ICU intubation scenario

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[VentdependenT]

Happened to me yesterday, i am not currently rotating through micu:

52 morbidly obese WM with OHS admitted for RUL white out mrsa pna was on 16/8 bipap for 12h for hypercarbic/hypoxic resp failure. transferred to micu for abg: 7.17/63/60 and lethargy. I get a text from my buddy which just contains the room #. never good.

I arrive. Pt flat in bed, no neck, beard, spo2 86, missing 2 front teeth test are intact, massive airleak around ambumask. they gave versed, fentanyl, etomidate. no NMB given. Pt has no respiratory movements.

proceed.

 

[jdh71]

Happened to me yesterday, i am not currently rotating through micu:

52 morbidly obese WM with OHS admitted for RUL white out mrsa pna was on 16/8 bipap for 12h for hypercarbic/hypoxic resp failure. transferred to micu for abg: 7.17/63/60 and lethargy. I get a text from my buddy which just contains the room #. never good.

I arrive. Pt flat in bed, no neck, beard, spo2 86, missing 2 front teeth test are intact, massive airleak around ambumask. they gave versed, fentanyl, etomidate. no NMB given. Pt has no respiratory movements.

proceed.

 

[excalibur]

Happened to me yesterday, i am not currently rotating through micu:

52 morbidly obese WM with OHS admitted for RUL white out mrsa pna was on 16/8 bipap for 12h for hypercarbic/hypoxic resp failure. transferred to micu for abg: 7.17/63/60 and lethargy. I get a text from my buddy which just contains the room #. never good.

I arrive. Pt flat in bed, no neck, beard, spo2 86, missing 2 front teeth test are intact, massive airleak around ambumask. they gave versed, fentanyl, etomidate. no NMB given. Pt has no respiratory movements.

proceed.

Good job Vent! Take over and keept the young guns working

 

[bkell101]

mask ventilation doesnt sound too good
If we havent already....
Throw in an oral airway
Two person bag
Raise head of bed a bit to relieve his diaphragm?
Try to adequately bag ....
I like giving paralytic -maximizes our chances, might make him easier to bag, and I don't get the feeling we have the option of waking back up
If sats don't correct..I think time to just take a look with the blade, unless they already have the glide scope ready ....if no view ask for the LMA

 

[bkell101]

OHS - gotta assume he has pa htn and be weary that hypercarbia and hypoxia can worsen his pa pressures and send him into obstructive shock if he isn't already hypotensive from sepsis


What's his and hr like?

 

[VentdependenT]

HR 120's

Oral airway placed with difficulty. Mouth opening 2cm only. 2 person mask bag. spo2 drops to 78 then climbs to 92 and stays there after several minutes of bagging. Its hard to get a good seal but its possible. Mask is not appropriate size but there are no large masks available in the ICU. The pts abdomen is getting larger with each breath.

Still no respiratory motion. Glidescope, mac4, and lma 4. There is no LMA 5 in kit. all at bedside. Resident and fellow havent opened bougie canister.

Resident cannot get glidescope into pts pharynx because of limited mouth opening. Sats drop to 84 while trying this. able to bag back up to 92, but it takes a while. Still no respiratory motion. Belly enlarging with each positive pressure ventilation.

What do you want to do?

 

[bkell101]

Man this does not sound good .....

Trying to go through the algorithm in my head...

Initial attempt unsuccessful
1. Call for help, but we are the help
2. Consider waking up - if he could breathe awake we wouldn't be trying so this sounds like its out

We can ventilate .......so try a new method

With a small mouth opening ....I'm thinking the Mac blade may not fit either since the glide didn't fit...Lma is in the algorithm but this might not fit either but thats probably what i would try next....i stink with a miller at this point but I've seen attendings use the straight blade with a bougie when there isn't much room to work with....other that that is a fiber optic scope available?



I

 

[VentdependenT]

Man this does not sound good .....

Trying to go through the algorithm in my head...

Initial attempt unsuccessful
1. Call for help, but we are the help
2. Consider waking up - if he could breathe awake we wouldn't be trying so this sounds like its out

We can ventilate .......so try a new method

With a small mouth opening ....I'm thinking the Mac blade may not fit either since the glide didn't fit...Lma is in the algorithm but this might not fit either but thats probably what i would try next....i stink with a miller at this point but I've seen attendings use the straight blade with a bougie when there isn't much room to work with....other that that is a fiber optic scope available?



