Let’s discuss a case

[Noyac]

66yo female with a IT hip fx with a h/o C-5 to occiput fusion 6months ago and virtually no ROM. Airway is otherwise favorable. Also has OSA (not overly obese) HTN, Chronic Pain Syndrome, severe anxiety (cooperation while awake is suspect), no cardiac workup since her neck fusion and this case were relatively emergent. She is currently nauseated with emesis basin on her chest. Plan is to open her hip in lateral position and take biopsies to rule out pathological fx. If no Mets then proceed with hemiarthroplasty.

Go:

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[nimbus]

NPO?

 

[Plead the Fifth]

Considering normal coags, platelet count, and no antiplatelet or anticoagulant meds I’d consider neuraxial with sedation - maybe Precedex or ketamine to minimize respiratory compromise with her OSA.

Spinal duration does worry me some considering we are sending frozen sections. CSE may be a better option.

 

[TheLoneWolf]

Ketamine, FOI, have a look. Proceed with GETA if good view. Otherwise, if poor or no view, CSE.

 

[TheLoneWolf]

Assuming NPO

 

[Bru]

Not super excited about MAC/neuroaxial with this patient's nausea/emesis, OSA and high anxiety but depends on airway exam as noted above.

 

[Mman]

well she's either getting a spinal or a tube and unless you go prop/sux/tube she's going to have to be compliant with some sort of state of wakefulness for either the airway or during the case.

If I decided to do the airway, I'd probably get her sedated with some ketamine and dexmeditomidine and have a look down her nose with the scope. And honestly if somebody is that nervous and is already kinda pukey, I'm usually leaning towards GA from the start. I dislike having people freaking out and/or puking in the lateral position.

 

[deleted763299]

Probably best just having her tubed from the get-go. If her airway is otherwise favorable, but she just doesn't have any neck mobility anymore I would choose GA starting with an asleep fiberoptic RSI.

If she has a nightmare airway and no neck mobility, she's gotta be coached through an awake fiberoptic. It's a pain, but it can be done with coaching and excellent topicalization.

If she wasn't nauseated with a decent airway, I would offer her neuraxial (probably a CSE for a case like this) with moderate sedation (actual moderate sedation, not GA without an airway). The OSA is a consideration, but most people breathe OK in the lateral position. And if they don't you can always stick in a nasal trumpet. If she's severely anxious, she'll probably refuse this plan anyway.

 

[narcusprince]

Fast or slow surgeon? Glidescope rsi intubation fiber in the room and a second set of hands to help me secure.. Higher on the narcotics for induction, Erector spinae block on the surgical side asleep assuming normal coags and platelet count. Sevo/Des maybe some ketamine.

 

[deleted162650]

Well I’m not lookin’ at the patient, but this doesn’t sound like much more than prop, sux, glidescope to me.

@narcusprince - erector spinae for a hip?? That’s new to me. What level you doin it at? I’ve never done one lumbar.

 

[MoMoGesiologist]

I wonder what the rate of difficult airways is with c-spine fusion. We do RSIs with in line stabilization which I'm assuming mimics C-spine fusion and those airways don't seem too bad, so maybe spinal fusion and no neck mobility isn't such a big deal?

 

[T-burglar]

If she can open her mouth and doesn’t have A history of airway surgery/cancer/radiation then prop roc tube

 

[Ronin786]

Ketamine, FOI, have a look. Proceed with GETA if good view. Otherwise, if poor or no view, CSE.

If your plan is a neuraxial pending airway status, why not just proceed with a CSE from the get go?

I'd do a CSE with propofol sedation. KISS.

 

[UKEMdoc]

Saltydog
Why sux rather than roc with suggamedex standing ready?

 

[deleted162650]

Saltydog
Why sux rather than roc with suggamedex standing ready?

Because “prop, sux, tube” sounds better than “prop, roc, tube, suggamedex.”

 

[TheLoneWolf]

If your plan is a neuraxial pending airway status, why not just proceed with a CSE from the get go?

