Interesting Case

[Hoya11]

Advertisement - Members don't see this ad

90yo AAF for nailing of femur fx. 80kg. 5'4. Severe dementia. Very Combative and pulls out IVs on the floor. She also has a very large goiter on the left side of her neck the size of a large grapefruit. CT scan says this mass displaces the trachea to the right significantly and causes "moderate" airway narrowing. It is thought to be a benign thyroid mass.

She is currently breathing on room air without difficulty satting 98. She has a working IV.

This is a person who has not had this worked up at all. Has been living with family when should have been living in a facility. No prior anesthetics on record. HCt 26. Normal EF. After long discussion onf RBA family wants it done as she was previously walking (hard to believe).

How do you do it?

 

[deleted59964]

Spinal

 

[BlueRug]

What side is the femur fx?

 

[Hoya11]

What side is the femur fx?

right

 

[NightNight]

Spinal

“Very combative”

I mean I’m sure you could sedate her into submission and have somebody hold her up or do it lateral. I am interested how people would approach this case if the patient/family refused neuraxial, however.

 

[narcusprince]

Why are you doing the case? Likely she will die from something else in the next 6 months. How about an inhalation induction maintain airway reflexes. Do not paralyze use remi or lta to place tube keep spontaneous breathing. Have ENT at bedside to cut if it hits the fan. Also have a discussion with ENT about possible tracheostomy long term.

 

[Hoya11]

“Very combative”

I mean I’m sure you could sedate her into submission and have somebody hold her up or do it lateral. I am interested how people would approach this case if the patient/family refused neuraxial, however.

This goiter was huge. I didnt want to sedate her into submission in the lateral position if im not able to intubate her if she starts to drop her sat...

 

[Hoya11]

Why are you doing the case? Likely she will die from something else in the next 6 months. How about an inhalation induction maintain airway reflexes. Do not paralyze use remi or lta to place tube keep spontaneous breathing. Have ENT at bedside to cut if it hits the fan. Also have a discussion with ENT about possible tracheostomy long term.

similarly, i did an awake-ish glide... 2 midaz, 0.4glyco, 40 ketamine.. very abnormal oropharynx but i was able to pass a 6.0 tube after some corkscrewing.. case went on alright under general but due to the sedation and her being 90 i elected to leave her intubated and she was slowly weaned from vent and extubated next day in sicu

after it was done it looked like this big massive swollen neck, a massive protruding tongue, and this small little 6.0 tube sticking out.. if i were to do it again the only thing i would change would be to probably use a reinforced tube..

 

[NightNight]

This goiter was huge. I didnt want to sedate her into submission in the lateral position if im not able to intubate her if she starts to drop her sat...

I agree. I guess I wasn’t clear, I didn’t think (based on your initial description) that neuraxial was a great choice.

I’m curious, was the goiter so obscuring/distorting of neck surface anatomy that a surgical airway would have been impossible, if you needed it?

 

[LunchMD]

Any thoughts on this? Would anyone do fiberopic laryngoscopy before formulating plan?

Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation.
Rosenblatt W, et al. Anesth Analg. 2011.

Abstract
BACKGROUND: Development of a perioperative plan for management of patients with airway pathology is a challenge for the anesthesiologist. Lack of comprehensive information regarding the architecture of airway lesions often leads the clinician to consider techniques of awake intubation (AI) to avoid catastrophic outcomes in this population. In one uncontrolled trial, endoscopic visualization of the airway lesion was included in the preoperative anesthetic assessment for planning of airway management. We sought to determine whether visual inspection of airway pathology would change the anesthesiologist's approach to the management of these patients.

METHODS: Patients presenting for elective diagnostic or therapeutic airway procedures were included in the study. After a standard examination of the airway, a management plan was recorded. Before entering the operating room, and after brief preparation of the nares with a vasoconstrictor and local anesthetic, the patients underwent a preoperative endoscopic airway examination (PEAE) and a final airway management plan was recorded and implemented. Four or more months after the procedure, video recordings of the PEAE were reviewed without other patient identifiers and a remote PEAE plan was recorded, to test for operator bias.