I

Good. we can ventilate. for now. I step in and make decision to use succinylcholine. Mouth can now open to 3cm. still able to ventilate. I let resident attempt glidescope. Cords visualized but edematous. lots of soft tissue.

The go to put tube in and the ETT totally obstructs their view. they didnt have the glidescope stylette....sats back down to 78. Nurse says the stylettes are missing

 

[Icefrog]

Is there a bougie available? Can bend a hockey stick curve onto bougie and pass through cords via glidescope. Then intubate over bougie.

 

[VentdependenT]

Is there a bougie available? Can bend a hockey stick curve onto bougie and pass through cords via glidescope. Then intubate over bougie.

BINGO. Bougie is my best friend. That little skinny plastic beautch has saved my ass every time in pts with limited mouth opening.

I ended up taking over,ditching the glide for MAC4, and getting grade I. I too lost the view with the ett but got it in anyways

 

[OB1🤙]

When the stylet for the Glidescope goes missing, no fret. Take your regular run-of-the-mill malleable stylet, hold the ETT next to the Glidescope blade, and bend the stylet to conform to its curve. Bingo. No need for the proprietary stylet.

 

[VentdependenT]

When the stylet for the Glidescope goes missing, no fret. Take your regular run-of-the-mill malleable stylet, hold the ETT next to the Glidescope blade, and bend the stylet to conform to its curve. Bingo. No need for the proprietary stylet.

Thats why I love this site.

Ive just bougied with the glide when thing is missing.

BTW, after our context sensitive halflife discussion with sufenta for micu sedation I asked the pharmacist if we could give it a whirl. He said that stuff is far more expensive than fentanyl.

 

[VentdependenT]

Point for the jr's was:
1) if you can ventilate then paralyse
2)pushing even small doses of drugs can knock out a sickies respiratory drive

 

[pgg]

BTW, after our context sensitive halflife discussion with sufenta for micu sedation I asked the pharmacist if we could give it a whirl. He said that stuff is far more expensive than fentanyl.

Really? That surprises me. It's been off patent forever. Did he give you numbers?

I always figured that the fentanyl cost is pennies, and sufentanil tens of pennies.

 

[OB1🤙]

Thats why I love this site.

Ive just bougied with the glide when thing is missing.

BTW, after our context sensitive halflife discussion with sufenta for micu sedation I asked the pharmacist if we could give it a whirl. He said that stuff is far more expensive than fentanyl.

It was alfentanil I was advocating, though sufent still better than fent. Alfenta should be cheap, but since almost nobody uses it these days YMMV.

 

[VentdependenT]

Really? That surprises me. It's been off patent forever. Did he give you numbers?

I always figured that the fentanyl cost is pennies, and sufentanil tens of pennies.

Thats what I thought too. didnt ask specifics. When i start fellowship ill dig into it more.

 

[bkell101]

Happened to me yesterday, i am not currently rotating through micu:

52 morbidly obese WM with OHS admitted for RUL white out mrsa pna was on 16/8 bipap for 12h for hypercarbic/hypoxic resp failure. transferred to micu for abg: 7.17/63/60 and lethargy. I get a text from my buddy which just contains the room #. never good.

I arrive. Pt flat in bed, no neck, beard, spo2 86, missing 2 front teeth test are intact, massive airleak around ambumask. they gave versed, fentanyl, etomidate. no NMB given. Pt has no respiratory movements.

proceed.

Vent, would you have given paralytic upfront? Or kept is this guy spontaneously breathing from the get go and establish airway awake?

 

[bkell101]

When the stylet for the Glidescope goes missing, no fret. Take your regular run-of-the-mill malleable stylet, hold the ETT next to the Glidescope blade, and bend the stylet to conform to its curve. Bingo. No need for the proprietary stylet.

This is sweet thanks for the tip.

 

[bkell101]

BINGO. Bougie is my best friend. That little skinny plastic beautch has saved my ass every time in pts with limited mouth opening.

I ended up taking over,ditching the glide for MAC4, and getting grade I. I too lost the view with the ett but got it in anyways

This sparked my interest in the bougie....I personally have never used it, but I can think of situations where it would have been useful.

nobody has ever shown me how to use one....I went to you tube and found a few videos with the basics and a few tricks of he trade

Anything wrong with using the bougie on a few easy airways just to get the feel of it, and be more confident the first time I truly need it?

 

[bkell101]

BINGO. Bougie is my best friend. That little skinny plastic beautch has saved my ass every time in pts with limited mouth opening.

