How do you secure this airway?

[ProRealDoc]

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27 y/o male with hx of Down's syndrome, BMI 42, HOCM and VSD with hx of episodic heart failure, dyspnea, severe LVH scheduled for myectomy and VSD repair.

Review of records indicate patient has a hx of recurrent pneumonia x 4 since beginning of the year requiring hospitalizations. I inquired with mother about recurring aspiration and she was not sure. Mother stated during one of his pneumonia episodes, patient developed ARDS requiring trach. Patient has not had any surgery since his trach.

Patient's cognition is marginal and is able to respond to simple commands.

On exam, patient is obese, short thick neck, has a large midneck scar from prior trach, MP 4, TMD 2 FBS. Mother states "make sure he is asleep when you put the breathing tube otherwise he will fight you".

How do you secure his airway?

 

[fastosprintini]

there are two answers, the oral board answer would be to do an "awake" trach, probably with ketamine and robinol, the pp answer would be to get an ent standby, obtain old intubation records and do a bullard intubation...
just my$0.02 , fasto

 

[Licoricestick]

there are two answers, the oral board answer would be to do an "awake" trach, probably with ketamine and robinol, the pp answer would be to get an ent standby, obtain old intubation records and do a bullard intubation...
just my$0.02 , fasto

Sorry - but what's a 'bullard intubation'?

Mouth opening?
Old notes from the tube he presumably had before the trach was placed?
Any previous GAs with comment on bag/mask ventilation?
Got a glidescope?

 

[ProRealDoc]

Sorry - but what's a 'bullard intubation'?

Mouth opening?
Old notes from the tube he presumably had before the trach was placed?
Any previous GAs with comment on bag/mask ventilation?
Got a glidescope?

Mouth opening is within normal parameters. Tongue is large as expected in this population. Patient is new to our hospital and no records from prior intubations are available.

 

[anesthesiadoc]

Sorry - but what's a 'bullard intubation'?

http://www.springerlink.com/content/h167u3t0l2461455/

I like the Bullard, but i think it's being phased out by tools like the glidescope and C-MAC.

Another option would be Ketamine + glycopyrrolate, topicalize, then Fast Track LMA lubricated with viscous Lidocaine. Then FOI through LMA.

 

[fastosprintini]

sorry about that . bullard intubation= pent-sux-tube placed with bullard rigid fibreoptic laryngoscope. anesthesiadoc has a point, it starts to look old next to newer products as the glidescope, but you are good only with what you have used many times , so take your pick....
fasto

 

[Masseter Spasm]

Get an old anesthetic record, if possible. If the patient has Trisomy 21 he probably has had some operative procedures in the past other than the trach. Remember the patient probably needed a tracheostomy for respiratory failure rather than a difficult airway. Most patients with Trisomy 21 are not difficult airways, although many have OSA.

Options for an elective (empty stomach) procedure:

Awake FOI--not a good choice with this uncooperative patient

Inhalational induction and maintain spontaneous breathing--will be difficult given patient's age, size, airway exam and likelihood of OSA

IV induction (my choice): Pre-oxygenate as much as possible. I would not use ketamine in this patient with HOCM, as you do not want to increase HR or sympathetic tone. (Glyco is also a bad idea for premedication.) Etomidate or Thiopental would be acceptable choices for induction given h/o cardiomyopathy. I would also give Succinylcholine up front and not attempt mask ventilation prior to giving a muscle relaxant. Have a bougie, glidescope, and fiberoptic scope available as adjuncts for intubation. Have an LMA ready (can use to assist with ventilation and/or intubation)

 

[huktonfonix]

Check mouth opening/ROM of neck +/- symptoms.

PreO2 with mother in room to calm patient if neccesary

Have crich kit/jet vent readily available

Iv induction with succ. Avoid tachycardia, rapid drop in SVR. Use esmolol, phenylephrine as neccesary.

Attempt mask ventilation

Follow ASA difficult airway algorithm (probably LMA with FBO if unable to ventilate/intubate or video laryngoscope)

Avoid hyperextension of head/neck.

