Jets nightmare case on call at 9pm

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jetproppilot

jetproppilot

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43 year old very nice gentleman who was an add on earlier in the day.

Of course we don't get to him until 9pm when any extra help has gone home.

He's got a huge right-sided facial abscess from a presumably abscessed tooth (right lower molars) whose infection has migrated thru fascial planes.

Oral maxillofacial guy wants to do an I&D and pull a buncha teeth.

Wants a nasal tube.

Guy shows up at the front desk and I pee pee in my panties a little.

He has a history of chronic hypopituitarism so is on pan-hormonal replacement therapy which includes prednisone.

He has the prototypical physique of someone on long-term corticosteroids...additionally he is obese....probably 5'6" sportin' about 210lbs.

His airway exam is where my peepee dribbles came from.

Jet: "Dude, open your mouth real wide for me?"

Dude's mouth opens literally about an inch and a half.

Jet: "Can you not open your mouth because it hurts?"

Dude: "No Doc, thats normal."😱

He also had a recessed mandible and because of his prednisone and obesity his neck was nonexistent....skin and fat ran from his chin to his clavicles.

This case didnt go like the plan I had in my head.

Had to resort to Plan C. And plan C sucked.

I'll fill you in on what happened......but since this is a great teaching case for my resident colleagues I'd like to hear how you'd handle the case initially. After that I'll throw some screwballs in (that happened) and see how you'd adapt to those as well.

LET THE BANTER BEGIN.:laugh:
 
The first thing that comes to my CA-1 mind-

To OR wide awake or minimal premed, sitting up. Topicalize nares and do the best you can in the mouth, pray you don't win the methemoglobinemia lottery. Bust out the smallest fiberoptic you have that you can load an ETT onto. Insert into nare du jour, maneuver into pharynx, find a view, get close enough to tickle cords. If this ends up being difficult/impossible, well, no bridges have been burned.

I haven't done enough of these to have a go-to next step, but I'd think either
A) squirt some lido through the fiberoptic and advance awake,
B) transtracheal and advance awake
C) A slickster around here told me you can put an epidural catheter through the fiberoptic port and advance that into the trachea awake, squirt lido through it LTA-style, then advance ETT awake. Never tried it but sounds Jedi-esque.
D) If you're right there and sure you can advance successfully, squirt in some induction agent in the IV and dive in.

This may be obviously wrong or obviously obvious to you vets out there, but I figure I'll learn better if I try to pipe up on some of these clinical threads.
 
Million ways to do this. Not an emergency. Board answer and what I would do if I was a new grad doing this after all my awesome pardners had left to gamble with Jet...

1. Glyco. Topicalize. Sedation with precedex gtt, maybe mini boluses of same or little midazolam and fentanyl with narcan and romazicon drawn up...
Awake Nasal FOI. USe a nasal rae if Surgeon demands or change over with Aintree.

WIth his obesity, may be tough ventilation so AWAKE
With his poor preexisting anatomy plus new badness, FOI

2. IF you thought u could ventilate, having seen him in person, you could have difficult airway cart in room with Fiberoptic ready. Do asleep look with propofol only or with squirt of sux. LMA for back up/ventilate. Drop FOB down LMA

3. Do inhalation induction, get him really deep, after glyco, do asleep nasal tube blind like the old dayz or with magill support. Or do quick look and if you see arytenoids, continue on to sux... and DL

4. Since I am the Jet-I-master, perform DL after giving propofol and pancuronium since I can intubate a fire ant!!! 🙂

jetproppilot said:
43 year old very nice gentleman who was an add on earlier in the day.

Of course we don't get to him until 9pm when any extra help has gone home.

He's got a huge right-sided facial abscess from a presumably abscessed tooth (right lower molars) whose infection has migrated thru fascial planes.

Oral maxillofacial guy wants to do an I&D and pull a buncha teeth.

Wants a nasal tube.

Guy shows up at the front desk and I pee pee in my panties a little.

He has a history of chronic hypopituitarism so is on pan-hormonal replacement therapy which includes prednisone.

