial line, if available.

I do realize that it's very easy to comment when one has a lot of options (we don't have "everything" either, just more alternatives), but then you should tell us: "I couldn't do A, B, C, and D, because we did not have it, not because I did not consider them". Then you'd get more respect from me. This is a very debatable case, and we don't have all the data, but it still feels that you got lucky.

 

[IMGASMD]

It just feels very muddy. Sure it’s almost like a board case, with challenges of a developing and resource poor country.

You have some conflicting goals here. But at least for the boards, the answer is almost airway airway airway. Elevated ICP? Do you know how high? GCS is 10-11, probably tells me it’s not super high?

Why would a contracted jaw mean a difficult intubation, especially when you said yourself, she couldn’t close it... are you worried you don’t have enough room in the mouth for the scope?

I am sure most attendings here can turn this into a oral board question and at the end you harmed the patient at the end of the case.

If you want a pat in the back. Yes. Good job the patient survived. But you want to learn, you need to be a little less defensive.

Good luck. And happy holidays.

 

[DrAmir0078]

"Narcissist and bully" must be how people talk when they are respectful.

There is more than one way to do things in anesthesia, but sevo plus propofol would have been pretty low on my list (I've seen enough oh-crap moments after propofol). More likely sevo plus ketamine, if I wanted to proceed faster than just with a pure sevo induction.

"If I know you prior, and you used A S S word, I will consider this, but can't consider this word with stranger" - Let us forget Dr FFP - I am learning !

OK, now I know your approach, you don't like Sevo + propofol (I used Sevo for 3 minutes - and actually run out too) and then she was sleeping and when I gave propofol (prior I sucked the NG tube and got some fluid) and then her jaw relaxed and I could see the cords !

I was hesitant of using Ketamine, because of ICP, since most of our Anesthesiologists didn't like it, so I can't use it, and even if I used it and anything bad happened, they will interrogate me of using Ketamine that increases the ICP !

But I am waiting of evidence based article about ICP and Ketamine (updates of agents increases ICP). I remember one of our great Anesthesiologist uses Ketamine and he mentioned what mentioned above about the updates of using those agents !

Cheers

 

[DrAmir0078]

It just feels very muddy. Sure it’s almost like a board case, with challenges of a developing and resource poor country.

You have some conflicting goals here. But at least for the boards, the answer is almost airway airway airway. Elevated ICP? Do you know how high? GCS is 10-11, probably tells me it’s not super high?

Why would a contracted jaw mean a difficult intubation, especially when you said yourself, she couldn’t close it... are you worried you don’t have enough room in the mouth for the scope?

I am sure most attendings here can turn this into a oral board question and at the end you harmed the patient at the end of the case.

If you want a pat in the back. Yes. Good job the patient survived. But you want to learn, you need to be a little less defensive.

Good luck. And happy holidays.

Yes Airway Airway Airway
Well contracted jaw, and clinging teeth, with long neck (she is tall woman), I couldn't asses her Mallampati and what worried me, I couldn't open her mouth and yes no room for my laryngoscope to be honest!
How did I harm the patient?
I preoxygenate 5 minutes, then used Sevoflurane for 3 minutes and no outcome to open her mouth (I can't just do a jaw thrust, it is painful and not fully relaxed to me), then I gave a sleeping dose gradually the propofol and then I was able to open her mouth of this poor patient and put my scope with ease and I would intubate her but I gave muscle relaxant and then what I saw, her tongue structure fallen deep, and I was able to intubate her !
I didn't use Ketamine, I feared the ICP and you question is how much elevated? I do NOT have the tool to measure the ICP, and when I asked the neuro-resident he said "YES she does because of the VP shunt is not working and we want to replace it and we have examined her", so I assumed elevated ICP !
I don't want any pat and the people here knew me with my cases, I am here to learn and change the idea of discussion !
I don't know where I was defensive ! Can you tell me ?
I am with full respect to all of you - I learned a lot from this forum and it has been a year since my last post - and how awful if I am defensive or less respectful, my apology to you all !
Happy Holidays too !
My apology !
with Love and Peace

 

[FFP]

ٍI considered it because of that contracted jaw, she was clinging her teeth, It is not the 55 kg issue ! I couldn't asses Mallampati like too !
She had already an NG tube in place and I did suction prior !
I don't have a bite block ! (I am in Iraq), may be we have to invent sometimes like what we do in the ICU
cheers

Things to remember:
1. There is no skeletal muscle contracture that cannot be resolved by a muscle relaxant, especially in intubating doses.
2. Most, if not all, patients are much easier to BOTH ventilate AND intubate if they have muscle relaxant on board. Many difficult intubations are due to positioning and not enough muscle relaxation.
3. Always have a backup plan to the backup plan, and maybe even to that.

