Induction on the wards

[Drangue]

It’s not just patient safety at stake.

I was also trained NOT to use paralysis for floor intubation.

During floor Intubation of hep c patient with UGI bleed 12 years ago, he coughed a bunch of black blood into my face and eyes.

100mg of roc for everyone since!

We have this really cool and young attending that always grabs a pair of eye protection every day before he starts the day and our class always makes a joke about it until one day I extubated a patient and they coughed blood into my face.

He now makes jokes about it to me.

I don't care if I am behind the ether drape; I am wearing my eye protection.

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[Bryan O’Blivion]

Junior trainees please ignore this.
There is no never in this business.

Each one is a case by case basis.

While I agree with you that each should be evaluated as a case by case basis, I’m not sure why you think people should ignore his/her statement. Why do you advise placing an arterial line in a hypothetical airway page prior to intubation? I can imagine specific situations in which I would do this, but more generally, in situation where I was called for an airway, I’d establish an airway. Please understand that I’m not attempting to engage you in a pedantic debate or deride your thinking.

One thing I’ve seen a lot of anesthesiologists do is insist on placing an arterial line prior to a therapeutic intervention, such as a CVC large bore peripheral access, medication admin, or endotracheal tube. This differs from my approach in these circumstances, in that, for instance, if I can’t palpate a peripheral pulse or get a cuff pressure, I know the situation is bad, and I’m less concerned about determining precisely how bad it is than I am about doing something about it. Again, I can think of delicate situations where the real time feedback of an arterial line would provide a framework for making rapid decisions, but I’m curious as to why so many people leap to place an a line in an airway discussion. An art line is very useful for guiding therapy, but it’s not a therapy. Often, I’m not sure that it is a great use of time and resources, or at the very least, poorly prioritized.

I think that this is what the other person is getting at.

Not to be contrary, but I would advise trainees not to ignore that statement, but rather to think why you’d take one approach or the other.

 

[vector2]

While I agree with you that each should be evaluated as a case by case basis, I’m not sure why you think people should ignore his/her statement. Why do you advise placing an arterial line in a hypothetical airway page prior to intubation? I can imagine specific situations in which I would do this, but more generally, in situation where I was called for an airway, I’d establish an airway. Please understand that I’m not attempting to engage you in a pedantic debate or deride your thinking.

One thing I’ve seen a lot of anesthesiologists do is insist on placing an arterial line prior to a therapeutic intervention, such as a CVC large bore peripheral access, medication admin, or endotracheal tube. This differs from my approach in these circumstances, in that, for instance, if I can’t palpate a peripheral pulse or get a cuff pressure, I know the situation is bad, and I’m less concerned about determining precisely how bad it is than I am about doing something about it. Again, I can think of delicate situations where the real time feedback of an arterial line would provide a framework for making rapid decisions, but I’m curious as to why so many people leap to place an a line in an airway discussion. An art line is very useful for guiding therapy, but it’s not a therapy. Often, I’m not sure that it is a great use of time and resources, or at the very least, poorly prioritized.

I think that this is what the other person is getting at.

Not to be contrary, but I would advise trainees not to ignore that statement, but rather to think why you’d take one approach or the other.

I’m not sure where or what kind of institution you’re at, but anecdotally at the 4 places I’ve trained and/or worked, literally the first thing taught to anesthesiology or ICU residents about art lines is that they are not a therapeutic intervention.

 

[MoMoGesiologist]

I’m not sure where or what kind of institution you’re at, but anecdotally at the 4 places I’ve trained and/or worked, literally the first thing taught to anesthesiology or ICU residents about art lines is that they are not a therapeutic intervention.

I’ve had enough people (nurses, RT, residents, surgeons, anesthesia) insist on alines and ABGs as though they are the treatment of choice for hypotension/hypoxia that I’m going to say I think I had a very different experience than you. I agree with you, but I don’t think everyone acts that way.

