Let’s discuss a case

[narcusprince]

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How many of you recheck the airway in the sniffing position once in the operating room and positioned prior to induction? IE mallampati assesment.

 

[Mman]

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.

yes, have done that many times, didn't work despite 2 anesthesiologists and 1 ENT trying to drive it in with someone else holding the glidescope view for them.

Radiation can be a beast to an airway

 

[Noyac]

Speaking retrospectively makes the 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!

I would have been the first to say that.

 

[nimbus]

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

I’d still like to know if she’s going to puke bile or burrito chunks.

 

[Noyac]

I’d still like to know if she’s going to puke bile or burrito chunks.

Fair enough.

 

[nimbus]

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?

It depends on the rest of the airway exam. Sometimes you need neck mobility if the airway is overwise unfavorable. However, VL has made those more rare.

 

[deleted162650]

I’d still like to know if she’s going to puke bile or burrito chunks.

Might not be much of a difference depending on which taco shop she went to.

 

[bz1024]

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

This!

Put her to sleep!
If she looks like a easy mask, then prop, fent, sux and cmac
If she looks like a hard mask, afoi with cmac assist (two machines, one with bronchoscope and one with the mac blade).

 

[narcusprince]

yes, have done that many times, didn't work despite 2 anesthesiologists and 1 ENT trying to drive it in with someone else holding the glidescope view for them.

Radiation can be a beast to an airway

This is probably a more interesting case and management. Unless their was some degree of subglottic pathology If their is a hole on the screen on the glidescope view i can drive a fiber past the cords. What was the case and How did you solve the problem?

 

[Mman]

This is probably a more interesting case and management. Unless their was some degree of subglottic pathology If their is a hole on the screen on the glidescope view i can drive a fiber past the cords. What was the case and How did you solve the problem?

I don't even remember what the case was. I think it was a recurrent tumor that they wanted to biopsy. Patient did not want a trach. Patient had a previous GA a month ago that was a difficult glidescope + fiberoptic but they were able to 2 person mask ventilate. Mal 4 airway, big thick neck with no extension. We could get the glidescope in the mouth but could not get cords on the screen with the glidescope. Myself, ENT surgeon, and my colleague that had done it the month prior all could barely see the cords through the scope but the angle was too acute and we could not pass the tube. We could come out and ventilate each time but it progressively got bloodier and we decided to abandon ship before there was no turning back.

But my moral of the story is that just because the glidescope fits in their mouth does not mean they can 100% be intubated.

 

[deleted162650]

I don't even remember what the case was. I think it was a recurrent tumor that they wanted to biopsy. Patient did not want a trach. Patient had a previous GA a month ago that was a difficult glidescope + fiberoptic but they were able to 2 person mask ventilate. Mal 4 airway, big thick neck with no extension. We could get the glidescope in the mouth but could not get cords on the screen with the glidescope. Myself, ENT surgeon, and my colleague that had done it the month prior all could barely see the cords through the scope but the angle was too acute and we could not pass the tube. We could come out and ventilate each time but it progressively got bloodier and we decided to abandon ship before there was no turning back.

But my moral of the story is that just because the glidescope fits in their mouth does not mean they can 100% be intubated.

Did you try nasal? Often times that makes for a much mellower angle - but - all bets are off with CA and radiation Hx.

 

[Mman]

Did you try nasal? Often times that makes for a much mellower angle - but - all bets are off with CA and radiation Hx.

yes we tried oral and nasal. Nasal is my preferred route for FOI.

 

[dhb]

So how long did the case last? 2h is ok in lateral.
I don't sedate for spinals more than 1-2md of midaz.

 

[dannyboy1]

So how long did the case last? 2h is ok in lateral.
I don't sedate for spinals more than 1-2md of midaz.

This. If you are doing a spinal that is your anesthetic. I never understood why people will do A spinal and then start a prop gtt at GA doses. For anxiolysis or just to make the patient go to sleep I use versed fentanyl. Benadryl also works well....

 

[T-burglar]

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.