Ask yourself:
What would you have done if, as expected by you, you couldn't have opened her mouth AT ALL, and she stopped breathing after your propofol (and you only have a nare to ventilate her through and maintain pCO2/pO2)? If this patient truly would have been a Cannot Ventilate, Cannot Intubate situation, as expected?
What would you have done if this patient vomited or coughed during your DL, or decreased her CPP for some other reason (hypoventilation, hypotension) and had a Cushing reflex/coded?

Next time, before you do a DL in an unparalyzed almost unconscious patient, fentanyl (or another short-acting opiate) may be more helpful instead of propofol (assuming you have naloxone) to inhibit those airway reflexes and decrease stimulation. Why? Because it can be easily reversed with naloxone, getting the patient back to spontaneous ventilation (not so easy if one overshoots with late-acting propofol).

 

[DrAmir0078]

I do realize that it's very easy to comment when one has a lot of options (we don't have "everything" either, just more alternatives), but then you should tell us: "I couldn't do A, B, C, and D, because we did not have it, not because I did not consider them". Then you'd get more respect from me. This is a very debatable case, and we don't have all the data, but it still feels that you got lucky.

I have to follow up your comment because you edited them, and it is Okay for me, I am seeking the knowledge !

So, next time I will call the ENT at the bedside, but why I didn't call them, because she was very easy to ventilate with a mask and as I said I was ready (anticipating difficult intubation).
Now I understand Dr FFP, and you gain my respect, because you are keeping talking and explaining even with such "friction of emotions" !
My apology Dr FFP
I am learning !
My respect !

 

[DrAmir0078]

Things to remember:
1. There is no skeletal muscle contracture that cannot be resolved by a muscle relaxant, especially in intubating doses.
2. Most, if not all, patients are much easier to BOTH ventilate AND intubate if they have muscle relaxant on board. Many difficult intubations are due to positioning and not enough muscle relaxation.
3. Always have a backup plan to the backup plan, and maybe even to that.

Ask yourself:
What would you have done if, as expected by you, you couldn't have opened her mouth AT ALL, and she stopped breathing after your propofol (and you only have a nare to ventilate her through and maintain pCO2/pO2)? If this patient truly would have been a Cannot Ventilate, Cannot Intubate situation, as expected?
What would you have done if this patient vomited or coughed during your DL, increased her ICP and had a Cushing reflex/coded?

Next time, before you do a DL in an unparalyzed almost unconscious patient, fentanyl (or another short-acting opiate) may be more helpful (assuming you have that and naloxone) to inhibit those airway reflexes (if one doesn't want to use ketamine, not to alter mental status and produce sialorrhea). Why? Because it can be easily reversed with naloxone, getting the patient back to spontaneous ventilation (not so easy if one overshoots with late-acting propofol).

Great Key points - They are Pearls to me Dr FFP !
I have to ask myself such question !
It will be disastrous indeed, if she didn't open her mouth with the propofol dose, but luckily did and my issue was once I gave the muscle relaxant the roc her tongue fallen down ... I can imagine if I gave her after propofol a muscle relaxant without prior looking up by DL, I would see the same tongue fallen down ...
But Can the Sevoflurane get the credits of abolishing the reflexes - I think I remember what MAC BAR means and it is 1.5 MAC and I opened the Sevo at 4 (double MAC), so I have to be NOT worried about reflexes, beside the propofol would gently abolish the reflexes too with some relaxation if I am not mistaken, I was very very cautious Dr FFP !
Those kind of Opioids weren't available at that time, the prior shift I have remifent handy, but not this shift ...
I will consider your key points
I hope I am not defensive at all !
I am learning !

 

[FFP]

I have to follow up your comment because you edited them, and it is Okay for me, I am seeking the knowledge !

So, next time I will call the ENT at the bedside, but why I didn't call them, because she was very easy to ventilate with a mask and as I said I was ready (anticipating difficult intubation).
Now I understand Dr FFP, and you gain my respect, because you are keeping talking and explaining even with such "friction of emotions" !
My apology Dr FFP
I am learning !
My respect !