 

[vector2]

I’ve had enough people (nurses, RT, residents, surgeons, anesthesia) insist on alines and ABGs as though they are the treatment of choice for hypotension/hypoxia that I’m going to say I think I had a very different experience than you. I agree with you, but I don’t think everyone acts that way.

Don’t get me wrong, I am very pro a-line when I am staffing the SICU and I probably overuse P/F ratios/follow Pco2 from ABGs too much rather than titrating vents to pulse ox, etco2. However, in the acute phase of resuscitation I like to think both myself and my colleagues are likely the first to actually use a push dose pressor and escalate to a definitive airway vs typing in an order for norepi and a non rebreather.

 

[Bryan O’Blivion]

I’m not sure where or what kind of institution you’re at, but anecdotally at the 4 places I’ve trained and/or worked, literally the first thing taught to anesthesiology or ICU residents about art lines is that they are not a therapeutic intervention.

We would all agree that it is a diagnostic rather than therapeutic measure. Yet many people seem to advocate placing them prior to intervention, in this very thread, which is presumably composed of anesthesiologists.

A person previously described a situation where a patient was satting 90-92 percent, was potentially hemodynamically unstable, and they couldn’t obtain a cuff pressure. Very reasonable to obtain a blood pressure by arterial line prior to anesthetizing and placing an ETT, if the oxygenation and ventilation is stable and the BP is potentially not. But not essential. Could you not titrate in pressor and then anesthetize with a reduced dose of etomidate? Ketamine? Midazolam? A combination thereof?

Not to create a straw man, but now that an arterial line is placed, are you completely confident of the patient’s hemodynamics? How’s their contractility? What if there is valvular pathology present? Are you sure you don’t want a bedside TTE? There are going to be unknowns.

A lot of the time, I’ve ended up using a combination of pressor and reduced weight based etomidate or ketamine in unstable patients requiring emergent intubation, and the main difference that the arterial line brought was reassurance. It’s great if it’s there.

The real question here is when called for an airway is how to determine what intervention is necessary and how soon, as well as what order. It’s difficult honestly. I appreciate the perspectives people have here. I’m just adding mine.

 

[nimbus]

We would all agree that it is a diagnostic rather than therapeutic measure. Yet many people seem to advocate placing them prior to intervention, in this very thread, which is presumably composed of anesthesiologists.

A person previously described a situation where a patient was satting 90-92 percent, was potentially hemodynamically unstable, and they couldn’t obtain a cuff pressure. Very reasonable to obtain a blood pressure by arterial line prior to anesthetizing and placing an ETT, if the oxygenation and ventilation is stable and the BP is potentially not. But not essential. Could you not titrate in pressor and then anesthetize with a reduced dose of etomidate? Ketamine? Midazolam? A combination thereof?

Not to create a straw man, but now that an arterial line is placed, are you completely confident of the patient’s hemodynamics? How’s their contractility? What if there is valvular pathology present? Are you sure you don’t want a bedside TTE? There are going to be unknowns.

A lot of the time, I’ve ended up using a combination of pressor and reduced weight based etomidate or ketamine in unstable patients requiring emergent intubation, and the main difference that the arterial line brought was reassurance. It’s great if it’s there.

The real question here is when called for an airway is how to determine what intervention is necessary and how soon, as well as what order. It’s difficult honestly. I appreciate the perspectives people have here. I’m just adding mine.

If the intubation is not emergent, it’s easier to insert an arterial line while the patient still has a pulse and a blood pressure. Sometimes they don’t after intubation. I’ve seen situations where people repeatedly feel for a pulse and recycle the NIBP in a pulseless patient, unable to process that the patient needs cpr.

 

[Ronin786]

We would all agree that it is a diagnostic rather than therapeutic measure. Yet many people seem to advocate placing them prior to intervention, in this very thread, which is presumably composed of anesthesiologists.

A person previously described a situation where a patient was satting 90-92 percent, was potentially hemodynamically unstable, and they couldn’t obtain a cuff pressure. Very reasonable to obtain a blood pressure by arterial line prior to anesthetizing and placing an ETT, if the oxygenation and ventilation is stable and the BP is potentially not. But not essential. Could you not titrate in pressor and then anesthetize with a reduced dose of etomidate? Ketamine? Midazolam? A combination thereof?