I'd do a CSE with propofol sedation. KISS.

epidural portion of CSE can fail and you wont know until spinal wearable off. Sucks to attempt GA in lateral position mid surgery if that's the case.

Taking a look with fiber through nose and prop sux glide is the KISS for this case.

Also, already nauseous patient that we will preform neuraxial in and place in lateral position. Not good. But if attempt at GA fails then it's the only option.

 

[deleted162650]

I agree that with the advent of sugg, the indications for sux are shrinking. But, I still think it’s the right drug for a real no bullsheet RSI. When the fasciculations stop, I know the pt is paralyzed and I can go ahead. I don’t want to think I gave the roc enough time only to have the pt gag and vomit in my face.

Or maybe like a good cocktail, I’m Old Fashioned.

 

[nimbus]

If there’s any doubt about the airway, it’s better to secure it up front.

 

[okayplayer]

If the rest of the airway exam is favorable, prop/sux/tube —> glidescope. I prefer a #3 GS in this setting. Have a #3/4 iGel ready.

No reason to think the pt won’t be an easy BMV. Could always do an ETT over FOB through the iGel once placed.

I’m betting easily intubated with a small glidescope.

 

[Psai]

Ketamine. Lidocaine in the mouth, b/l recurrent laryngeal, transtracheal. Awake og and suction. 14g retrograde 7.0. Put her to sleep.

 

[dhb]

Spinal
I'd rather have her puke in lateral then when i'm mucking around her airway.

 

[T-burglar]

Put all the prop fentanyl 100mg of roc in one 30cc syringe and push that sucker

 

[Arch Guillotti]

Bad airway, nauseous, anxious, possibly long surgery, OSA, chronic pain, lateral position - what could possibly go wrong with neuraxial anesthesia and sedation?

 

[narcusprince]

Neuraxial in my opinion is not an option. I have a few partners who do thoracic erector spinae blocks and a few that do lumbar erector spinae(quadratus lumborum). Either way the block is for post op pain control. The question is would you do it in a asleep patient? What your gathering is typically the erector spinae block is more for thoracic pain. This patient is screaming RSI with glidescope with glide/fiber backup. Multimodal pain control block/narcotic. Neuraxial in a full stomach/ uncooperative patient in lateral position in addition to biopsises requiring frozen sections screams secure the airway.

 

[vector2]

MAC/spinal is a pretty dumb plan for this patient. It takes some work for older folks to get nauseated in the 1st place, and now some of you want to dose intrathecal and sedate her (likely heavily given the anxiety) without a protected airway?

She gonna barf the second after the bupi is in.

 

[Shimmy8]

In our shop this is 100% at GA case. Do you have access to previous record of cervical fusion and airway for that?

Depends on your personal preference/exam, but I’d prob do RSI glidescope after giving her every IV antiemetic in the book.

 

[anbuitachi]

rsi tube. you dont want to deal with anxious patient with spinal

 

[Noyac]

NPO?

Yes I guess. But hr active nausea with some emesis negates that position.

 

[Noyac]

Considering normal coags, platelet count, and no antiplatelet or anticoagulant meds I’d consider neuraxial with sedation - maybe Precedex or ketamine to minimize respiratory compromise with her OSA.

Spinal duration does worry me some considering we are sending frozen sections. CSE may be a better option.

So, you are willing to take a chance that this CSE will be done under spinal? We are taking biopsies and waiting for path. This pt has no cervical range of motion and will be lateral. I was not willing to deal with this intraop.

 

[Noyac]

Saltydog
Why sux rather than roc with suggamedex standing ready?

Because sux still is bettering some situations. Plus the cost of 16mg/kg sugamadex is out of this world.

Plus the onset may be similar but the depth of paralysis is much better with sux from the get go. Give yourself the best opportunity the first time.

 

[Noyac]

The typical characters here ( read: the old phucks) are spot on. I did an RSI with a glidescope and all went well.
I would hate to have her lateral, puking and freaking out while her spinal is wearing off.

 

[Ronin786]

epidural portion of CSE can fail and you wont know until spinal wearable off. Sucks to attempt GA in lateral position mid surgery if that's the case.