No worries. English is neither my nor your native tongue.

Having ENT (or any other surgeon who can do a rapid cryc) around is a matter of judgment regarding the probability of getting into a Cannot Intubate Cannot Ventilate (well-enough) situation, also depending on this patient's ICP, or NPO status.

There is no perfect response that's always true, but you should always consider as many backup plans as you can, even if you lack resources. Keep asking yourself "What will I do if A/B/C happens?". If your attendings don't push you about this, push yourself (and even them, if allowed). This case could have gone bad in many ways. That's what made me grumpy (and my natural charm, as @chocomorsel kindly pointed out). I'll take my charming personality elsewhere, and let her teach you/us more/better.

Happy Holidays to you, too!

 

[FFP]

Ok you are not narcissistic, good for you !
I will change my behavior next time when somebody use A S S word with me ... come on, you deleted it (you felt the error of using such words !)
Anway I do respect you whatsoever, but we are learning !
My Plan A was Sevo, and it didn't actually bring her jaw down ! and I moved with Propofol then it worked ... I understand what inhalational induction only ! and I used the propofol for a purpose !
No one is in defense, but everybody have to respect !

I wrote "your lazy-ass attending", meaning your very lazy supervising consultant/specialist/attending anaesthetist physician. It wasn't about you. I initially thought it had been only you and the PGY-1 for some reason. In America, a resident is almost never left alone when starting a difficult case.

The expression is probably more offensive in your country than in America. Sorry. I am also used to the forum software replacing it with ***.

 

[DrAmir0078]

No worries. English is neither my nor your native tongue.

Having ENT (or any other surgeon who can do a rapid cryc) around is a matter of judgment regarding the probability of getting into a Cannot Intubate Cannot Ventilate (well-enough) situation, also depending on this patient's ICP, or NPO status.

There is no perfect response that's always true, but you should always consider as many backup plans as you can, even if you lack resources. Keep asking yourself "What will I do if A/B/C happens?". If your attendings don't push you about this, push yourself (and even them, if allowed). This case could have gone bad in many ways. That's what made me grumpy (and my natural charm, as @chocomorsel kindly pointed out). I'll take my charming personality elsewhere, and let her teach you/us more/better.

Happy Holidays to you, too!

Many thanks Dr FFP

I am getting your points, again as you read that I have no tool to measure ICP, except what neuro resident said, probably he examined her with DO for papilledema (I know this resident when I call him at the ICU)

I appreciate your time !

 

[DrAmir0078]

I wrote "your lazy-ass attending", meaning your very lazy supervising consultant/specialist/attending anaesthetist physician. It wasn't about you. I initially thought it had been only you and the PGY-1 for some reason.

The expression is probably more offensive in your country than in America. Sorry.

I understood, no worries - I used to live in the United States for 8 years, and I know such words, but still I don't like it when it comes from a person who is stranger to me and never spoke with him before, and also like what you said is offensive !
Honestly, I was alone with my PGY1, our Attending wasn't absent, but he was taking a rest and we work like a team, my supervisor was CA3 or PGY4 and I spoke with her about my plans ahead !
It was a challenging case !


Your comments will make me write more about my cases to see your perspectives !

I appreciate your time Dr FFP !

 

[economycian]

Ketamine has been shown to not increase ICP as initially thought, we use it for pretty much every neurotrauma intubation when tubing someone down in the ED. Sux does transiently increase ICP but this is nothing in comparison to the effect on ICP of a poorly performed intubation.

I would have thought the clenched mouth would be due to increased tone from the brain pathology? That is to say, once muscle relaxants were in, it would cease to be a problem.

 

[DrAmir0078]

Ketamine has been shown to not increase ICP as initially thought, we use it for pretty much every neurotrauma intubation when tubing someone down in the ED. Sux does transiently increase ICP but this is nothing in comparison to the effect on ICP of a poorly performed intubation.

I would have thought the clenched mouth would be due to increased tone from the brain pathology? That is to say, once muscle relaxants were in, it would cease to be a problem.

