How do we get around this situation

[me454555]

I'm on a surgery rotation and I was asked to scrub this case about 1/2 way through so I don't have much background info on this pt but here's the scenerio

We're doing a total hip replacement in a 50 y/o AA male. He's prolly about 100 lbs overweight but I dont know any specific medical history so assume he's in good health. We've given him a bupivicane spinal that should give him ~5 hrs of aneshesia in his lower body for us to work. About halfway through the case, the prostetic we are putting in can't seem to fit right. We're trying a bunch of different things but we can't seem to get the prostesis to click in an not dislocate when we move the pt around. Well, a 2.5hr surgery is now approaching 4 hrs and the anesthesiologist says we've gotta intubate him if we want to continue much longer. As of right now hes in the lateral recumbant postion and hes got an open wound on his hip for the hip replacement. What is your plan for intubation?

Do you cover the wound, break sterilization, flip him on his back, tube him, then flip him back or can we thread a tube in when he's on his side?

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[powermd]

Lma.

 

[zippy2u]

Slow, slow, slow. Tell the Orthopod attending to please stay at the academic center, he ain't ready for the real private practice world yet. Place the LMA #4 in and go on down the road. Keep the pt. in the exact same position to do this. Regards, ---Zip

 

[militarymd]

Fas track....then maybe intubate through it if necessary.

 

[Tenesma]

any redo hip or overweight patient gets a spinal epidural combo from me... when you hit the 3 hour mark it is hard to maintain MAC sedation - then LMA gets popped in... but if i did decide to LMA the guy which implies induction of anesthesia - I would definitely have an ETT ready over a fiberoptic for back-up (this guy is overweight, so i am sure his airway has some redundancy)

 

[adleyinga]

I'm on a surgery rotation and I was asked to scrub this case about 1/2 way through so I don't have much background info on this pt but here's the scenerio

We're doing a total hip replacement in a 50 y/o AA male. He's prolly about 100 lbs overweight but I dont know any specific medical history so assume he's in good health. We've given him a bupivicane spinal that should give him ~5 hrs of aneshesia in his lower body for us to work. About halfway through the case, the prostetic we are putting in can't seem to fit right. We're trying a bunch of different things but we can't seem to get the prostesis to click in an not dislocate when we move the pt around. Well, a 2.5hr surgery is now approaching 4 hrs and the anesthesiologist says we've gotta intubate him if we want to continue much longer. As of right now hes in the lateral recumbant postion and hes got an open wound on his hip for the hip replacement. What is your plan for intubation?

Do you cover the wound, break sterilization, flip him on his back, tube him, then flip him back or can we thread a tube in when he's on his side?

I agree with LMA but I have been in this situation before LMA around. You can airplane the table with the surgeon holding the patient stable. turn the head slightly so can mask and then intubate directly with the patients head tuened slightly. Really is not hard.
BUT nowadays- LMA is answer

 

[me454555]

Fas track....then maybe intubate through it if necessary.

Is there any advantage to using an LMA over a Fas track? I think i'd prefer the fas track if I had a choice b/c you can intubate through it but I really don't know the finer points of each

 

[Tenesma]

you can intubate through an LMA just as well - just requires a few small adjustments...

i recently reviewed a case of a trauma patient whose only airway was a fast-track - unable to intubate through it, but able to ventilate... and then the patient subsequently got massive transfusions (surprise, surprise), and the anesthesiologist was still able to ventilate through the fast track... anyway, the patient kept the fast-track for 24 hours until she was finally trached... and the fast track had TOTALLY ulcerated and necrosed her palate... that sucks...

 

[VentdependenT]

Pro Seal LMA is a good way to go if this guy is portly.

We always do combined spinal epidurals. If time runs out on the spinal just start pushing meds through the catheter. Problem averted.

Fastrach is a special intubating LMA. So in this case, with less than optimal positioning for direct laryngoscopy you can place one of these. Bam, you got an airway. Bam you can now intubate your pt "blindly" so to speak.

Other options for intubation without direct laryngoscopy: Fiberoptic scope, lightwand, glide scope.

LMA's
http://www.lmana.com/prod/components/products/lma_classic.html

 

[Noyac]

Here's another approach. Crawl under the drapes and do another spinal.

I was doing a case one day when the surgeon was ready for the implant and the rep. got this awful blank look on his face. Come to find out the only implant was in a town 1 hr away. The pt was a 80 something year old ESRD, DM, Severe COPD,etc,etc type of pt that I put a spinal (bupiv) for a THA. We covered the incision while the rep had his partner meet him 1/2 way with the implant. We were about 1 hour into the case and had 1 hr to go b/4 the impant was even in the hosp at best. When the impant arrived (1 1/2 hrs later) the pt was c/o some burning in the incision area. I grabbed some hypobaric bupiv and crawled under the drapes and popped in another spinal. Piece of cake.

If this is not an option for you (not sure why it wouldn't be an option) then ketamine is a great adjunct to your spinal. Tell the surgeon to get his **** together or get some help.

If you are going to intubate someone like this on their side, it is alot easier in the left lat. decub position then in the right.

 

[rn29306]

If you are going to intubate someone like this on their side, it is alot easier in the left lat. decub position then in the right.

Is that because of the tongue falls in the direction you want it to go anyways rather than having it fall into your view when on the right lat decub?
Or is it something else?

 

[Noyac]

Is that because of the tongue falls in the direction you want it to go anyways rather than having it fall into your view when on the right lat decub?
Or is it something else?

You got it!