I ended up taking over,ditching the glide for MAC4, and getting grade I. I too lost the view with the ett but got it in anyways

This sparked my interest in the bougie....I personally have never used it, but I can think of situations where it would have been useful.

nobody has ever shown me how to use one....I went to you tube and found a few videos with the basics and a few tricks of he trade

Anything wrong with using the bougie on a few easy airways just to get the feel of it, and be more confident the first time I truly need it?

 

[VentdependenT]

Vent, would you have given paralytic upfront? Or kept is this guy spontaneously breathing from the get go and establish airway awake?

Asleep and paralysed or awake lido and maybe tiny bump of propofol are my two options. always have backup gear available if any question of difficult intubation/ventillation exists. This consists of a minimum of: LMA, oral and nasal airway, 2 different styletted sized tubes, 2 blades of different sizes, and a bougie

I wasnt there to evaluate his airway initially. But those are the two paths for me.

 

[bkell101]

Asleep and paralysed or awake lido and maybe tiny bump of propofol are my two options. always have backup gear available if any question of difficult intubation/ventillation exists. This consists of a minimum of: LMA, oral and nasal airway, 2 different styletted sized tubes, 2 blades of different sizes, and a bougie

I wasnt there to evaluate his airway initially. But those are the two paths for me.

I listened to a debate between the em crit Guy and one of his colleagues about the use of paralytics in the icu .....I'm assuming you would be in the camp of using paralytics if going to sleep....

In our micu the residents can't use paralytics and even when the pulm cc attending is bedside they don't push paralytics either.

When you showed up to the above situation, no paralytics had been given.

Why not? (The guy in the debate against Scott w made no real good arguments)

 

[VentdependenT]

I listened to a debate between the em crit Guy and one of his colleagues about the use of paralytics in the icu .....I'm assuming you would be in the camp of using paralytics if going to sleep....

In our micu the residents can't use paralytics and even when the pulm cc attending is bedside they don't push paralytics either.

When you showed up to the above situation, no paralytics had been given.

Why not? (The guy in the debate against Scott w made no real good arguments)

I have no idea. I think they wanted to do some sort of awakish look but overshot? Thats the only thing that makes sense. If pushing induction agents then push paralytics

 

[bkell101]

I seeeeeeee, hence the learning point that just a little bit can knock out the respiratory drive of a sick pt.

You mentioned a bump of propofol with an awake look, how much in a big/sick guy? Why not ketamine to keep the resp drive?

 

[bkell101]

Point for the jr's was:
1) if you can ventilate then paralyse
2)pushing even small doses of drugs can knock out a sickies respiratory drive

Originally, I totally missed point number two .


For point number number 1, I originally said raise the head of the bed a little bit in order to make diaphragm excursion a little easier...is that accurate in a tough to ventilate obese guy, or just a theoretical thing that sounds good in my head?

 

[VentdependenT]

Originally, I totally missed point number two .


For point number number 1, I originally said raise the head of the bed a little bit in order to make diaphragm excursion a little easier...is that accurate in a tough to ventilate obese guy, or just a theoretical thing that sounds good in my head?

Accurate in terms of lining up your airway axis. Line up ear with sternal notch. May also help also with increasing FRC in lung and slowing tome to desat. Wont help too much with bagging.

 

[VentdependenT]

Ketamine would be fine but can make airway juicy. Main reason though is that its a pain in the ass to get it in the unit in a timely manner.

10mg bumps until pt drowsy but still responsive

 

[Bostonredsox]

ketamine and Roc are both about as easy to get ahold of for my MICU airways as herpes from a nun.

 

[VentdependenT]

lmfao

 

[Idiopathic]

I listened to a debate between the em crit Guy and one of his colleagues about the use of paralytics in the icu .....I'm assuming you would be in the camp of using paralytics if going to sleep....

In our micu the residents can't use paralytics and even when the pulm cc attending is bedside they don't push paralytics either.

When you showed up to the above situation, no paralytics had been given.

Why not? (The guy in the debate against Scott w made no real good arguments)

im sorry, but i just dont see a debate here. if you have committed to the intubation pathway (which most likely is the case in this type of patient), then you gain nothing by not paralyzing.

unless you are truly keeping the patient awake (i.e. topicalization and FOI or awake DL) then I just cant fathom the benefit in this strategy, especially when dealing with the MICU/ER/etc.