Great and I would love to read an update about Ketamine vs Sux (I just looked it up on Barash in Clinical Anesthesia 8th Ed, and it says"Patients with elevated ICP may receive a short-acting opioid and lidocaine (1.5 mg/kg) intravenously to blunt the sympathetic response to laryngoscopy ... Following induction of anesthesia, a muscle relaxant should be administered. Succinylcholine should be used with caution in patients with pre-existing motor deficits as upregulation of nicotinic receptors at the neuromuscular junction can lead to increased risk of hyperkalemia. Also, succinylcholine can increase ICP but this effect is of short duration."
Haven't seen on Ketamine, and I just saw lots of researches online about it too !
So, next time, I won't fear the ICP and give Ketamine too !
Probably the patient's clinched mouth due to increased tone due to the pathology.

 

[chocomorsel]

I don't know ... he is very smart and I like talking to smart people too like him !

He may be smart, but he is a total ass. The same word he used on you.
He often rudely offends people, goes after them personally and promptly deletes it when he thinks better of it. Or more likely when he thinks he will be called out on it. Not before he gets caught, quoted and and then apologizes.
Tells me all I need to know.
Vicious cycle.
He’s a narcissist. Your instincts are correct.
Being smart does not give you an excuse to be a total dingus. Although in medicine it is quite common and acceptable.
I mean, it’s the internet. It is quite easy to think on and type not so offensive responses. It’s not like a real life argument. But somehow, it doesn’t dawn on him to be less of a jerk to people.

 

[DrAmir0078]

He may be smart, but he is a total ass. The same word he used on you.
He often rudely offends people, goes after them personally and promptly deletes it when he thinks better of it. Or more likely when he thinks he will be called out on it. Not before he gets caught, quoted and and then apologizes.
Tells me all I need to know.
Vicious cycle.
He’s a narcissist. Your instincts are correct.
Being smart does not give you an excuse to be a total dingus. Although in medicine it is quite common and acceptable.
I mean, it’s the internet. It is quite easy to think on and type not so offensive responses. It’s not like a real life argument. But somehow, it doesn’t dawn on him to be less of a jerk to people.

I got his point "we both are not native Americans (I know I am and then he said it), he had a bad experience before with words too and then he realized that with me when he used such word thinking I understand the American use of such word - like it is Okay but it appeared Offensive to me".
He is free to talk and I am free to respond. We are in such a good month, it is December and I love the Christmas spirit of it, so I am tolerant with love, and many thanks to all of you who provide me with knowledge !
Happy Holidays and let us forget and smile ! ! !

 

[chocomorsel]

I got his point "we both are not native Americans (I know I am and then he said it), he had a bad experience before with words too and then he realized that with me when he used such word thinking I understand the American use of such word - like it is Okay but it appeared Offensive to me".
He is free to talk and I am free to respond. We are in such a good month, it is December and I love the Christmas spirit of it, so I am tolerant with love, and many thanks to all of you who provide me with knowledge !
Happy Holidays and let us forget and smile ! ! !

You are better than me. Go ahead and be gracious and forgiving.
Clearly he and I have history. I keep trying to be forgiving but I am done.
Yeah, maybe it's a language thing.

 

[FFP]

He may be smart, but he is a total ass. The same word he used on you.
He often rudely offends people, goes after them personally and promptly deletes it when he thinks better of it. Or more likely when he thinks he will be called out on it. Not before he gets caught, quoted and and then apologizes.
Tells me all I need to know.
Vicious cycle.
He’s a narcissist. Your instincts are correct.
Being smart does not give you an excuse to be a total dingus. Although in medicine it is quite common and acceptable.
I mean, it’s the internet. It is quite easy to think on and type not so offensive responses. It’s not like a real life argument. But somehow, it doesn’t dawn on him to be less of a jerk to people.

Matthew 7:3.

 

[chocomorsel]

Matthew 7:3.

Not a Christian.

 

[FFP]

Not a Christian.

Me not really either (more of an agnostic), but I thought you had Internet search capability (like me, when I looked up the classic quote).

“Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?"

 

[chocomorsel]

Me not really either (more of an agnostic), but I thought you had Internet search capability (like me, when I looked up the classic quote).

“Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?"

Hmm. I don’t personally attack people on here the way you do.
I have questioned someone and asked if they were daft recently and told people they are ignorant about others’ lived experiences but I try to leave personal attacks out of stuff unless someone really comes after me.
I am not condescending and constantly think I am better and smarter than other people the way you do and in the process put others down. Like when they ask a simple clinical question.
It’s quite simple really.