He has the prototypical physique of someone on long-term corticosteroids...additionally he is obese....probably 5'6" sportin' about 210lbs.

His airway exam is where my peepee dribbles came from.

Jet: "Dude, open your mouth real wide for me?"

Dude's mouth opens literally about an inch and a half.

Jet: "Can you not open your mouth because it hurts?"

Dude: "No Doc, thats normal."😱

He also had a recessed mandible and because of his prednisone and obesity his neck was nonexistent....skin and fat ran from his chin to his clavicles.

This case didnt go like the plan I had in my head.

Had to resort to Plan C. And plan C sucked.

I'll fill you in on what happened......but since this is a great teaching case for my resident colleagues I'd like to hear how you'd handle the case initially. After that I'll throw some screwballs in (that happened) and see how you'd adapt to those as well.

LET THE BANTER BEGIN.:laugh:
Click to expand...
 
Awake FOI.....doesn't work? Call your friendly neighborhood ENT and do an awake trach. NEXT!
 
sedate with whatever and paralyze with whatever, then put him in an iron lung.
 
Local and vocal??

No...really, the first try should clearly be awake nasal FOI. Plan B would be asleep nasal if I thought I could get an lma in to ventilate if necessary.
 
pushthesux said:
Local and vocal??

No...really, the first try should clearly be awake nasal FOI. Plan B would be asleep nasal if I thought I could get an lma in to ventilate if necessary.
Click to expand...

ditto. PLan B should include LMA followed by aintree and a look with pedi FOB for placement followed by tube.
 
AWAKE AWAKE AWAKE
I'd do an awake whatever.

I like the transtracheal and I'd leave a 14-16g jelco cath in to jet ventilate through if i needed to buy some time or lost the airway. You can also pass a guide wire through it and do a retrograde intubation.

I suspect the lack of neck made the DL very difficult. The abscess made the mask ventilation difficult and together it got real bad. The LMA didn't seal well enough to ventilate the guy due to his size and the abscess with the local edema caused the difficulty experienced with the LMA. I'm assuming an LMA was tried at some point.

Its easy being the monday morning QB but if you had trouble Jet, I'm sure it would have been a nightmare for the rest of us. If you chose the asleep approach I don't know that I would have done differently. All i can say is that we need to have a very low threshold for the awake intubation in this business. I find myself guilty of not pulling the awake trigger from time to time.
 
Awake FOI, if not that mask induction place a fastrack LMA ( if possible) if you can ventilate intubate via LMA, but awake would seem to be the best choice IMHO.
 
Plan A. awake look. Glyco. light sedation of choice (midaz/fent, dex, whatever works as long as you dont obtund him. Work it in slowly. I would personally topicalize orally and take a peek first to see if the anatomy has been distorted. I would also ask if it can be drained prior to the procedure under local. If it looks like theres no way in hell a scope is getting in there, he may have bought himself a trach. If it looks reasonable, then I may proceed with a transtracheal and nasal topicalization (with a vasoconstrictor) and then nasal intubation.


plan B would involve a video stylet or laryngoscope if available. I would be reluctant to drop an LMA since it means Im shoving it at the abscess in an assumed induced patient and am now risking lung contamination. However, if I needed to do it I still would and then try to fiberoptic through it.

Since it doesnt seem like opening his mouth pains him much, I would try to see if he can open it more with some additional force. If it does at least I know I have more room to work with. In that case plan C would involve a DL with some combination of FBO, intubating stylet, light wand. Again this is dependent on anatomical distortion

Plan D: trach or some combo or draining the abscess under anesthesia (again definitely not a good choice since it risks lung contamination, then proceeding with intubation assuming this relieves some of the anatomical distortion.
 
Consigliere said:
Awake FOI.....doesn't work? Call your friendly neighborhood ENT and do an awake trach. NEXT!
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This is ABSOLUTELY what I'd say for the boards.

With this guy's f'ed up anatomy and weight, I'd be pretty apprehensive to trust an LMA to seat well enough to ventilate this dude. Not that it wouldn't work, but there's a WAY better chance than usual that it won't.