I think "OSA" should be taken off the list of things that suggest difficult ventilation. You can ventilate almost anyone regardless of OSA severity, and almost regardless of BMI. Obstructive tissue collapse is 100% circumvented by an oral airway. And a correctly applied mask strap can get you a very high seal pressure.

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.

The 3 airways that scare me are cancer, radiation, and previous major airway surgery. The patient described in the OP is nowhere near the same league as these 3.

 

[nimbus]

So how long did the case last? 2h is ok in lateral.
I don't sedate for spinals more than 1-2md of midaz.

This. If you are doing a spinal that is your anesthetic. I never understood why people will do A spinal and then start a prop gtt at GA doses. For anxiolysis or just to make the patient go to sleep I use versed fentanyl. Benadryl also works well....

What if they talk a lot? I’m not there to entertain them for 2 hours.

 

[nimbus]

I think "OSA" should be taken off the list of things that suggest difficult ventilation. You can ventilate almost anyone regardless of OSA severity, and almost regardless of BMI. Obstructive tissue collapse is 100% circumvented by an oral airway. And a correctly applied mask strap can get you a very high seal pressure.



The 3 airways that scare me are cancer, radiation, and previous major airway surgery. The patient described in the OP is nowhere near the same league as these 3.

LMA cures OSA too.

 

[Noyac]

Did you try nasal? Often times that makes for a much mellower angle - but - all bets are off with CA and radiation Hx.

Wow Salty, did you just ask an experienced anesthesiologist this question?

I think "OSA" should be taken off the list of things that suggest difficult ventilation. You can ventilate almost anyone regardless of OSA severity, and almost regardless of BMI. Obstructive tissue collapse is 100% circumvented by an oral airway. And a correctly applied mask strap can get you a very high seal pressure.

The 3 airways that scare me are cancer, radiation, and previous major airway surgery. The patient described in the OP is nowhere near the same league as these 3.

Dont take this the wrong way but you have some surprises coming your way.

 

[narcusprince]

I think "OSA" should be taken off the list of things that suggest difficult ventilation. You can ventilate almost anyone regardless of OSA severity, and almost regardless of BMI. Obstructive tissue collapse is 100% circumvented by an oral airway. And a correctly applied mask strap can get you a very high seal pressure.



The 3 airways that scare me are cancer, radiation, and previous major airway surgery. The patient described in the OP is nowhere near the same league as these 3.

I disagree with this in my humble opinion. Patients that have home nasal cpap are easier to ventilate versus people with full mask cpap and bipAp is a higher risk of ventilation issues. Appropriately managed osa gives you great clues about ventilation.

 

[dhb]

This. If you are doing a spinal that is your anesthetic. I never understood why people will do A spinal and then start a prop gtt at GA doses. For anxiolysis or just to make the patient go to sleep I use versed fentanyl. Benadryl also works well....

What if they talk a lot? I’m not there to entertain them for 2 hours.

I'm not "there" for 2h 😉

 

[Maverikk]

The glidescope assisted bronch is good, I've used it for a few pts with no pulmonary reserve and bad airways.
Propofol gtt for spinals are the best option especially after any sedation for the spinal. I do minimal IV sedation and mostly verbal sedation for the spinals, prop gtt for the surgery. You don't want the patient pulling at the drapes or telling you they were awake for the surgery. Wtf would anyone use fentanyl or midaz after the spinal? Apnea and more pacu time are not good

 

[narcusprince]

The glidescope assisted bronch is good, I've used it for a few pts with no pulmonary reserve and bad airways.
Propofol gtt for spinals are the best option especially after any sedation for the spinal. I do minimal IV sedation and mostly verbal sedation for the spinals, prop gtt for the surgery. You don't want the patient pulling at the drapes or telling you they were awake for the surgery. Wtf would anyone use fentanyl or midaz after the spinal? Apnea and more pacu time are not good

Let me stress something for the younger docs. Neuraxial anesthesia in orthopedic surgery requires surgeon who is efficient in the OR. Total knees taking longer then 2 1/2 hours no put the patient to sleep. Weak whiny surgeon who cannot handle a little movement as they close the joint = GA in my book. I have worked with orthopedic surgeons whos tka take 45 min skin to skin. Those guys have earned neuraxial approaches. Cse technique is great for tka but it does not cover back pain from laying on a table for 3 hours. Prop gtt works but you have to increase the dose in your osa/mp4 patient. Add fent/midaz and you see the rest. I have been burned by slow surgeons let them earn your spinal!