I talk about gun lovers when there’s a shooting and White people not seeing their own privileges.. and non maskers/Trumpers going out and being selfish and infecting others, and people in medicine being greedy and narcissistic jerks.
But attack you and try to make you feel completely idiotic and stupid, and go below the belt on personal stuff...that’s your forte.

 

[MirrorTodd]

Could we please not turn this thread into a pissing match?

 

[WholeLottaGame7]

Dear All,

Sincerely,
Amir

Anesthetics are kind of like plane crashes: any one you can walk away from (or the patient walks away from) is, on some level, a success.

That said, I will echo others who have said you got lucky, because you did, and hopefully you learn from it.

You started out fine. You elected to breathe them down and keep them breathing spontaneously, which is totally reasonable if you were concerned that they were going to be a difficult ventilation/intubation. I agree with @FFP in that the problem is with the propofol. You said you gave it because you couldn't open the mouth any further, so you wanted more relaxation, but propofol is not a muscle relaxant, it is an anesthetic, and one that causes apnea. If you wanted better muscle relaxation and weren't worried about the airway anymore, give them a real muscle relaxant like rocuronium. If you wanted to keep them breathing but wanted them deeper, just go up on the sevo concentration. If you wanted to give them roc but weren't sure what was going to happen and didn't have a fiberoptic scope, then you have to be ready to cut the neck or have someone around who can.

 

[MirrorTodd]

Dear All,
I hope you are doing well, it has been a year since my last post where I told you about passing my 1st year residency exam (like ABA) here in Iraq where I am now a third year resident in Anesthesia and Intensive Care / Iraqi Board. It has been a tough year for all of us, and for me since Covid hits Iraq, we worked very hard to contain the crisis especially with a weak and devastated health system, it wasn't easy at all, we have lost so many doctors in Iraq and well known Anesthesiologists too unfortunately, because of covid, and for me I had contracted the infection last August, and it wasn't that severe too.
I started my third year residency back in October in another teaching center in Baghdad, and day after day, I am realizing how different my approach in dealing with the cases, and as you remember, I had shared my cases especially in late 2018 and through 2019; and I hope I can say I am back with my backpack of interested cases to me at least, and looking always for an answer from a different perspective.
My New Case - I believe case #5 on SDN:
10 days ago, I had a shift to run the ORs of the emergency cases - not OBGYN (it is usually a 24 hour shift at our medical city), anyway - a neuro team approached me to tell me about a case they need to replace her VP shunt because of blocking issue, and they request to have a reserved OR room, because it was full house, and I asked them about the case and here is the summary from the neurosurgeon : 30 years old female with a current GCS of 10, had an OP of VP shunt 2 weeks ago, because of a brain tumor, and she was kept at the ward for observation.
The patient arrived to the OR to examine her, she was skinny like 55 Kg, (x 2.2 = 121 Ib), and yes, she was GCS of 10 - 11, with barely closed mouth, like contracted jaw and neck muscles, and I couldn't even open her mouth and wouldn't try the jaw thrust, and I got the consent for the anesthesia (consent of death complications), her vitals was upper normal, except a bit tachycardia.
Interestingly, I had with me a PGY1 resident and she was in her first weeks of residency and you know they keep ask valuable questions and sometime those questions based on logical prediction while I believe Anesthesia is unpredictable and sometime Logic means Guidelines !
I anticipated difficult intubation scenario, and I was ready, I had some Sevoflurane, and I started preoxygenation for 5 minutes, then I opened Sevo for another 3 minutes with a tight mask, and gave her propofol a sleeping dose and it was around 100 mg (10 ml slowly) and the jaw relaxed a bit, and I came with my laryngoscope and I saw the vocal cords shining like a star, and the resident said "did you see them?", I said "yes", she said "Lets give her muscle relaxants", I said "Okay, we may but (started to think about this logic, since you have seen the vocal cord proceed with MR as usual, and my heart was aching I don't know why) - Okay give her MR doctor", we only have rocuronium (C/I succinylcholine because of ICP).
Well, after 1 minute, she became very relaxed and I opened her mouth, her tongue disappeared - fallen down in her throat like, and I don't have Magill forceps handy, but with my fingers and laryngoscope manipulation was able to see the field and intubated her, I was relieved guys to be honest!
The operation went smooth and another problem was how to awake a GCS of 10 like?, and the patient at the end of the operation was taking full breath (end Tv was great) and she was like biting on the ETT (she had excised premolars and fortunately was creating a nice gap for the ETT - without it she was biting the ETT for sure) - and her eye muscles and especially the corrugator supercilii was functioning to tell me "EXTUBATE", and I did honestly and tried to do suction and barely from the premolars area. The patient was well and the same voice of mumbling like, and just like I received her prior!
I maintained the Operation with Isoflurane, analgesics and set the RR 16 (for ICP), and at the end of the operation, I shifted her to SIMV-PC and then PSPro modes !
My question, what is your opinion about the whole process? Any comment? Will you do an inhalational technique?
Love to hear from you friends !
Sincerely,
Amir