The catheter for jet ventilation is a good idea, but I don't think I'd feel comfortable defending it in a "semi" emergent case. Sticking an angiocath and needle through however many inches of neck fat is a little more dangerous than in an ideal situation, and even then is probably less safe than having a surgeon cut you an airway (by FAR will provide you better ventilation). The retrograde is also a good idea, but still not ideal, and again, with his anatomy, it might not work real easilly.

I don't think I'd try the mask induction. OK, if you get to stage 2 you'll avoid laryngospasm, but that dude's going to have to be DEEP to tolerate whatever maneuver you try. And he still may breath hold, and it may be difficult to get him breathing again if a mask ventisreally hard.

Posting on this board is obviously not a live situation, and I'd probably be more likely to try something to make the surgery happen. I'd definitely pee too, though.

Jet, did you have a CT to look at so you could see where exactly the abscess extended and what the guy's airway looked like?
 
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No question:


awake awake awake....
I dont do awake looks because I feel that it doesnt really tell you anything.... if you did an awake look on this guy and saw the cords... who the hell knows what will happen if you propofol sux him....

FOI. Nice and easy. Good local (4% to nares and trickle down. If I could find the trachea i would do a transtracheal.. sounds like i wont be able to find the superior laryngeal nerve....

Dexmedotomidine? I can't even spell it..... Some midaz, some fentanyl... but mostly the come to jesus talk with the patient... ie you need to cooperate or you could die....

if all that mucking around fails-> why is OMFS here? call a real surgeon to do a real surgery...
 
I chose to sleep the guy with sevoflurane only. No opoids, no muscle relaxant. Just gas. This is certainly not the answer for the oral boards as all of you eluded. It is fast though, requires no prep work, has a very high success rate.

I figure with this guy as long as he is breathing on his own, he is safe and I'm golden. I'll crank up the O2 to 10 liters a minute, crank the sevo up all the way and let him breathe it for a few minutes. He'll also be denitrogenated which'll buy me enough time to whip off the mask, insert the ETT thru his nare, seat it into the posterior pharynx, then guide it thru cords after I put the scope thru the tube and visualize cords and drive the scope thru the cords.

Glyco .2mg IV like Dre said. Both sides of nose squirted with Afrin a buncha times.

To the back, positioned on bed, O2 flow up, sevo on all the way.

Dude starts to go to sleep. Beatiful! Slip in a well lubricated nasal airway easily.

Ventilate away for several minutes until I'm convinced he's deep enough.

Heres where the problems started and the problem may have been from a variable I didnt even consider until later....

I pull the nasal airway out, which went in easily, and epistaxis was evident.

Beware of nasal intubations on someone on chronic corticosteroid replacement. I wouldntve expected a big (not huge, but big) nosebleed just from the easily inserted nasal airway. Dude had no other explanation for the bleeding...not on ASA, no NSAIDS, coags normal....so I attribute the ease of which he bled to mucosal friability from the chronic prednisone.

So now youre planning on doing a nasal fiberoptic with a nosebleed.

Any suggestions?

Still no problem with ventilation. Dudes asleep, breathing away with jaw lift while youre doing your thing.
 
Awake FOI with nRAE. And I think it would have to be a nRAE; otherwise, your tube may not be long enough!
 
For clarity lemme make a cuppla points I think are important:

1)Next time someone requests a nasal intubation on someone on chronic prednisone I may think otherwise.

2)Once bleeding occurs in the airway it makes a fiberoptic intubation much more difficult since blood is constantly getting on the end of the scope....and rather than a constant view of where you are you get glimpses of anatomy.

3)I made a point in a previous thread that I'll reemphasize: Don't marry your initial plan if it is not working. Think about plans A, B, and C before you start a case and give yourself a hypothetical time limit before you try the next plan, or call off the situation altogether.
 
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At this point, with a bloody field, I think you're pretty much stuck with emergently traching this guy. Doing it now while he's asleep and maskable would likely be better than waking him up and praying he doesn't laryngospasm...
 
Blind nasal

Retrograde- although will likely end up with oral tube.

Regular DL if you can open his mouth big enough.