Not to create a straw man, but now that an arterial line is placed, are you completely confident of the patient’s hemodynamics? How’s their contractility? What if there is valvular pathology present? Are you sure you don’t want a bedside TTE? There are going to be unknowns.

A lot of the time, I’ve ended up using a combination of pressor and reduced weight based etomidate or ketamine in unstable patients requiring emergent intubation, and the main difference that the arterial line brought was reassurance. It’s great if it’s there.

The real question here is when called for an airway is how to determine what intervention is necessary and how soon, as well as what order. It’s difficult honestly. I appreciate the perspectives people have here. I’m just adding mine.

To put things into perspective, unless it's an absolutely **** airway, my confidence level in being able to secure it is supremely high. I know that if the sats start dropping, I can pop a tube in seconds.

A lot of times, I'm called to intubate somebody without all the pieces being in place. This is because (rightfully so), many specialties do not have the same comfort level with a deteriorating airway. If it's a pure respiratory failure, then placing an arterial line is straight folly instead of securing the airway. But ask anybody on this board about the hemodynamic consequences of induction, intubation, PPV, etc.. and you'll get thirty different stories thrown at you. That's my thought process as far as arterial lines go.

I don't want it to be misconstrued that I won't secure an airway before having an arterial line in place. But ultimately, I am the best person to judge who does and does not need an airway in 60 seconds or less and how that's going to impact their system as a whole. Too often you're called as an airway jockey and our training means a whole lot more than that IMO.

 

[deleted162650]

Too often you're called as an airway jockey and our training means a whole lot more than that IMO.

Yeah, we’re A-line jockeys too damnit!

 

[Bryan O’Blivion]

If the intubation is not emergent, it’s easier to insert an arterial line while the patient still has a pulse and a blood pressure. Sometimes they don’t after intubation. I’ve seen situations where people repeatedly feel for a pulse and recycle the NIBP in a pulseless patient, unable to process that the patient needs cpr.

This is very true. On the other hand, I’ve found that the photoplethysmograph of the pulse oximeter is very good at demonstrating a peripheral pulse, often better than frantic fingers attempting to palpate a central pulse in an obese groin. Often times a noninvasive is having trouble it’s due to an agitated patient or an obese one. If there’s a pulse ox waveform and robust ETCO2, there is perfusion. If you don’t see both of those things, there’s a problem. I appreciate that most people here are trying to make the point that placing an arterial line can guide anesthetic doses to facilitate intubation and help determine unexpected results. That’s good quality care. But the point I’m making is that it seems like people I’ve observed want to place an arterial line prior to an intervention. One of the most emergent cases I’ve ever had I induced with pressor, reduced dose anesthetic, and succinylcholine, while the cuff was cycling, and blood was being pumped in. After securing central line and organizing the drips and blood/product, I thought about getting an a line. Then I realized that I was titrating volume and pressor to ETCO2, the pulse ox, and getting rising cuff pressures. I thought, why do I want an a line? I can run venous gases, get labs, and I know the patient is perfusing. What more will it get me? If I’d been more confident of the BP, maybe I’d have given more etomidate, more vapor up front, and there would be less risk of recall. But the point is, the critical window passed quickly, and it seemed more important to perform an intervention than an assessment.

 

[Bryan O’Blivion]

To put things into perspective, unless it's an absolutely **** airway, my confidence level in being able to secure it is supremely high. I know that if the sats start dropping, I can pop a tube in seconds.

A lot of times, I'm called to intubate somebody without all the pieces being in place. This is because (rightfully so), many specialties do not have the same comfort level with a deteriorating airway. If it's a pure respiratory failure, then placing an arterial line is straight folly instead of securing the airway. But ask anybody on this board about the hemodynamic consequences of induction, intubation, PPV, etc.. and you'll get thirty different stories thrown at you. That's my thought process as far as arterial lines go.