RESULTS: One hundred thirty-eight patients were studied. Although AI was initially planned in 44 patients, only 16 of these patients underwent preinduction airway control after PEAE (P > 0.05). Additionally, of the 94 patients for whom the initial plan was airway control after the induction of anesthesia, 8 patients were found to have unexpectedly severe airway pathology on PEAE, and also underwent AI. There was no significant difference between the post-PEAE airway management plan and the remote plan recorded 4 or more months later.

CONCLUSIONS: In 26% of the patients studied, PEAE affected the planned airway management. We believe that PEAE can be an essential component of the preoperative assessment of patients with airway pathology; airway visualization reduces the number of unnecessary AIs while providing superior information about the airway architecture. PEAE could be applied to other populations of patients at risk for airway control failure with the induction of anesthesia.

 

[pgg]

20 mg ketamine
spinal

 

[deleted87051]

Any thoughts on this? Would anyone do fiberopic laryngoscopy before formulating plan?

Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation.
Rosenblatt W, et al. Anesth Analg. 2011.

Abstract
BACKGROUND: Development of a perioperative plan for management of patients with airway pathology is a challenge for the anesthesiologist. Lack of comprehensive information regarding the architecture of airway lesions often leads the clinician to consider techniques of awake intubation (AI) to avoid catastrophic outcomes in this population. In one uncontrolled trial, endoscopic visualization of the airway lesion was included in the preoperative anesthetic assessment for planning of airway management. We sought to determine whether visual inspection of airway pathology would change the anesthesiologist's approach to the management of these patients.

METHODS: Patients presenting for elective diagnostic or therapeutic airway procedures were included in the study. After a standard examination of the airway, a management plan was recorded. Before entering the operating room, and after brief preparation of the nares with a vasoconstrictor and local anesthetic, the patients underwent a preoperative endoscopic airway examination (PEAE) and a final airway management plan was recorded and implemented. Four or more months after the procedure, video recordings of the PEAE were reviewed without other patient identifiers and a remote PEAE plan was recorded, to test for operator bias.

RESULTS: One hundred thirty-eight patients were studied. Although AI was initially planned in 44 patients, only 16 of these patients underwent preinduction airway control after PEAE (P > 0.05). Additionally, of the 94 patients for whom the initial plan was airway control after the induction of anesthesia, 8 patients were found to have unexpectedly severe airway pathology on PEAE, and also underwent AI. There was no significant difference between the post-PEAE airway management plan and the remote plan recorded 4 or more months later.

CONCLUSIONS: In 26% of the patients studied, PEAE affected the planned airway management. We believe that PEAE can be an essential component of the preoperative assessment of patients with airway pathology; airway visualization reduces the number of unnecessary AIs while providing superior information about the airway architecture. PEAE could be applied to other populations of patients at risk for airway control failure with the induction of anesthesia.

If you’re going through the trouble of a PEAE, why not just stick a tube in? Isn’t a PEAE always a part of awake fiber optic intubation?

 

[Arch Guillotti]

Why are you doing the case? Likely she will die from something else in the next 6 months. How about an inhalation induction maintain airway reflexes. Do not paralyze use remi or lta to place tube keep spontaneous breathing. Have ENT at bedside to cut if it hits the fan. Also have a discussion with ENT about possible tracheostomy long term.

Tracheostomy sounds like a pain in the arsenal.

No way I would ask ENT to be at the bedside nor would ENT want to be at the bedside.

 

[Arch Guillotti]

90yo AAF for nailing of femur fx. 80kg. 5'4. Severe dementia. Very Combative and pulls out IVs on the floor. She also has a very large goiter on the left side of her neck the size of a large grapefruit. CT scan says this mass displaces the trachea to the right significantly and causes "moderate" airway narrowing. It is thought to be a benign thyroid mass.