 

[Jeff05]

giving a dose of glyco and ketamine and causing tachycardia in a HOCM situation is not good.

give po midazolam. EMLA to multiple IV sites. let it sit. get iv in once kid is sedated from midaz. you must be able to control SVR, HR in this patient. for me, a preinduction iv is a must.

get him down with some etomidate or a bit of prop with phenylephrine chaser. keep breathing spontaneously with oxygen/sevo.

i would go with miller 2. if that doesn't work glidescope. if that doesn't work fiberoptic via LMA. if that doesn't work have the surgeon trach while kid is down with mask.

 

[Noyac]

I would not have the mother in the room but thats me. I frequently don't problems with this but if we are going to have to do a trach, I don't want any other distractions.

I think ketamine can be used very effectively in this pt. The sympathetic stimulation comes from larger doses than we typically us for sedation. I wouldn't hesitate to use it judiciously.

I'd probably try using precedex (carefully) keeping him breathing spontaneously. Then do a transtracheal injection leaving an 18 or 16 g cath in place for jet ventilation if needed. Then I'd insert either a glidescope or a FOB in hopes of an easy intubation.

ENT would be present or course.

Oh, and I wouldn't use glyco. I want his heart to have time to fill minimizing the obstruction.

Just my approach.

 

[Planktonmd]

Start IV, Give Glyco and put him to sleep with Propofol and NO OTHER MEDICATION.
Take 1 look with Gidescope (or whatever toy you like the most) if no good do asleep fiberoptic.
If you get in trouble he will most likely start breathing on his own as long as you don't feel inclined to give Midazolam or Fentanyl pre-op.

 

[anesthesiadoc]

I would not have the mother in the room but thats me. I frequently don't problems with this but if we are going to have to do a trach, I don't want any other distractions.

I think ketamine can be used very effectively in this pt. The sympathetic stimulation comes from larger doses than we typically us for sedation. I wouldn't hesitate to use it judiciously.

I'd probably try using precedex (carefully) keeping him breathing spontaneously. Then do a transtracheal injection leaving an 18 or 16 g cath in place for jet ventilation if needed. Then I'd insert either a glidescope or a FOB in hopes of an easy intubation.

ENT would be present or course.

Oh, and I wouldn't use glyco. I want his heart to have time to fill minimizing the obstruction.

Just my approach.

Good call on the gentle precedex. I agree that the low dose ketamine can be well tolerated from a cardiovascular standpoint. (Probably get a worse cardiovascular response if the patient is undersedated/anxious).

 

[Jeff05]

plankton, i disagree.

hemodynamic goals in management of HOCM are:

1. decreased contractility. we still have halothane vaps in the cardiac rooms, so this is one way of doing it. prop would certainly accomplish this, but would also drop preload/afterload - not desired.

2. maintain preload - fluids/avoidance of tachycardia. glyco would not accomplish this. propofol would drop preload.

3. maintain svr/aL - propofol would drop svr.



also, sympathetic stimulation 2/2 ketamine is not dose dependent. so even a smaller dose would cause SNS windup. this drug is not advisable for HOCM (increased contractility and HR).


actual plan - awake fiberoptic while maintaining hemodynamic goals.

start IV. give glyco and beta blocker. droperidol 20mg. AFI. if you got some halothane run that with fentanyl to maintain.

 

[SleepIsGood]

I dont know what happend to the response I posted a few hours back.

But here's my opinion. Local anesthesia to all nerves innervating the larynx. Also some nebulized lido. Give some midaz. Try awake FOI. If unsuccesful. Do AWAKE trach with ENT.

This kid with downs already has a reduced laryngeal diameter. On top of that, he had a trach before and probably has some degree of tracheal stenosis.

So my 'final answer' is awake trach, secure the a/w

 

[Planktonmd]

plankton, i disagree.

hemodynamic goals in management of HOCM are:

1. decreased contractility. we still have halothane vaps in the cardiac rooms, so this is one way of doing it. prop would certainly accomplish this, but would also drop preload/afterload - not desired.

2. maintain preload - fluids/avoidance of tachycardia. glyco would not accomplish this. propofol would drop preload.