Taking a look with fiber through nose and prop sux glide is the KISS for this case.

Also, already nauseous patient that we will preform neuraxial in and place in lateral position. Not good. But if attempt at GA fails then it's the only option.

If the airway is so bad that you can't get it with a fiberoptic scope then you're even more screwed if you need it to secure it with a failed spinal.

If it's a ****ty airway, why wouldn't I just do whatever I can to avoid having to manipulate it. Make sure you have a functioning CSE or use tetracaine. Light sedation and do the case. Regional anesthesia is perfect for bad airways, yet we seem to avoid it particularly in those patients.

 

[nimbus]

Put all the prop fentanyl 100mg of roc in one 30cc syringe and push that sucker

When I do that I label the syringe “ANESTHESIA”.

 

[okayplayer]

I wonder what the rate of difficult airways is with c-spine fusion. We do RSIs with in line stabilization which I'm assuming mimics C-spine fusion and those airways don't seem too bad, so maybe spinal fusion and no neck mobility isn't such a big deal?

I had a guy that sounded like a clone of this lady a few months ago. C7-occiput fusion a few months prior (so no anesthetics/records since the fusion). Impressive exam in the sense he was completely 100% fused (reminiscent of ankylosing spondylitis bamboo spine if you guys have seen that - equally impressive). OSA + as well, but otherwise normal airway exam (no other predictors of diff intub/bmv).

Prop/roc/tube. Pristine view with GS #3. Impressive the view you can get in a patient with that little C-spine ROM. As I mentioned, I highly recommend a small glidescope blade (#3, or even #2) because you won’t battle getting the blade in the mouth and optimally positioned because of the smaller foot print.

Good case and discussion.

 

[deleted162650]

The typical characters here ( read: the old phucks) are spot on.

Are you calling me an old phuck?? Pretty sure I’m like 1/2 your age.

 

[okayplayer]

Are you calling me an old phuck?? Pretty sure I’m like 1/2 your age.

I guess we both are now that we have 10+ year member next to our name.

 

[TheLoneWolf]

If the airway is so bad that you can't get it with a fiberoptic scope then you're even more screwed if you need it to secure it with a failed spinal.

If it's a ****ty airway, why wouldn't I just do whatever I can to avoid having to manipulate it. Make sure you have a functioning CSE or use tetracaine. Light sedation and do the case. Regional anesthesia is perfect for bad airways, yet we seem to avoid it particularly in those patients.

You cant guarantee the CSE works until the spinal wears off. Tetracaine spinal is ok but not guaranteed to provide about 2-3 hours of coverage. Higher rate of failed spinals vs bupi.

Light sedation in a severely anxious patient in a weird lateral position for a few hours is horrible. She may be screaming the whole time that shes nauseous and her legs feel numb. Think OB anesthesia but worse. Hammers and saw noises will freak her out. Orthopod will freak and insist on GA intraop. Not cool.

Only would attempt neuraxial on her if failed GETA as there is no other option at that point.

Prop sux glide

 

[Noyac]

Are you calling me an old phuck?? Pretty sure I’m like 1/2 your age.

That’s still pretty phucking old.

Can you hear me?

I said, THATS STILL PRETTY PHUCKING OLD!!!

 

[Plead the Fifth]

Good responses. I agree GETA would be high on my options list but I almost always follow the mantra that one attending told me, “Three things in anesthesia will get you in trouble: bad hearts, bad lungs, and bad airways.”

 

[Iso4ane]

I wish we could tell patients to put their big boy/girl pants on.

 

[MoMoGesiologist]

The typical characters here ( read: the old phucks) are spot on. I did an RSI with a glidescope and all went well.
I would hate to have her lateral, puking and freaking out while her spinal is wearing off.

I feel like, given the neck fusion, the board answer is AFOI. Residency made me scared of neck fusions. Glad to hear glidescope went without issue.

Thanks for a great case discussion!

 

[narcusprince]

Another strong consideration that would bolster the afoi argument is someone you are concerned about having a full stomach. Had an attending that used to say afoi are indicated when patients had full stomachs.