FOB-maybe you can see.
 
jetproppilot said:
Dude's mouth opens literally about an inch and a half.
Click to expand...

That's pretty big. Were you thinking maybe 1 centimeter and a half?

Fastrach said:
At this point, with a bloody field, I think you're pretty much stuck with emergently traching this guy. Doing it now while he's asleep and maskable would likely be better than waking him up and praying he doesn't laryngospasm...
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Too early for that.
 
dl now, tube, bag through tube and drop 2nd tube through nose into post pharynx, disonnect bag, attach etts to each other, check for co2 return
 
urge said:
That's pretty big. Were you thinking maybe 1 centimeter and a half?



Too early for that.
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Well ok then, MAYBE, while still asleep, I'd put a nasal trumpet that's been slit down it's edge (so you can pull it out easily afterward) to tamponade things, pass a soft suction catheter down to try to dry things up gently, then go down with your scope and see what you can see. Decent view? Tube goes. No view due to blood bath? Trach time.
 
Here's a CA-2 guess:

If he's deep and he's an easy mask, then I topicalize orally and use the Glidescope to visualize and squirt some local on the cords and pass the tube nasally.

If the topicalization is not working, but I still get a decent view of the cords with the Glidescope, then I induce with a small amount of sux and pass the tube nasally.

I'm still not feeling the urge for awake trach yet.
 
I wouldn't have put this guy to sleep with sevo but I know where Jet is coming from and in real life you develop a certain style to do things.
I would have done the following:
Glyco preop.
Applied Phenylephrine to the nose.
Lidocaine 4% Neb.
Lidocaine ointment to the slitted nasal airway, and a a good amount of Lido ointment on the back of the tongue while holding the the tongue out with gauze and asking the patient to swallow.
Transtracheal if possible.
Given some Midazolam, strat a Remifentanyl drip.
Load the tube on the scope like when you are doing oral FOB (I don't insert the tube in the nose for nasal Fiberoptic).
FOB through the nasal airway and once you go through the cords remove the airway and inset the tube.

If I am at the point that Jet had reached:
Patient asleep with inhaled agents, tube in the nose but bleeding and FOB not working here is my plan:
Take one look after good suctioning with a glidescope if available otherwise DL and if you can see advance the tube.
If that look with glidescope or DL is not successful this would be a good time to stop, wake him up then do awake tracheostomy rather than risking the airway any further.
 
getting someone deep with gas can still cause relaxation of the pharyngeal muscles and UAO. this guy has a difficult airway - mass in mouth and limited MO. he deserves an AFI. not sure why risking the patient's life is necessary.
 
Although I like the awake FOI, one other point to make is just because the oral surgeon wants a nasal tube doesn't mean he's gonna get one. It's more convenient with a nasal tube, but it just ain't that difficult to work around. If you have a bloody mess while in the middle of the FOI, at least try a DL with your "tube a gravid fire ant" blade of choice before trying the cric or trach route.
 
Hawaiian Bruin said:
C) A slickster around here told me you can put an epidural catheter through the fiberoptic port and advance that into the trachea awake, squirt lido through it LTA-style, then advance ETT awake. Never tried it but sounds Jedi-esque.
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One of the pedi-anesthesiologists back home did this for a case very similar to this one (40-something yom with Ludwig's angina, no chronic steroids, though). 'Twas pretty friggin slick. She also slit the trumpet down the side, much like Fastrach stated, so the ET tube slid along it, rather than the friable nasal mucosa, and went with DrDre's option number 1 (midaz/fent, not precedex) without any difficulty.
 
#1 option awake FOI, what i don't understand is why you would use a respiratory depressant eg fent remi in a compromised airway 😕 you do nothing for anxiolysis (i can understand a little midaz) if the patient can't take a scope under local **** him...

#2 if 1 fails awake trach

in this scenario you could put the nasal trumpet back in to get some compression on the mucosa and try again with the scope. no luck wake up and trach.
 
dhb said:
#1 option awake FOI, what i don't understand is why you would use a respiratory depressant eg fent remi in a compromised airway 😕 you do nothing for anxiolysis (i can understand a little midaz) if the patient can't take a scope under local **** him...