I don't want it to be misconstrued that I won't secure an airway before having an arterial line in place. But ultimately, I am the best person to judge who does and does not need an airway in 60 seconds or less and how that's going to impact their system as a whole. Too often you're called as an airway jockey and our training means a whole lot more than that IMO.

I think this is the best answer to the OP.
I completely agree with you, and I am always trying to hone and better develop that judgment. It becomes pretty high stakes in these situations. It’s really the crux of what we are discussing. If you think that there is time to safely place an arterial line, and the hemodynamics concern you enough to utilize one, then place it. If you recognize the rapidly progressing need to secure the airway, and you are concerned about blood pressure, yet will require some anesthetic, as there is evidence that the patient is mentating, the question is, how much, and of what. I’m not sure an arterial line will clearly give you the answer. I just see people reflexively wanting an arterial line to address that uncertainty. It’s not wrong, it will help, but to me, you have to act on what you know: Is the circulation borderline? Treat it. Do you anticipate a loss of preload and contractility in this patient in this circumstance, with the agent available? Treat it. Of course you cannot know any of these things truly and precisely, even with invasive monitoring. That’s the point when you have to make a decision based on what you have available.

 

[fakin' the funk]

This is very true. On the other hand, I’ve found that the photoplethysmograph of the pulse oximeter is very good at demonstrating a peripheral pulse,

Yeah but first you have to ask the nurses not to futz with the probe every 5-10 seconds, and then teach them about it when they look at you like you have two heads

 

[coffeebythelake]

If the intubation is not emergent, it’s easier to insert an arterial line while the patient still has a pulse and a blood pressure. Sometimes they don’t after intubation. I’ve seen situations where people repeatedly feel for a pulse and recycle the NIBP in a pulseless patient, unable to process that the patient needs cpr.

Yes! Absolutely agree with this.
only takes a few seconds to do
Not everyone needs an art line before induction,
When I put one in, I don't really care about the ABG from it
I want to be able to respond to hemodynamic changes
in a patient in physiologic extremis
in most cases they end up getting one in the ICU anyways

 

[deleted697535]

While I agree with you that each should be evaluated as a case by case basis, I’m not sure why you think people should ignore his/her statement. Why do you advise placing an arterial line in a hypothetical airway page prior to intubation? I can imagine specific situations in which I would do this, but more generally, in situation where I was called for an airway, I’d establish an airway. Please understand that I’m not attempting to engage you in a pedantic debate or deride your thinking.

One thing I’ve seen a lot of anesthesiologists do is insist on placing an arterial line prior to a therapeutic intervention, such as a CVC large bore peripheral access, medication admin, or endotracheal tube. This differs from my approach in these circumstances, in that, for instance, if I can’t palpate a peripheral pulse or get a cuff pressure, I know the situation is bad, and I’m less concerned about determining precisely how bad it is than I am about doing something about it. Again, I can think of delicate situations where the real time feedback of an arterial line would provide a framework for making rapid decisions, but I’m curious as to why so many people leap to place an a line in an airway discussion. An art line is very useful for guiding therapy, but it’s not a therapy. Often, I’m not sure that it is a great use of time and resources, or at the very least, poorly prioritized.

I think that this is what the other person is getting at.

Not to be contrary, but I would advise trainees not to ignore that statement, but rather to think why you’d take one approach or the other.

With respect I don't get called to establish an airway. A nurse can do that. A 1st yr ca1 can probably do that.

I get called to assess a patient. So that's what I do. Not once in 8 years have I 'had' to intubate on the wards and I basically never ever will. There's a never lol

The reason I say that is as I've described above. I've seen ppl die from it. Missing or broken equipment, no suction, esophageal undiagnosed.

All these things happen much less frequently in icu

You're in the wild west on the wards. Good luck

 

[coffeebythelake]

With respect I don't get called to establish an airway. A nurse can do that. A 1st yr ca1 can probably do that.