 

[vector2]

AFOI in stone neck may be right answer on the boards but it is the WRONG real world answer for someone with severe anxiety and nausea with recent emesis. Mostly because she'll require so much sedation that you might as well have induced, or barring that, your scope bangs against that one square centimeter of gag tissue that was relatively unanesthetized and the field is now filled with vomit.

The failure rate with highly angulated blades (either glide, cmac d-blade, McGrath x blade) is so vanishingly low that the only ppl I AFOI are those with airway trauma, angio edema, congenital malformation, ent surgery/radiation, and jaws that are wired shut.

 

[Planktonmd]

Speaking retrospectively makes the solution that worked the right solution, but I wonder if people would have applauded Noyac's plan had he said that when he did RSI he got into a (cannot intubate cannot ventilate) situation and the patient vomited and ended brain dead... I bet everyone would have said he should have done AFOI!

 

[Hoya11]

sounds like that may require a lot of sedation for this old demented lady to cooperate with an AFOI, after dex or versed or ketamine, youve already taken on some aspiration risk while you then dick around with the scope....

and for those in favor of spinal, yes you avoid bad airways... BUT you dont put yourself at risk of having to intervene on that airway in suboptimal position once the case has started, and with this demented nauseous lady for a long case there is significant chance of having to do that

maybe im just cavalier, but when i hear neck mobility is limited, BFD... as long as i can stick a glidescope in the mouth the game is over and thats not a "difficult airway" to me

 

[Mman]

While I'd probably do GA on this case, for those discussing neuraxial and CSE and tetracaine and OMG what if it wears off. Why not just grab an 18 g Touhy needle and shove it into CSF and thread a catheter. Continuous spinal. Boom done. Now you've got your perfect regional for as long as needed. No worrying about an iffy epidural catheter. The incidence of PDPH in 66 year olds is pretty damn low.

 

[Mman]

maybe im just cavalier, but when i hear neck mobility is limited, BFD... as long as i can stick a glidescope in the mouth the game is over and thats not a "difficult airway" to me

While I mostly agree, I have had an ENT radiation patient that could open their mouth enough to get the glidescope in but we had to wake up and cancel the case because neither myself, one of my colleagues, or the ENT surgeon could actually get the tube to go through the cords. And we spent damn near 30-45 minutes trying everything under the sun. It's a long story, but the moral is not everybody that you can get a glidescope in their mouth can be intubated.

 

[narcusprince]

We are missing a point here. She has no risk factors for difficult ventilation other then history of emesis and nausea. Suction air sucking and ready go in case she vomits and head above the heart positioning and if she vomits head down. I do not think she would be a tough mask ventilation. Also for the life of me if their is a hole I can put in a tube with the glidescope and fiberoptic. She is most certainly not a tough ventilation. My sphincter tone is much higher in SEVERE osa versus stone neck.

 

[Mman]

We are missing a point here. She has no risk factors for difficult ventilation other then history of emesis and nausea. Suction air sucking and ready go in case she vomits and head above the heart positioning and if she vomits head down. I do not think she would be a tough mask ventilation. Also for the life of me if their is a hole I can put in a tube with the glidescope and fiberoptic. She is most certainly not a tough ventilation. My sphincter tone is much higher in SEVERE osa versus stone neck.

this patient has OSA which is a risk factor for difficult ventilation. And no I'm not saying I awake FOI all these people. Obviously it just depends what they look like and if you have records of prior intubations.

 

[VisionaryTics]

While I mostly agree, I have had an ENT radiation patient that could open their mouth enough to get the glidescope in but we had to wake up and cancel the case because neither myself, one of my colleagues, or the ENT surgeon could actually get the tube to go through the cords. And we spent damn near 30-45 minutes trying everything under the sun. It's a long story, but the moral is not everybody that you can get a glidescope in their mouth can be intubated.

Try glidescope-assisted fiberoptic? I've found it very helpful in patients that a glidescope gives a great view but the tube just can't make the turn.