#2 if 1 fails awake trach

in this scenario you could put the nasal trumpet back in to get some compression on the mucosa and try again with the scope. no luck wake up and trach.
Click to expand...

The remifentanyl is because you most likely are not going to get perfect airway anesthesia in this patient and if you know what you are doing it will improve you fiberoptic conditions without losing the airway.
The keyword here is gradual titration of whatever you use.
 
Arch Guillotti said:
I am having a hard time rationalizing a trach when you are ventilating adequately.
Click to expand...

agree there are multiple acceptable ways of attempting intubation under this scenario - fasttrack, foi, videolaryngoscope, lighted stylet, blind nasal, and so forth and - you can wake him up and do it awake(probably the safe choice)
 
jwk said:
Although I like the awake FOI, one other point to make is just because the oral surgeon wants a nasal tube doesn't mean he's gonna get one. It's more convenient with a nasal tube, but it just ain't that difficult to work around. If you have a bloody mess while in the middle of the FOI, at least try a DL with your "tube a gravid fire ant" blade of choice before trying the cric or trach route.
Click to expand...
Depending on the situation, it can be impossible to work around. A number of dental and OMFS procedures require the teeth to be occluded at various points during the case (though it's not typically necessary for an abscess). Patient safety obviously trumps all other considerations, but when dentists/OMFS ask for a nasal tube, we're not just asking to make the anesthesiologist's life more difficult.
 
Alright I will give it a shot.

First of all, at this point in my career I would have done it awake, no questions asked. That is the oral boards answer and that is what I would have done in real life. I would give .2 mg of glyco EARLY followed by minimal/moderate amounts of sedation. A little fentanyl, a little versed, would not sedate past the point of eyes closing. Remember that these two are reversible if needed. Prior to the sedation I would give 4 cc lido neb 4% followed by nasal cannula. Liberal Afrin. Precedex is a viable alternative for sedation but alas I don't have too much practice using it in this scenario. There are case reports of precedex only (no topicalization) being used for AFOI w/good results. Anyways to the OR, monitors on. Black sharpie dot on neck "just in case". I would serially dilate the nares VERY carefully w/lidocaine coated trumpets. I would test the gag reflex w/an oral airway and if needed smear some lido paste around the posterior orpharnyx. I would then deliver 4% lido via atomizer to the posterior pharnyx, aimed towards the cords. Then gently pass the ET tube till it passes followed by passing the scope. Bumps of ketamine if needed. I would have oxygen hooked up to the suction port to blow away blood and/or secretions. Then I would drive it home, step out and pack a fat dip.

Unfortunately in the case of bleeding visualization could become damn near impossible. I would suction carefully yet aggressively, take my time and just keep looking. As long as the sats are good and the pt. is good and numbed up you can take all the time you need up to the point where you become acutely aware of everyone staring intently at you. Try looking for bubbles wher air might be coming out. Maybe somebody could try and push on the chest to get some bubbles visible at the glottic opening. If all else fails, keep flailing😎

In Jet's case the situation is much more complicated since the pt. is asleep. There are plenty of options (Bullard, Fasttrack, light wand) but unfortunately these are all oral when as the previous poster astutely commented on the fact that an oral ETT just might not cut it. I would attempt to take a quick DL but this might not be possible due to the limited oral aperture. If I could squeeze a Miller 2 in there I might be able to get a peek at something and be able to guide the tube in w/ a set of Magills. If brief relaxation is needed a bump of propofol or sux can briefly help your conditions. If dude is still breathing then you can go for the rarely used but rokkstarish blind nasal intubation. If all this fails then I would wake up if you are able to and regroup. I would not do a trach unless absolutely necessary, and not until the pt. was reawakened and the possiblity of oral tube was revisited w/the surgeon.
 