 

[Bostonredsox]

im sorry, but i just dont see a debate here. if you have committed to the intubation pathway (which most likely is the case in this type of patient), then you gain nothing by not paralyzing.

unless you are truly keeping the patient awake (i.e. topicalization and FOI or awake DL) then I just cant fathom the benefit in this strategy, especially when dealing with the MICU/ER/etc.

agreed. Once youve pushed amidate or a nice smooth bolus of prop, you can only gain by paralyzing. The caveat I would add, especially for fellow non anesthesia guys who probably by definition have less total airways then the gas guys, is for patients that look like they could be difficult and you dont have a Glide at hand, if you can ventilate easily after pushing your etom/prop/keta, I peak at the airway and make sure I can atleast see into the vicinity of the cords. If i cant get the blade in through the teeth, I push the succ/roc. again, youve knocked out the airway with etom/prop already cant worsen it really by giving succ. But If I can easily insert the blade, get a view and easily ventilate, I peak in after induction and quite frequently pass the tube without a paralytic, but it is always drawn up in case I decide I need it. It may be a false sense of security for obese sleep apneics failing bipap that I am electively intubating, but in those pts I like to know that I can atleast see the cords before paralyzing. Everyone else is etom/sux/tube the moment I decide to tube them without any hesitation.

 

[OB1🤙]

OK everybody go read my favorite editorial- "Anesthesia Dogmas and Shibboleths: Barriers to Patient Safety?" http://www.anesthesia-analgesia.org/content/114/3/694.full . Especially #2

Then go read this- "Could 'safe practice' be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker?" http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05429.x/full

Then realize that test ventilation is dogmatic. If you have a truly difficult airway in front of you, do it awake. If you're going to push an amount of an induction agent that will render the patient oblivious to a large metal object in their pharynx, you should paralyze too. From the get go.

 

[VentdependenT]

The key issue should then be reversal of induction agent in UNANTICIPATED difficult ventillation. Half-assen it makes ventillation harder and increases risk of aspiration.

 

[fakin' the funk]

OK everybody go read my favorite editorial- "Anesthesia Dogmas and Shibboleths: Barriers to Patient Safety?" http://www.anesthesia-analgesia.org/content/114/3/694.full

While a little dogmatic/shibbolethy itself, what a great freakin editorial.

I love the point of giving alfentanil instead of fentanyl for "blunting the sympathetic response to intubation." I use alfenta a fair amount and think it has a really important role in our practice.

 

[bkell101]

OK everybody go read my favorite editorial- "Anesthesia Dogmas and Shibboleths: Barriers to Patient Safety?" http://www.anesthesia-analgesia.org/content/114/3/694.full . Especially #2

Then go read this- "Could 'safe practice' be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker?" http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05429.x/full

Then realize that test ventilation is dogmatic. If you have a truly difficult airway in front of you, do it awake. If you're going to push an amount of an induction agent that will render the patient oblivious to a large metal object in their pharynx, you should paralyze too. From the get go.

Can't wait to read this....Thank you for posting.

Only an intern but The more I read and listen to lectures the more I realize how a s s. backwards we do stuff at my residency ....I can't tell you how many botched airways with adverse events I've seen because of 1. Never doing awake looks in the 600 lb OSA pt and 2. Never using paralytics .........people are resistant to change though.

 

[Idiopathic]

Can't wait to read this....Thank you for posting.

Only an intern but The more I read and listen to lectures the more I realize how a s s. backwards we do stuff at my residency ....I can't tell you how many botched airways with adverse events I've seen because of 1. Never doing awake looks in the 600 lb OSA pt and 2. Never using paralytics .........people are resistant to change though.

i know its hyperbole, but i doubt youve seen too many 600 lb patients.

 

[Idiopathic]

OK everybody go read my favorite editorial- "Anesthesia Dogmas and Shibboleths: Barriers to Patient Safety?" http://www.anesthesia-analgesia.org/content/114/3/694.full . Especially #2

Then go read this- "Could 'safe practice' be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker?" http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05429.x/full

Then realize that test ventilation is dogmatic. If you have a truly difficult airway in front of you, do it awake. If you're going to push an amount of an induction agent that will render the patient oblivious to a large metal object in their pharynx, you should paralyze too. From the get go.

this point is still up for debate in the controlled setting of the OR, in my opinion. there are many reasons to mask ventilate prior to pushing paralytic, and the case has not been decided by one or two editorials, no matter how esteemed the author.