She is currently breathing on room air without difficulty satting 98. She has a working IV.

This is a person who has not had this worked up at all. Has been living with family when should have been living in a facility. No prior anesthetics on record. HCt 26. Normal EF. After long discussion onf RBA family wants it done as she was previously walking (hard to believe).

How do you do it?

Assume the patient is on a blood thinner so a spinal is not possible.

I think the most important thing is to set expectations.

Tell the orthopedic surgeon what a cluster it may be.

Tell the family how serious the situation is and that the patient may die. Explain everything the best that you can. Document accordingly.

Hope that the patient is transferred elsewhere.😵

If she isn't transferred, figure out how to to do an awake intubation of some sort. I would not do an inhalation induction even if my hand were forced. Use a small reinforced tube. Send the patient to the ICU intubated, set this expectation from the start.

 

[facted]

20 mg ketamine
spinal

100% this. 0.5 midaz and 20-30mg ketamine go a LONG way in this type of patient. They'll maintain their airway and be sedated enough for you to place the spinal no problem and she'll snooze easily through the first 30 minutes of the case no problem. After that, titrate a little more ketamine 10mg/time. Works remarkably well.

Not to mention, who said anything about the patient on their side? It's a femur nailing? I've always done those with patient supine at 3 different institutions.

 

[facted]

Assume the patient is on a blood thinner so a spinal is not possible.

Why are we assuming this?

 

[LunchMD]

If you’re going through the trouble of a PEAE, why not just stick a tube in? Isn’t a PEAE always a part of awake fiber optic intubation?

Agreed if you are planning on doing AFOI then not really adding anything. But if you are not, then I would imagine it would be very useful. You have CT imaging from ?? time ago. May have become more severe or imaging may be underestimating effect on airway. The authors cited 8 cases in which their plan changed from no AFOI to AFOI based on fiberoptic exam.

 

[Psai]

Ketamine im, place iv under a million layers of 4x4s, bupi spinal ??? Profit

 

[Arch Guillotti]

Why are we assuming this?

To make it more interesting.

20 of ketamine and a spinal is too easy😉

 

[Arch Guillotti]

Ketamine im, place iv under a million layers of 4x4s, bupi spinal ??? Profit

Why IM?

 

[Hoya11]

20 mg ketamine
spinal

Due to her behavior i thought a spinal would be tough to acheive in the first place and then i wasnt sure that even after the spinal was in she would be cooperative during the case and not moving her upper body all over and yelling.. and yes i can sedate her to submission again but now with that goiter up on the fracture table...i wasnt sure that was the way to go but interesting perspective

 

[Hoya11]

I agree. I guess I wasn’t clear, I didn’t think (based on your initial description) that neuraxial was a great choice.

I’m curious, was the goiter so obscuring/distorting of neck surface anatomy that a surgical airway would have been impossible, if you needed it?

I think it would have been possible but difficult

 

[deleted171991]

Agreed if you are planning on doing AFOI then not really adding anything. But if you are not, then I would imagine it would be very useful. You have CT imaging from ?? time ago. May have become more severe or imaging may be underestimating effect on airway. The authors cited 8 cases in which their plan changed from no AFOI to AFOI based on fiberoptic exam.

PEAE, which is usually trans-nasal and requires minimal airway preparation, is for the nasopharynx and supraglottic area, not for the trachea. I personally think it's a pain in the rear and worthless, especially if one is not planning for nasal intubation.

It takes 5 minutes to numb the throat enough so that the patient can stick the glidescope down himself (I do it all the time when in doubt). Much more reliable then the nasal FO for oral tubes. (I induce the patients in the same 30 degrees head-up position in which I did the awake exam, so I get the exact same view.)