Anesthesia resident here, I think you did what you could for the pt given the resources you had available and you did the "right" thing meaning that the pt came out of it without any complications. I do agree with most here in that there is certainly more that you can do, but given the circumstances, I understand that's not always possible. The bit block with gauze works like a charm and I would advocate doing it for basically every pt. 3 pieces for females, 4 for males of 4x4" gauze, rolled and tape wrapped around, stuff that along their molars and they won't bite the tube.

I did want to ask for clarification on some parts of your post...
1: You said that you had a shift to run the OR's for emergency cases. What does that mean? Are you coordinating the flow of OR's and which emergency cases go first or are you just the resident assigned to emergencies and you take whatever case gets sent your way?
2: You said you had some sevoflurane. What do you mean by that? You had some in a vaporizer or were you administering that via open drop? I don't remember what machines you all have out there. Do you have gas analyzers that tell you the mac estimate and inspired/end tidal sevoflurane totals?
3: What type of laryngoscope blade were you using? Mac or miller?
4: What do you mean by saying her tongue fell down in her throat? I'm having trouble imagining what that means. Why did you need to use your fingers or think of using the mcgills to move her tongue and not just insert the laryngoscope as you did previously? Cause that should get the tongue out of the way even when she is relaxed and it has fallen back.
5: What emergency equipment do you all keep available in the room? Do you have video laryngoscopes? I understand fiberoptic bronchoscopes aren't available. What about emergency trach kits? Is there an 11 blade kept handy within reach? Do you have a jet ventilator on every machine? Have you performed or learned about performing needle cricothyrotomies can can attach the circuit to the catheter left in the crico membrane? Have you ever performed or learned about retrograde wire intubation?

One thing I love about anesthesia is that there are many ways to get the same result. And there are so many ways you could've done this. I think you probably could've taken more time to evaluate her. Truly find out the extent of the jaw rigidity and why it seemed difficult to open her mouth. I do agree with FFP and others in that you didn't necessarily need to give propofol. From your other comments, it sounds like she was fully induced on the sevo, so you could've just done the roc at rsi dose and performed your DL.

Overall, it's easy to judge from the couch online, especially if one frames it in the context of the resources we have here in the US, so don't take anything anyone says here too critically, especially me. Cheers.

 

[MirrorTodd]

Oh btw, I'm glad you are alive and well. Please keep posting. It's very interesting to hear about how anesthesia is practiced around the world!

 

[woopedazz]

Thoughts on breathing down with Sevo when two of your stated goals are attempting to maintain PaCO2 and ICP? I.e. obtunding chemoreceptors, flow-metabolism coupling, airway patency, etc immediately prior to intubation, but not obtunding the pressor response to intubation. Did you let them spontaneously breath and deepen themselves over 3 minutes or did you assist-bag them?

I'd probably just do a normal IV induction personally, but I should come up with some more excuses to practice gas inducitons.

 

[DrAmir0078]

Anesthesia resident here, I think you did what you could for the pt given the resources you had available and you did the "right" thing meaning that the pt came out of it without any complications. I do agree with most here in that there is certainly more that you can do, but given the circumstances, I understand that's not always possible. The bit block with gauze works like a charm and I would advocate doing it for basically every pt. 3 pieces for females, 4 for males of 4x4" gauze, rolled and tape wrapped around, stuff that along their molars and they won't bite the tube.