if you are mask ventilating to decide whether or not to paralyze a patient as a matter of course, that is probably wrong. however, if it is your preference to use long acting NMB then there may be value to a test ventilation before pushing that drug. i try to avoid sux when i can, before i push the roc or vec i feel reassured by seeing easy chest rise from a one handed mask. i also think its important to use this opportunity to teach young providers nuances of mask ventilation (i.e. when you come upon the obtunded/apneic but not chemically paralyzed patient, do you have to intubated immediately? can you mask them? lets practice...)

in the ICU, there is almost no role for this, except when you are waiting that 40 seconds for the roc to take effect, or if a patient had been on BIPAP, but realize these are different things and you shouldnt rely on mask ventilation in the ICU setting to determine whether to paralyze. once you push an induction med you have committed yourself to a worst a supraglottic airway, and so waking up these patients is not an option.

 

[bkell101]

i know its hyperbole, but i doubt youve seen too many 600 lb patients.

I know i know , you're right...only said that exaggerating, buuuuuuttttt, unfortunately I can recall a small handful this year so far who were pushing 5 bills

 

[OB1🤙]

I'll concede the point that if one of the goals of your induction is to make your trainee struggle with a more difficult patient to ventilate, you should withhold the relaxant.

If your goal is to optimize airway conditions, you should paralyze from the get go.

 

[soonerfrog]

I tend to side with Idiopathic in so far as the ability to mask ventilate should not in and of itself make up an entire limb of your decision tree. It is like everything else in the OR: it may or may not be simply another data point you use to finalize a greater decision based on other variables ie-how much airway experience do I have, what tools are going to be available to me if I fail in my initial steps down the airway algorithm, what will my patient be able to tolerate, how cowboy am I feeling today, ect ect ect. You don't let a BIS of 65 dictate your entire anesthetic so maybe the ability to mask ventilate (or the lack thereof) should also be just that: one piece of info you may or may not chose to consider important in a greater context of other pertinent clinical information.

 

[leviathan]

Thing of the King like a Combitube.

It's a rescue device, or a device for non-experts to shove in the mouth and hopefully get a decent result.

So no, we don't have these in the OR. One of our airway guys is trying to figure out a way to use it as an intubation conduit though, given the increased frequency that the EMS people are using them.

We have LMAs in the OR, and as far as I'm aware there's not much difference between an LMA and other supraglottic airways. It's a rescue device and part of management for the can't intubate+can't ventilate scenario. Is there a reason why the LMA is used in the OR over these other devices beyond familiarity and tradition?

 

[stonemd]

How do you optimally preoxygenate a patient in the ICU who is breathing spontaneously, has a low sat and needs urgent intubation?

 

[Lightwand]

We have LMAs in the OR, and as far as I'm aware there's not much difference between an LMA and other supraglottic airways. It's a rescue device and part of management for the can't intubate+can't ventilate scenario. Is there a reason why the LMA is used in the OR over these other devices beyond familiarity and tradition?

It is virtually impossible to fiber through a King and successfully use it as a conduit for intubation. There are a few videos on YouTube of people attempting to exchange over a Bougie, but I'm not impressed. If you do need to switch from supraglottic to tube, you have to pull the airway out. If you're using it in a rescue situation, having to pull one airway out to place another one is suboptimal.

Kings and Combitubes save lives in the field for trauma patients, but I don't see much of a role for them in the OR.

 

[Idiopathic]

How do you optimally preoxygenate a patient in the ICU who is breathing spontaneously, has a low sat and needs urgent intubation?

BIPAP while you are setting up if you have time. Also consider awake procedure, or support with mask while paralytic is taking effect. Sometimes you have to realize that sats in the 80s may be as good as you get.

 

[Idiopathic]

It is virtually impossible to fiber through a King and successfully use it as a conduit for intubation. There are a few videos on YouTube of people attempting to exchange over a Bougie, but I'm not impressed. If you do need to switch from supraglottic to tube, you have to pull the airway out. If you're using it in a rescue situation, having to pull one airway out to place another one is suboptimal.

Kings and Combitubes save lives in the field for trauma patients, but I don't see much of a role for them in the OR.

Agreed you have to pull these out to really do anything with the airway.

 

[Bostonredsox]

BIPAP while you are setting up if you have time. Also consider awake procedure, or support with mask while paralytic is taking effect. Sometimes you have to realize that sats in the 80s may be as good as you get.

agreed. I have people failing bipap all the time with sats down to mid 80s I then decide to intubate. Theyre sats are 85% on 18/8 @100%...your not going to improve them by bagging. Etom/Sux/pull of bipap/tube.