 

[Mman]

I think "OSA" should be taken off the list of things that suggest difficult ventilation. You can ventilate almost anyone regardless of OSA severity, and almost regardless of BMI.

I'm just going to disagree. I've seen quite a few big fat OSA patients that were almost impossible to ventilate. When they lose their airway tone and all that fat falls back into their throat it is not fun to deal with.

 

[deleted162650]

Let me stress something for the younger docs. Neuraxial anesthesia in orthopedic surgery requires surgeon who is efficient in the OR. Total knees taking longer then 2 1/2 hours no put the patient to sleep. Weak whiny surgeon who cannot handle a little movement as they close the joint = GA in my book. I have worked with orthopedic surgeons whos tka take 45 min skin to skin. Those guys have earned neuraxial approaches. Cse technique is great for tka but it does not cover back pain from laying on a table for 3 hours. Prop gtt works but you have to increase the dose in your osa/mp4 patient. Add fent/midaz and you see the rest. I have been burned by slow surgeons let them earn your spinal!

Disagree. My arthropods ain't the speediest bunch. Total joints typically in the 2.5-3hr range. Low dose ISO Bupi (7.5mg)+ low dose prop gtt (65-75) works great. Higher dose ISO Bupi +/- fent still works great for revisions going upwards of 5.5hrs still with the same prop gtt. If you are having trouble getting an SAB to last a solid 2.5-3hrs then something fishy is going on.

 

[Arch Guillotti]

Let me stress something for the younger docs. Neuraxial anesthesia in orthopedic surgery requires surgeon who is efficient in the OR. Total knees taking longer then 2 1/2 hours no put the patient to sleep. Weak whiny surgeon who cannot handle a little movement as they close the joint = GA in my book. I have worked with orthopedic surgeons whos tka take 45 min skin to skin. Those guys have earned neuraxial approaches. Cse technique is great for tka but it does not cover back pain from laying on a table for 3 hours. Prop gtt works but you have to increase the dose in your osa/mp4 patient. Add fent/midaz and you see the rest. I have been burned by slow surgeons let them earn your spinal!

too dogmatic

 

[Noyac]

I use Midaz all the time for sedation in totals. I like it be propofol cause it doesn’t lead to as much obstruction. They just doze off and breath better. I usually give 5mg or less during a 2 hr case.
Also, it is way less maintenance. Us old guys can’t be bothered with all that infusion nonsense.

 

[Mman]

I use Midaz all the time for sedation in totals. I like it be propofol cause it doesn’t lead to as much obstruction. They just doze off and breath better. I usually give 5mg or less during a 2 hr case.
Also, it is way less maintenance. Us old guys can’t be bothered with all that infusion nonsense.

Midazolam is nice for total joint sedation because of the amnesia. Most patients do not want to remember the hammering sound and the bed shaking. If they wake up a little during the case but don't remember, they don't care. I have had patients that had straight propofol sedation for a total knee and told me they hated that they remember waking up and hearing the hammering.

 

[Maverikk]

I still use midaz so they don't remember the spinal usually 1-2 for the elderly group, I think 5 in that situation is fine but the prop gtt is less confusion in my opinion and I'm comfortable doing it this way; choice of style, I think they wake up and talk to their family coherently sooner, happier experience. For the ones who've lived rough, smokers, drinkers I think a lot of midaz gets them disinhibited but not calm, I've had 60 yr old ladies with a bunch of tattoos trying to pull down the drape when I used midaz/fent, I would have to use enough midaz where they'd be sedated until the next morning, not as clean. I use prop gtt and a set of headphones, ask them what they like to listen to and turn on the pandora, by the time we get to PACU they're asking how the surgery went and when they can have a drink

 

[pgg]

too dogmatic

Maybe a little, but I freely admit I have a mental list of surgeons whose patients always get GA.