But neither is the issue here, because this is a large subglottic mass compressing the trachea. Even if the trachea is open when the patient is awake, there may not be enough muscle tone to compensate for the compression and tracheomalacia when the patient is deeply sedated. Inducing one of these people (even inhalationally) is a lottery. This needs to be as close to an awake intubation as possible, so good job @Hoya11! (Although I would have tried the spinal first - with ketamine or precedex.)

 

[facted]

Due to her behavior i thought a spinal would be tough to acheive in the first place and then i wasnt sure that even after the spinal was in she would be cooperative during the case and not moving her upper body all over and yelling.. and yes i can sedate her to submission again but now with that goiter up on the fracture table...i wasnt sure that was the way to go but interesting perspective

20 of ketamine and 0.5 midaz makes these patients super cooperative 😉

 

[deleted59964]

similarly, i did an awake-ish glide... 2 midaz, 0.4glyco, 40 ketamine.. very abnormal oropharynx but i was able to pass a 6.0 tube after some corkscrewing.. case went on alright under general but due to the sedation and her being 90 i elected to leave her intubated and she was slowly weaned from vent and extubated next day in sicu

after it was done it looked like this big massive swollen neck, a massive protruding tongue, and this small little 6.0 tube sticking out.. if i were to do it again the only thing i would change would be to probably use a reinforced tube..

Pfft you gave 40 of ketamine to a 90 year old ... that’s twice what I’d need to keep her still enough for a spinal

 

[Weisenheimer]

If the spinal is not an option or you're worried she's not-cooperative, why even attempt AFOI? Pre-ox, asleep with Roc and have Suggamadex available if you can't intubate.

 

[Ronin786]

If the spinal is not an option or you're worried she's not-cooperative, why even attempt AFOI? Pre-ox, asleep with Roc and have Suggamadex available if you can't intubate.

As scary as tracheal deviation sounds, a goiter is less scary than a mediastinal mass. The goiter doesn't have anything restricting it from moving upwards so you can usually force a tube past it. Especially if the tracheal deviation is on the main bronchus. Logically, the thyroid is going to be distal to your glottic opening.

"Eighteen patients underwent i.v. induction of anaesthesia, one had an inhalation induction using sevoflurane and one had an awake fibreoptic intubation (AFOI). In the 18 patients undergoing i.v. induction of anaesthesia neuromuscular block was provided by atracurium in a dose of 0.5 mg kg21 after confirmation of the ability to ventilate the lungs using a bag and mask technique. Two patients received succinyl- choline 1 mg kg21 followed by atracurium 0.5 mg kg21. All patients undergoing i.v. induction had their tracheas intu- bated uneventfully (Cormack and Lehane classifications detailed in Table 3) as did the patient having the AFOI. The patient having inhalation induction of anaesthesia developed airway obstruction, was impossible to ventilate using a bag/ mask technique, rapidly progressed to a ‘can’t intubate, cannot ventilate’ scenario, and required an emergency tracheostomy. This was complicated by significant bleed- ing—the intended thyroidectomy was therefore abandoned. The patient ultimately made a good recovery and had his tracheostomy tube removed. The patient re-presented 16 months later when he eventually underwent a successful thyroidectomy (patient having AFOI described above). Direct laryngoscopy after AFOI revealed a Grade II laryngoscopy "

From the article mentioned above.

 

[deleted162650]

And remember, positive pressure tends to help extra thoracic masses. This isn't an anterior mediastinal mass.

 

[deleted171991]

If the spinal is not an option or you're worried she's not-cooperative, why even attempt AFOI? Pre-ox, asleep with Roc and have Suggamadex available if you can't intubate.

So how much sugga do you use to reverse a dose of 1.2 mg/kg of roc which results in zero twitches?

 

[anbuitachi]

So how much sugga do you use to reverse a dose of 1.2 mg/kg of roc which results in zero twitches?

16 per kg.