3. maintain svr/aL - propofol would drop svr.



also, sympathetic stimulation 2/2 ketamine is not dose dependent. so even a smaller dose would cause SNS windup. this drug is not advisable for HOCM (increased contractility and HR).


actual plan - awake fiberoptic while maintaining hemodynamic goals.

start IV. give glyco and beta blocker. droperidol 20mg. AFI. if you got some halothane run that with fentanyl to maintain.

😀
OK Jeff.
So, you are saying that a Halothane induction is better than Propofol in this case because Halothane preserves contractility, preload and afterload?? Who told you that??
I hope that you are not saying that Halothane induction will produce more hemodynamic stability in this patient than Propofol!
The main issue here is the airway all that other stuff is irrelevant if you can't intubate the patient (remember ABC).
So what I was saying is: Induce hypnosis with an induction agent (I prefer Propofol) and please avoid Halothane if you could, don't combine agents because this would be a recipe for trouble, and dry the secretions with an antisialogogue because there is a good chance you are going to need FOB here.

 

[Jeff05]

actually, halothane would be an excellent drug for an inhalational induction for hocm. it maintains svr, does not increase HR, while providing myocardial depression.

prop is ok (good for the myocardial depression), as long as you maintain SVR with phenylephrine as needed.

and if you're really worried about intubating this patient - he should have AFOI.

 

[huktonfonix]

I dont know what happend to the response I posted a few hours back.

But here's my opinion. Local anesthesia to all nerves innervating the larynx. Also some nebulized lido. Give some midaz. Try awake FOI. If unsuccesful. Do AWAKE trach with ENT.

This kid with downs already has a reduced laryngeal diameter. On top of that, he had a trach before and probably has some degree of tracheal stenosis.

So my 'final answer' is awake trach, secure the a/w

good luck with that awake trach if you cant get him to cooperate with awake FOI.

 

[Planktonmd]

I dont know what happend to the response I posted a few hours back.

But here's my opinion. Local anesthesia to all nerves innervating the larynx. Also some nebulized lido. Give some midaz. Try awake FOI. If unsuccesful. Do AWAKE trach with ENT.

This kid with downs already has a reduced laryngeal diameter. On top of that, he had a trach before and probably has some degree of tracheal stenosis.

So my 'final answer' is awake trach, secure the a/w

Have you ever seen awake procedures in ******ed kids???
They are not very pretty.

 

[Planktonmd]

actually, halothane would be an excellent drug for an inhalational induction for hocm. it maintains svr, does not increase HR, while providing myocardial depression.

and if you're really worried about intubating this patient - he should have AFOI.

Halothane is a crappy drug and should never be used (if you don't believe me now you will in a few years).
And, we are obviously worried about intubating this patient, this is the point of this thread!
And awake intubations in ******ed kids are not very elegant to say the least but it doesn't hurt to mention them on the oral boards because they might let you slide.

 

[Planktonmd]

actually, halothane would be an excellent drug for an inhalational induction for hocm. it maintains svr, does not increase HR, while providing myocardial depression.

prop is ok (good for the myocardial depression), as long as you maintain SVR with phenylephrine as needed.

and if you're really worried about intubating this patient - he should have AFOI.

Who told you that Halothane maintains SVR???

 

[huktonfonix]

Have you ever seen awake procedures in ******ed kids???
They are not very pretty.

Also, this is also NOT a kid. It is a 29 yo with likely a kids mentality and adult strength. That makes for a bad experience when combined with sharp objects and medications.

 

[IceDoc]

Nobody's said it yet, so I will: Who took the trach out???? 4 recent aspirations and someone takes the trach out? *******.

Step 1: Find whoever it was and berate them prior to starting any induction.

 

[Jeff05]

FFECTS ON THE CARDIOVASCULAR SYSTEM
Halothane, desflurane, enflurane, sevoflurane, and isoflurane all decrease mean arterial pressure in direct proportion to their alveolar concentration. With halothane and enflurane, the reduced arterial pressure appears to be caused by a reduction in cardiac output because there is little change in systemic vascular resistance despite marked changes in individual vascular beds (eg, an increase in cerebral blood flow). In contrast, isoflurane, desflurane, and sevoflurane have a depressant effect on arterial pressure as a result of a decrease in systemic vascular resistance with minimal effect on cardiac output.
Basic and Clinical Pharmacology >
Chapter 25. General Anesthetics

"decreases in MAP associated with halothane, although similar to other VA, parallel the decrease in CO, and the calculated SVR remains unchanged"
basics of anesthesia by robert stoelting and ronald miller p. 49. see figure 4-6 for an illustration (while all other VA decrease SVR, halothane maintains an almost complete parallel to the x axis)

so good ol' rob and ron told me. who told you that it doesn't?