I have to think that any consideration of blind techniques in this guy is dicey at best. With all that steroid-induced friable mucosa back there as JPP pointed out, if a friggin nasal trumpet gave this guy a nosebleed, I'd be truly frightened to think what a blind nasal, a Fastrach LMA, or god forbid a lightwand could stir up in this guy's pharynx. It's not going take a helluva lot to turn what is currently an easily ventilatable pt into the dreaded can't intubate/can't ventilate scenario...
 
Fastrach said:
I have to think that any consideration of blind techniques in this guy is dicey at best. With all that steroid-induced friable mucosa back there as JPP pointed out, if a friggin nasal trumpet gave this guy a nosebleed, I'd be truly frightened to think what a blind nasal, a Fastrach LMA, or god forbid a lightwand could stir up in this guy's pharynx. It's not going take a helluva lot to turn what is currently an easily ventilatable pt into the dreaded can't intubate/can't ventilate scenario...
Click to expand...

Absolutely. Dinking around in the airway can turn a difficult situation into an impossible one. I have attempted one nasal fiberoptic in which bleeding was stirred up and it was a MESS. Red EVERYWHERE. I am not sure that a windshield wiper on the scope would have helped me. Fortunately I swallowed my pride and someone with THE FORCE rescued me.
 
I really like the sevo-only method for FOI since the patients are asleep, obviously comfortable, and have no recall of the situation. I learned it from a pediatric anesthesiologist who I saw do this several times during my 6 months of pedi anesthesia I did during residency and have performed it without issue many times over my career.

Most of you said awake with 4% nebulized lidocaine and sedation....nerve blocks in this guy wouldve been very difficult due to his cushinoid appearance. I've done the 4% lido neb with nerve blocks many times too.

I'm convinced since the nasal route was chosen any technique would've been screwed secondary to the blood.

JWK made a good point in that just because a surgeon requests a nasal doesnt necessarily mean you have to do it that way unless of course its a mandibular case with wiring the mouth shut...

The patient continued to breathe thru the entire event so I never felt endangered....just frustration with not being able to accomplish what I needed. At any point we couldve just shut off the gas and dude wouldve awakened.

I never attempted DL. His anatomy and small mouth opening contributed to that decision. Ended up putting in a fast track and the small tubewent in...had ETCO2...didnt have alotta faith in that small very flexible LMA tube for an extended procedure so requested that the surgeon do the I&D part of the case only, which took only ten minutes or so to complete. If further work was needed we could come back another day and do an oral FOI to begin with. He did the I&D...turned out to be a large abscess, packed it, we turned the sevo off, patient awakened, pulled tube.

Patient ended up coming back and the surgeon was able to accomplish his tooth extractions under MAC.

Again, had I to do it over again I would've chose the oral route to begin with, which it turns out the surgeon couldve tolerated....which would've eliminated the epistaxis that caused all my headaches.

Beware of nasal intubations if your patient is on long term predisone!
 
Arch Guillotti said:
I am having a hard time rationalizing a trach when you are ventilating adequately.
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The point is that you need to know when it's time to stop before you cause complete airway obstruction.
Sure there are multiple ways to instrument an airway but you don't want to transform an elective situation into a dire emergency.
 
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Planktonmd said:
The point is that you need to know when it's time to stop before you cause complete airway obstruction.
Sure there are multiple ways to instrument an airway but you don't want to transform an elective situation into a dire emergency.
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Understood. Sometimes you just need to cut your losses and bail out. I would rather bail w/a wake up and regroup than a trach in this scenario.
 
I missed out on the first part of the discussion because I was passed out post call.

My initial plan would have been an awake nasal intubation in the following sequence.

1> ENT surgeon in the room who can perform an emergent trach.
2> All equipment necessary for emergent trach in room.
3> Anesthesia partner in room if available.
4> Glyco 0.4 IV
5> Cocaine soaked plegets to both nares and ask him to snort a little
6> Routine ASA monitors, suction, emergency drugs and anesthesia machine
7> Preoxygenate/ denitrogenate
8> Load FOB with a warmed (softened) nasal RAE with bevel facing toward the lateral wall of the naris to be attacked
9> Proseal LMA ready for emergency backup
10> Pass FOB trans nasally and into posterior pharynx until a view of the cords is obtained.
11> I always have a 10cc syringe with 60 mg propofol and 60 mg of lidocaine in it. Depending on this guys history I would give 5-10 cc of this and wait for 45-60 seconds.
12> Pass FOB into trachea.
13> +/- additional 50 mg bolus of propofol
14> N2B8 gently

If I am stuck with the nosebleed that JPP mentioned, I would readdress the need for nasal intubation with surgeon. If mandatory nasal I would consider delaying. If mandatory to proceed, I would do one of 2 things.