I did want to ask for clarification on some parts of your post...
1: You said that you had a shift to run the OR's for emergency cases. What does that mean? Are you coordinating the flow of OR's and which emergency cases go first or are you just the resident assigned to emergencies and you take whatever case gets sent your way?
2: You said you had some sevoflurane. What do you mean by that? You had some in a vaporizer or were you administering that via open drop? I don't remember what machines you all have out there. Do you have gas analyzers that tell you the mac estimate and inspired/end tidal sevoflurane totals?
3: What type of laryngoscope blade were you using? Mac or miller?
4: What do you mean by saying her tongue fell down in her throat? I'm having trouble imagining what that means. Why did you need to use your fingers or think of using the mcgills to move her tongue and not just insert the laryngoscope as you did previously? Cause that should get the tongue out of the way even when she is relaxed and it has fallen back.
5: What emergency equipment do you all keep available in the room? Do you have video laryngoscopes? I understand fiberoptic bronchoscopes aren't available. What about emergency trach kits? Is there an 11 blade kept handy within reach? Do you have a jet ventilator on every machine? Have you performed or learned about performing needle cricothyrotomies can can attach the circuit to the catheter left in the crico membrane? Have you ever performed or learned about retrograde wire intubation?

One thing I love about anesthesia is that there are many ways to get the same result. And there are so many ways you could've done this. I think you probably could've taken more time to evaluate her. Truly find out the extent of the jaw rigidity and why it seemed difficult to open her mouth. I do agree with FFP and others in that you didn't necessarily need to give propofol. From your other comments, it sounds like she was fully induced on the sevo, so you could've just done the roc at rsi dose and performed your DL.

Overall, it's easy to judge from the couch online, especially if one frames it in the context of the resources we have here in the US, so don't take anything anyone says here too critically, especially me. Cheers.

Thanks for having the time Todd to write and explain in a very detailed way that everybody would understand, a very creative writing ability.

1- Here we go, bite block isn't a common practice over here, we only used it commonly at the ICU, beside and this is my own headache and want to buy original bite block the same one that can fit the ETT with it, and a little story "the US when invaded Iraq back in 2003,they brought it and I saw it in my hospital prior to my residency program, our ministry of health won't buy bite block for feasibility issue probably who knows", again what we do, we use airways like guedel airway, and using the guaze technique isn't strange for us, it is fabulous too and I learned the lesson, will use it as a bite block and finally it is not a common practice but I believe it is a best practice!

2- Our shifts in this hospital is different from the past one the Baghdad Medical City, in our Teac Hospital our Cheif resident make the schedule that fitted for the best interest for all of us and adhering with the program vs administration; moreover every day we have 2 residents for Emergency Surgeries, 2 residents for OBGYN cases, one resident for answering consultations and one resident at the ICU, beside the availability of PGY1 shadowing the PGY2 or PGY3 aka CA1 or CA2 respectively. I hope I answered the question!

3- Yes Sevoflurane is expensive, and not always supplied, they can supply you once a day or no supply at all, and I had at that vaporizer only to the half, and my machine was Dhatex Omeda Aspire S/5 I belive and it comes without Gas analyzer unlike the others like Drager station we have it at the elective surgery ORs or the one at BMC the previous teaching hospitals complex too.

4- I used a laryngoscope of Mac not Miller blade - very rarely using Miller, only in pediatrics.

5 and 6 - The description of tongue fallen down her throat, it is my own description to make it clear, when I opened her mouth, her tongue tip was down to the back pharynx - can you bring your tongue to the back right? Yes you can and my patient with her long lower jaw a bit, skinny, and I couldn't see the tongue, i used my finger to just push the tongue anteriorly to allow a room for my blade, I wished if I had a Magill forceps with a gauze in order to lift her tongue for my blade, in this part of the story I was using rocuronium, because before that when I looked at her Vocal cord, she was deeply sleeping with Sevoflurane for 3 minutes that didn't bring her jaw down but Propofol did and in literature it does have a muscle relaxation effect (at least let her sleeps deeply that Sevoflurane didn't allow it.
I didn't want to give her right away a full induction with propofol and then muscle relaxants fearing I won't be able to open her mouth or can't see the field like to difficult to see her vocal cord, and I only have an LMA, iGel next to me, with stylet (for my second trial of ETT), (but no bougie) and no VL - The VL is available yes and haven't seen it, it is always kept in the locker for other cases and you know it is expensive and honestly I have never thought of requesting it !
There are no Fiberoptic at all only at BMC and for elective and because it is expensive, and you asked for jet ventilators, no way! What else? Tracheal kits?, but honestly we have all different airways, nasal trumpet like airway and different sizes of tubes!