Who told you that Halothane maintains SVR???

 

[Planktonmd]

FFECTS ON THE CARDIOVASCULAR SYSTEM
Halothane, desflurane, enflurane, sevoflurane, and isoflurane all decrease mean arterial pressure in direct proportion to their alveolar concentration. With halothane and enflurane, the reduced arterial pressure appears to be caused by a reduction in cardiac output because there is little change in systemic vascular resistance despite marked changes in individual vascular beds (eg, an increase in cerebral blood flow). In contrast, isoflurane, desflurane, and sevoflurane have a depressant effect on arterial pressure as a result of a decrease in systemic vascular resistance with minimal effect on cardiac output.
Basic and Clinical Pharmacology >
Chapter 25. General Anesthetics

"decreases in MAP associated with halothane, although similar to other VA, parallel the decrease in CO, and the calculated SVR remains unchanged"
basics of anesthesia by robert stoelting and ronald miller p. 49. see figure 4-6 for an illustration (while all other VA decrease SVR, halothane maintains an almost complete parallel to the x axis)

so good ol' rob and ron told me. who told you that it doesn't?

You are confusing Halothane maintenance with Halothane Induction!
Halothane induction (1.5-3) MAC causes DECREASE in calculated SVR like the other Vapors.

Read this:
Effects of the Anesthetics on Calculated Hemodynamic Parameters

Stroke volume index was preserved at 1 and 1.5 MAC in the sevoflurane, the isoflurane, and the fentanyl-midazolam groups. Stroke volume index decreased with halothane at both anesthetic concentrations. Left ventricular end diastolic volume, a measure of left ventricular preload, was not changed from baseline by any anesthetic regimen. Systemic CI was preserved at 1 and 1.5 MAC in the sevoflurane and isoflurane groups. CI decreased at both concentrations in the fentanyl-midazolam group and at 1.5 MAC in the halothane group. Figure 1 shows the changes in cardiac index in each individual patient in the four groups. Systemic vascular resistance index was preserved at 1 and 1.5 MAC in the sevoflurane and the fentanyl-midazolam groups. Systemic vascular resistance index decreased in the halothane group at 1.5 MAC but was conserved at 1 MAC, and decreased at both MACs in the isoflurane group.

Here is the full article:
http://journals.lww.com/anesthesiol...=2001&issue=02000&article=00010&type=fulltext

 

[Hockeyguy]

My approach PO precedex. We give it to our downs kids all the time works like a charm. Start IV when chilled out. If HR decreases which it likely will then would be a good time to give glyco. Preoxygenate like crazy. Give little propofol then take a look with the glide scope as soon as cords in view smash prop - sux - tube. If no view asses ventliation. If easy to ventilate deepen and and asleep scope. If feels tough to ventliate wake up reasses.

 

[Jeff05]

My approach PO precedex. We give it to our downs kids all the time works like a charm. Start IV when chilled out. If HR decreases which it likely will then would be a good time to give glyco. Preoxygenate like crazy. Give little propofol then take a look with the glide scope as soon as cords in view smash prop - sux - tube. If no view asses ventliation. If easy to ventilate deepen and and asleep scope. If feels tough to ventliate wake up reasses.

what dose of precedex po?

 

[Hockeyguy]

what dose of precedex po?

Hey Jeff,

5 to 6 micrograms/kg. For the kids we mix it in with a little sprite. It takes 30 minutes to kick in fully so thats a downside. But the attending I have used it with has convinced me. We have taken care of the 300 pound clausterphobic DS kids and haven't had a problem yet. OR staff has even commented how smoothly some of the rougher customers have been induced. It sure beats IM ketamine while everyone holds them down. ONe kid was bassically out on the stretcher so we just quitely wheeled him back placed pulse ox and BP cuff and did a nice steal induction.

Mario