1> Pass one of those floppy flexible ETT's from the fastrack through the naris of choice. This should tamponade the bleeding somewhat, or make it worse. Most of the blood will pool in the posterior pharynx or run down the esophagus if he is sitting up. So as long as he isn't coughing you should be able to get past it to get a view. Suction with ETT sucker through ETT and Yankauer via mouth. Pass FOB though tube and into trachea. You get the point.

2> Pre-bend a gum elastic bougie into a semi-circle. Pass gently through nose. With FOB introduced through mouth for visualization, guide the bougie into the trachea. Tube over bougie and into trachea. You may have to hold onto the bougie with a pair of macgills initially as they are pretty short.

I am surprised that as comfortable as we as anesthesiologists are with propofol, nobody mentioned using a small dose for sedation/amnesia. This is a short, stacato stimulus procedure that, like cardioversion, is perfect for a quick propofol bump. Or do most of you just give a full stick whenever you use it and therefore do not appreciate what a good sedative it is for a procedure lasting for seconds?

-pod
 
dhb said:
His mouth opening wasn't that bad if you could get a fast track in?
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All I can say is he had a small mouth and he couldnt open it wide. Your point is taken about the fastrach but I was able to get it in. As you know with the fasttrach you go midline; with a blade you don't. His mouth, his hard-palate-only appearing airway on preop exam, small mandible, no-neck all contributed to my lack of interest in taking a look with a blade.

If the fastrach hadntve worked I would've woke him up.

Enough havoc was reeked on this go around.
 
this is my go to device...the guy in the video doesn't make it look slick, but you get the idea.

[YOUTUBE]http://www.youtube.com/watch?v=9Op_iSDqrsE[/YOUTUBE]
 
aphistis said:
Depending on the situation, it can be impossible to work around. A number of dental and OMFS procedures require the teeth to be occluded at various points during the case (though it's not typically necessary for an abscess). Patient safety obviously trumps all other considerations, but when dentists/OMFS ask for a nasal tube, we're not just asking to make the anesthesiologist's life more difficult.
Click to expand...

I was only referring to this particular case. I understand that for those lovely extended LaForte I-II-III-BSSO facial/jaw reconfigurations that a nasal tube is necessary and we happily provide one. That's clearly not the case here.
 
aphistis said:
Depending on the situation, it can be impossible to work around. A number of dental and OMFS procedures require the teeth to be occluded at various points during the case (though it's not typically necessary for an abscess). Patient safety obviously trumps all other considerations, but when dentists/OMFS ask for a nasal tube, we're not just asking to make the anesthesiologist's life more difficult.
Click to expand...

Good dentists can work around an oral tube.
 
jetproppilot said:
Beware of nasal intubations if your patient is on long term predisone!
Click to expand...

Most important point of the post that bears repeating. Newbies, sear this into your craniums. Wish I would have read this post about a year ago as I had the same thing happen.
 
Consigliere said:
Good dentists can work around an oral tube.
Click to expand...
Good anesthesiologists can place a nasal tube.

I'm done bickering with you about it, though. Even if you seriously want to go down this road, I'm not going there with you. This is Jet's teaching thread and I'm not going to participate in its hijacking.

(Jet, no criticism to you. I'm just surprised at how petty consigliere is trying to get about this.)
 
Last edited:
militarymd said:
this is my go to device...the guy in the video doesn't make it look slick, but you get the idea.
Click to expand...

Mil, I am interested in learning this tool, I will have to root around in the anesthesia closet and see if I can find one buried somewhere.

Do you typically use a Parker ETT or does it matter?

-pod
 
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