I get called to assess a patient. So that's what I do. Not once in 8 years have I 'had' to intubate on the wards and I basically never ever will. There's a never lol

The reason I say that is as I've described above. I've seen ppl die from it. Missing or broken equipment, no suction, esophageal undiagnosed.

All these things happen much less frequently in icu

You're in the wild west on the wards. Good luck

You are lucky. I've had to deal with airway disasters where the patient is peri-code from hypoxemia at the time of assessment. Angioedema, Ludwig's angina, all this on the Wards

 

[Bryan O’Blivion]

You are lucky. I've had to deal with airway disasters where the patient is peri-code from hypoxemia at the time of assessment. Angioedema, Ludwig's angina, all this on the Wards

This most closely resembles my experience. Indeed, I’m not the only person who can intubate, so when I get called it’s for a reason. As far as assessing the airway, in the instances this thread reminds me of, I have concurred with the person calling me: This cyanotic stridorous patient with the glazed look of exhausted terror on their face needs an airway. I’m sure they appreciate my opinion, but that’s no really why they stat paged.

Certainly, I would not attempt so secure an airway without suction, some means of PPV, and at the very least color capnometry. I don’t think anyone would, honestly. What I’ve found in this situation is that there’s actually an abundance of airway supplies and support, with people very anxious to hand you anything you ask for. The reason they haven’t done it themselves is that they’ve recognized that there’s a problem.

Agree, it is always better to do this in the unit, the resus bay, or the OR. If there’s time to do that, someone has probably thought of that.

Those places are also better to utilize an a line. Sure, a lot of the time I can dart someone’s wrist quickly, but unless the staff knows how to pressurize flush, connect and zero the tubing and transducer, I’m left holding pressure on a wrist while hurriedly providing instruction on this topic. In these circumstances, that’s never seemed like a good use of resources (like my hands). The problem often really is related to oxygenation/ventilation.

For the record, if given the choice, I too prefer to have an arterial line when injecting medications in the unstable patient.

 

[Ronin786]

This most closely resembles my experience. Indeed, I’m not the only person who can intubate, so when I get called it’s for a reason. As far as assessing the airway, in the instances this thread reminds me of, I have concurred with the person calling me: This cyanotic stridorous patient with the glazed look of exhausted terror on their face needs an airway. I’m sure they appreciate my opinion, but that’s no really why they stat paged.

Certainly, I would not attempt so secure an airway without suction, some means of PPV, and at the very least color capnometry. I don’t think anyone would, honestly. What I’ve found in this situation is that there’s actually an abundance of airway supplies and support, with people very anxious to hand you anything you ask for. The reason they haven’t done it themselves is that they’ve recognized that there’s a problem.

Agree, it is always better to do this in the unit, the resus bay, or the OR. If there’s time to do that, someone has probably thought of that.

Those places are also better to utilize an a line. Sure, a lot of the time I can dart someone’s wrist quickly, but unless the staff knows how to pressurize flush, connect and zero the tubing and transducer, I’m left holding pressure on a wrist while hurriedly providing instruction on this topic. In these circumstances, that’s never seemed like a good use of resources (like my hands). The problem often really is related to oxygenation/ventilation.

For the record, if given the choice, I too prefer to have an arterial line when injecting medications in the unstable patient.

I'll never forget an overzealous resident attempting to place an arterial line in a patient that had briefly coded/vagaled on the floor (like literally on the floor of the room). He didn't stop to think that there was no pressure transducer, no monitor and nothing to hook the arterial line to. Or that poking somebody who is now wide awake probably isn't going to go over very well.

 

[deleted162650]

I'll never forget an overzealous resident attempting to place an arterial line in a patient that had briefly coded/vagaled on the floor (like literally on the floor of the room). He didn't stop to think that there was no pressure transducer, no monitor and nothing to hook the arterial line to. Or that poking somebody who is now wide awake probably isn't going to go over very well.

Pressure transducer? Monitor? Pffffft. Just pop in that 20g angiocath, point it straight up, and see how high the blood squirts. Boom, that’s your SBP.