Also it's just a goiter deviating the trachea. Just induce and DL and pull the trachea back to the normal direction

 

[Hoya11]

If the spinal is not an option or you're worried she's not-cooperative, why even attempt AFOI? Pre-ox, asleep with Roc and have Suggamadex available if you can't intubate.

she was particularly combative, it took 2, and 40 just to get the monitors on...

and while im a big fan of just put them to sleep and mask with roc, with her i was really worried about airway compromise as soon as apnea develops and get into a cant intubate cant venitlate situation..

i am still doubtful she would have tolerated a spinal and the case under sedation without the need to convert in an uncontrolled situation

 

[deleted171991]

16 per kg.

Also it's just a goiter deviating the trachea. Just induce and DL and pull the trachea back to the normal direction

I know the dose, I am mostly curious if it has ever worked for anybody, especially without bradycardia. It's like 6 vials for the average adult.

 

[Arch Guillotti]

Simple answer for this case.

Retrograde wire😎

 

[anbuitachi]

I know the dose, I am mostly curious if it has ever worked for anybody, especially without bradycardia. It's like 6 vials for the average adult.

Oh we have the 500mg vials so it's only like 2-3 for avg adult

 

[deleted697535]

Simple answer for this case.

Retrograde wire😎

?? In a large goitre?? And a combative patient? Please do elaborate!

 

[Weisenheimer]

I know the dose, I am mostly curious if it has ever worked for anybody, especially without bradycardia. It's like 6 vials for the average adult.

First time I ever used it was for reversal 10 min after we gave a double dose and intubated. It was amazing but within 30 sec of giving it the patient was bucking on the tube.

As for putting her to sleep in the first place, you have a reliable reversal agent so you could always wake her up if need be. Another option, if you're really worried of losing the airway, would be to ultrasound the airway before hand and mark off where the rings and the CT membrane is, in the event you had to insert a needle and jet. It is easy to learn (I'm referring to the US) and one of the reasons we were taught to do trans-tracheal blocks for our AFOI's was so that an emergency cric wouldn't be the first time we're inserting a needle into the neck.

At the end of the day, in a combative, non-cooperative patient, the easiest and surest way to control the airway is to take it over yourself. My 2 cents

 

[dannyboy1]

100% this. 0.5 midaz and 20-30mg ketamine go a LONG way in this type of patient. They'll maintain their airway and be sedated enough for you to place the spinal no problem and she'll snooze easily through the first 30 minutes of the case no problem. After that, titrate a little more ketamine 10mg/time. Works remarkably well.

Not to mention, who said anything about the patient on their side? It's a femur nailing? I've always done those with patient supine at 3 different institutions.

In a 90 y/o demented patient you can do a little ketamine/versed and probably not even need the spinal

 

[deleted162650]

?? In a large goitre?? And a combative patient? Please do elaborate!

You need to learn how to smell the sarcasm through the screen. Since you’ve been around for a while now I guess we should let you in on it:

Retrograde wire is a long running joke on this forum.

It’s right up there with:

Prop, sux, tube.

 

[AdmiralChz]

Simple answer for this case.

Retrograde wire😎

Come on. Blind nasal with a ring tube, anyone got an old one in their locker?

 

[Ronin786]

You need to learn how to smell the sarcasm through the screen. Since you’ve been around for a while now I guess we should let you in on it:

Retrograde wire is a long running joke on this forum.

It’s right up there with:

Prop, sux, tube.

I'd be curious if anybody's ever dropped retrograde wire on the oral boards. I imagine the value would be lost on them.

 

[facted]

In a 90 y/o demented patient you can do a little ketamine/versed and probably not even need the spinal

Let's not go crazy...

 

[dannyboy1]

Assume the patient is on a blood thinner so a spinal is not possible.