Yes she was induced on Sevoflurane (Double Mac - intubation Mac and over Mac Bar) but I needed the Propofol prior to muscle relaxants to see if she can open her jaw while she is deep sleep!
Do you have problems with Propofol nowadays?
I had spoken clearly, once I used the muscle relaxant, I faced that relaxed tongue going back deep and couldn't catch it with blade unless using my finger to push it anteriorly and let my blade finds its way with ease and to see the shining vocal cords that I previously had seen but honestly was much easier!

Thanks for your valuable explanation Todd.

Yes I am still alive and I wished to write about covid experience, but I was down depressed because one year of practice gone with the winds, the PGY2 should've be the year of regional anesthesia practicing, I am so sad and I don't know when I will have the time to practicing it or find a suitable workshop like!
No worries, I will still write my cases and ask you guys, and always and forever we are learning together!

With Love and Peace

 

[DrAmir0078]

Thoughts on breathing down with Sevo when two of your stated goals are attempting to maintain PaCO2 and ICP? I.e. obtunding chemoreceptors, flow-metabolism coupling, airway patency, etc immediately prior to intubation, but not obtunding the pressor response to intubation. Did you let them spontaneously breath and deepen themselves over 3 minutes or did you assist-bag them?

I'd probably just do a normal IV induction personally, but I should come up with some more excuses to practice gas inducitons.

Thanks for the comment..
Yes I did, I used Sevoflurane for induction (double the Mac = Mac intubation and it is over Mac bar), but it didn't work - did I mention that she had NG tube so fitting a mask was troublesome (leaking issue), but she kept breathing normally and no apnea noticed. Did I assisted her breath? No, she was breathing very well and since NG tube in place, and I was putting a mask, I didn't want to make a trouble with opened cardiac sphincter by the feeding tube and although I did suction and the color was dark yellow like with mucous, so no way to assist breathing, I considered aspiration risk and since her GCS was 11 like!
I was so cautious and yet I believe and from all the comments, I was lucky at the beginning, and I respect your academic view, and I am not looking for a pat or anything like "Good Job", I need to learn the best practice!
I am tolerant!

 

[DrAmir0078]

Anesthetics are kind of like plane crashes: any one you can walk away from (or the patient walks away from) is, on some level, a success.

That said, I will echo others who have said you got lucky, because you did, and hopefully you learn from it.

You started out fine. You elected to breathe them down and keep them breathing spontaneously, which is totally reasonable if you were concerned that they were going to be a difficult ventilation/intubation. I agree with @FFP in that the problem is with the propofol. You said you gave it because you couldn't open the mouth any further, so you wanted more relaxation, but propofol is not a muscle relaxant, it is an anesthetic, and one that causes apnea. If you wanted better muscle relaxation and weren't worried about the airway anymore, give them a real muscle relaxant like rocuronium. If you wanted to keep them breathing but wanted them deeper, just go up on the sevo concentration. If you wanted to give them roc but weren't sure what was going to happen and didn't have a fiberoptic scope, then you have to be ready to cut the neck or have someone around who can.

Yup, you are saying what in my heart in every single word. But again, and I said that, using propofol was to deepen her state and it was only sleeping and once she slept, I was able to open her mouth (she was like resisting opening her mouth - stubborn jaw) and I know it is not a muscle relaxant but has relaxation effects I believe. So, when I gave muscle relaxants, the tongue issue was there and his position went back down and require my fingers to bring it anteriorly and then to allow the blade to smoothly go down and elevate the tongue with ease and I intubated her!
Many Thanks
By the way this OR has no Capnography monitoring!

 

[Katheudontas parateroumen]

Basic question. So let’s say we did the inhalation induction and patient is still spontaneously breathing but the mouth is still too rigid to open, so you decide to give roc. Is there a part that we are still rolling the dice that roc will work to open her mouth? Giving roc in a closed mouth can make her obstruct with tongue/ soft tissue rolling back after muscle relaxation to make her difficult to mask? I feel like this whole situation is predicated in that we have to be 100% sure that roc will relieve her jaw rigidity. Even with mask induction getting her deep enough she can obstruct too and then lead to difficult ventilation and intubation. Personally given all that I would have done awake foi nasal as my first attempt. If in a place without fiber optic, I would do inhalational and ketamine. If that didn’t work I’d do roc and hope it opens the mouth. And with all this having colleague ready for surgical airway. My main goal is airway so would not to burn bridges by maintaining spontaneous ventilation, secondary goal would be maintaining her CPP. Keeping a close eye on BP. Thoughts?