Just don’t forget to convert from cmH2O to mmHg - that’s a rookie mistake.

 

[CavGas]

I read the entirety of the thread and I would like to thank everybody who took the time to answer.
I feel like i m learning x10 in this forum than the actual hospital!

 

[IMGASMD]

I read the entirety of the thread and I would like to thank everybody who took the time to answer.
I feel like i m learning x10 in this forum than the actual hospital!

Where are you, if I may ask?

 

[CavGas]

@IMGASMD

Northern Greece, in Europe.

 

[castafari]

“I can’t tell you how many times I gave 4% lido through a BIPAP and did an awake FOI.”
How do you give 4% lido through a bipap?

 

[CopaceticOne]

How do you give 4% lido through a bipap?

I'm going to assume they're talking about doing an inline nebulizer with Lido 4%.

I've only done the Lido neb thing once, but it was pretty cool how there was absolutely no sympathetic response on the monitors when I DL'd the patient - no HR or A-line changes.

 

[Ronin786]

I'm going to assume they're talking about doing an inline nebulizer with Lido 4%.

I've only done the Lido neb thing once, but it was pretty cool how there was absolutely no sympathetic response on the monitors when I DL'd the patient - no HR or A-line changes.

Probably because they had no sympathetic response left to give.

 

[deleted697535]

You are lucky. I've had to deal with airway disasters where the patient is peri-code from hypoxemia at the time of assessment. Angioedema, Ludwig's angina, all this on the Wards

Interesting. Never seen those on the wards and don't want to. Definitely seen them in Emerg, where there is a difficult aw cart etc.

How did you intubate either successfully on the wards? How did either get thru Emerg to the wards without ICU etc?

 

[WholeLottaGame7]

@IMGASMD

Northern Greece, in Europe.

Not to be confused with the Northern Greece, in South America.

 

[coffeebythelake]

Interesting. Never seen those on the wards and don't want to. Definitely seen them in Emerg, where there is a difficult aw cart etc.

How did you intubate either successfully on the wards? How did either get thru Emerg to the wards without ICU etc?

That Ludwig angina case was a patient who had just had emergent surgery for same issue and was around 24h on the floor for airway monitoring. Had progressive worsening sob and difficulty handling secretions, evaluated multiple times by hospitalist, went to CT scan, and then airway code called when he came back. ENT and anesthesia were never given notification of this until patient was periarrest. Too unstable, couldnt roll him to OR to intubate in more controlled conditions. He looked like hell, i warned ENT that he will likely need surgical airway. Attempted FB x2, nothing but saliva and tissue, then i told ENT to cut his neck. Coded and was brought back after a round of ACLS.

Less than 10 min from time I lay eyes on patient to arrwst. Worst airway ****ing disaster I've had in recent times

 

[vector2]

That Ludwig angina case was a patient who had just had emergent surgery for same issue and was around 24h on the floor for airway monitoring. Had progressive worsening sob and difficulty handling secretions, evaluated multiple times by hospitalist, went to CT scan, and then airway code called when he came back. ENT and anesthesia were never given notification of this until patient was periarrest. Too unstable, couldnt roll him to OR to intubate in more controlled conditions. He looked like hell, i warned ENT that he will likely need surgical airway. Attempted FB x2, nothing but saliva and tissue, then i told ENT to cut his neck. Coded and was brought back after a round of ACLS.

Less than 10 min from time I lay eyes on patient to arrwst. Worst airway ****ing disaster I've had in recent times

Wait, this guy had bad Ludwig’s, had emergent surgery, and they sent him to the floor for monitoring?

 

[IMGASMD]

Not to be confused with the Northern Greece, in South America.

There is apparently Greece, NY.
Where it’s situated, it might as well be in a foreign country. But in North America though.

 

[coffeebythelake]

Wait, this guy had bad Ludwig’s, had emergent surgery, and they sent him to the floor for monitoring?

yes, crazy,

 

[CavGas]

@WholeLottaGame7 haha well I had a few Americans ask me if Greece is in the Middle East so I sometimes clarify