 

[narcusprince]

Disagree. My arthropods ain't the speediest bunch. Total joints typically in the 2.5-3hr range. Low dose ISO Bupi (7.5mg)+ low dose prop gtt (65-75) works great. Higher dose ISO Bupi +/- fent still works great for revisions going upwards of 5.5hrs still with the same prop gtt. If you are having trouble getting an SAB to last a solid 2.5-3hrs then something fishy is going on.

My neuraxial block lasts that long with epi wash, I rarely give intrathecal narcotics with tka and blocks. Its moreso with certain surgeons the tka times can vary greatly. I need to see their skill set under GA or hear from a trusted colleague that they are fast and efficient. I have worked at my new gig for about 3 months and I may have to bring back IT fentanyl. Im flexible. Its not the block its the back pain from laying flat for a 3 hour knee that concerns me with neuraxial approach.

 

[nimbus]

How many of you recheck the airway in the sniffing position once in the operating room and positioned prior to induction? IE mallampati assesment.

Never even heard of this. Perhaps a deficit in my knowledge base.

 

[nimbus]

My neuraxial block lasts that long with epi wash, I rarely give intrathecal narcotics with tka and blocks. Its moreso with certain surgeons the tka times can vary greatly. I need to see their skill set under GA or hear from a trusted colleague that they are fast and efficient. I have worked at my new gig for about 3 months and I may have to bring back IT fentanyl. Im flexible. Its not the block its the back pain from laying flat for a 3 hour knee that concerns me with neuraxial approach.

LMA works fine when they get back pain or if the block wears off. It’s not a failure.

 

[Consigliere]

Prop, sux, tube. CA-1 case.

 

[Noyac]

My neuraxial block lasts that long with epi wash, I rarely give intrathecal narcotics with tka and blocks. Its moreso with certain surgeons the tka times can vary greatly. I need to see their skill set under GA or hear from a trusted colleague that they are fast and efficient. I have worked at my new gig for about 3 months and I may have to bring back IT fentanyl. Im flexible. Its not the block its the back pain from laying flat for a 3 hour knee that concerns me with neuraxial approach.

My only caution with IT fent in these cases is that the pts will occasionally start fidgeting because of the pruritis. This can be a real distraction for everyone.

 

[narcusprince]

LMA works fine when they get back pain or if the block wears off. It’s not a failure.

I get it but throwing in a LMA when the surgeon is closing skin sure feels like a failure. If this happens I try to give a little more propofol to limp through the last 15-30 minutes. Of course if you have more then 30 minutes to go induce GA place a Lma especially since in a tka ur supine. Hips are more complex. And it depends on surgical approach.

 

[vector2]

I get it but throwing in a LMA when the surgeon is closing skin sure feels like a failure. If this happens I try to give a little more propofol to limp through the last 15-30 minutes. Of course if you have more then 30 minutes to go induce GA place a Lma especially since in a tka ur supine. Hips are more complex. And it depends on surgical approach.

Very rarely have I run into a MAC situation where 20-30 mg of ketamine didn't smooth out a squirrely patient. Also lets you keep your prop gtt to a level where you're not putting a nasal trumpet in everyone and running essentially an unprotected airway GA. The ketamine is a little detrimental to PACU times and you do have to watch the drool factor tho...

 

[narcusprince]

Very rarely have I run into a MAC situation where 20-30 mg of ketamine didn't smooth out a squirrely patient. Also lets you keep your prop gtt to a level where you're not putting a nasal trumpet in everyone and running essentially an unprotected airway GA. The ketamine is a little detrimental to PACU times and you do have to watch the drool factor tho...

I too have used ketamine. The limitation in my current system is in order to get the ketamine you have to get it from a central pyxis. Its more of a convenience issue I have more propofol in the cart versus central supply ketamine.