And if they are on a blood thinner is it absolutely contraindicated in every case ? This patient is a true potential can’t intubate/ventilate scenario who will not tolerate AWFIO 2/2 mental status. No matter how little you give for intubation if you lose the airway someone will say that you gave too much. Is the (likely theoretical) risk of a hematoma from a 25g (or even a 22) greater than the real risk of losing the airway? And what is the reason that this case can’t be delayed and the blood thinner reversed ?

 

[anbuitachi]

And if they are on a blood thinner is it absolutely contraindicated in every case ? This patient is a true potential can’t intubate/ventilate scenario who will not tolerate AWFIO 2/2 mental status. No matter how little you give for intubation if you lose the airway someone will say that you gave too much. Is the (likely theoretical) risk of a hematoma from a 25g (or even a 22) greater than the real risk of losing the airway? And what is the reason that this case can’t be delayed and the blood thinner reversed ?

I agree. The risk of clinically significant hematoma is very small even on blood thinner from a 25g needle. however because we live in the US, if it does occur you are screwed.

 

[deleted59964]

Due to her behavior i thought a spinal would be tough to acheive in the first place and then i wasnt sure that even after the spinal was in she would be cooperative during the case and not moving her upper body all over and yelling.. and yes i can sedate her to submission again but now with that goiter up on the fracture table...i wasnt sure that was the way to go but interesting perspective

Generally the very old and very young (neonates) fall asleep after a spinal ... lack of sensory input I think

 

[vector2]

Half load precedex plus 10-20 of ketamine. Spinal. Keep low precedex running during the case. If spinal fails, ketamine plus roc plus reinforced tube with sug at the ready.

 

[Hoya11]

Half load precedex plus 10-20 of ketamine. Spinal. Keep low precedex running during the case. If spinal fails, ketamine plus roc plus reinforced tube with sug at the ready.

So when shes up in the air on the fracture table, spinal is not going as smooth as you had planned, you would lower the fracture table, stop the case, paralyze her (!!) and intubate her on the fracture table? I'm not sure why anyone would give roc to this person prior to the tube being in..

 

[deleted87051]

So how much sugga do you use to reverse a dose of 1.2 mg/kg of roc which results in zero twitches?

But 30mg of roc will be more than enough to intubate this patient. And 1vial 200mg of suga will be more than enough to reverse that.

 

[vector2]

So when shes up in the air on the fracture table, spinal is not going as smooth as you had planned, you would lower the fracture table, stop the case, paralyze her (!!) and intubate her on the fracture table? I'm not sure why anyone would give roc to this person prior to the tube being in..

When I said spinal fails, I was referring to failing for whatever reason at procedurally placing the spinal while she's still on the stretcher. If the SAB was successful but the block isn't great or she's still moving significantly after a little more ketamine, I'd let her breathe down some sevo, keep her spontaneous, and slip in an LMA while she's still lateral.

TBH, I'm not super worried about her airway or a left-sided goiter if in my preop exam I find she's able to lie supine or right (operating) side up while breathing comfortably without auscultated stridor and still maintaining sp02 of 98 on RA as the OP says. Same goes for mediastinal masses- the history and physical exam is just as if not more important than what the CT looks like. People with critical airway narrowing at baseline don't have stone-cold normal physical exams- they just don't. That being said, if the plan was general I'd still most likely do a AFOI if her trachea was severely (sagittal diameter < ~5mm) narrowed on imaging but yet she (by some impossible chance) was showing no outward signs or symptoms.

 

[deleted697535]

But 30mg of roc will be more than enough to intubate this patient. And 1vial 200mg of suga will be more than enough to reverse that.

Why a Half dose? She will likely be a difficult bvm so you're gonna extend your misery for a few more minutes...
Just being devil's advocate

 

[deleted87051]

Why a Half dose? She will likely be a difficult bvm so you're gonna extend your misery for a few more minutes...
Just being devil's advocate

Because it works, it’s enough. I intubate most of my patients with 30 of roc and usually don’t mask ventilate at all. I don’t consider it a half dose.