Nasal Intubation for CEA?

[Shimmy8]

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Anyone's vascular surgeons requesting this for "high" carotids? The vascular surgery folks say that it is well described in their textbooks, but after digging around I really couldn't find much outside of a few old studies.

Thinkig is that with a high carotid bifurcation, distal exposure is improved if they can close the mouth (i.e., necessitating nasal intubation) they can gain quite a bit of exposure and make surgery quicker, safer, etc. They also can avoid the mandibular subluxation (which I've never seen).

Obviously many of these patients are on platelet inhibitors not to mention intraop heparinization.

The original "study" in 1986 reported 120 cases with 0 complications and only a couple minor epistaxis 3-5 days post-op.

Thoughts? Experiences?

http://www.ncbi.nlm.nih.gov/pubmed/3748355

 

[Guillemot]

I the surgeon wants a nasal tube youre giving them one. A potential nose bleed is better than worse surgical exposure. Even if there is no literature, but the surgeon likes it youre giving them one. A nose bleed can be dealt with.

 

[drmwvr]

I get the tube gooey warm, lots of lube and nasal spray...have not had a problem.

 

[pgg]

This sounds ridiculous to me.

The thickness of a 7 mm endotracheal tube is the difference between good exposure and bad exposure? Just tilt the head another 2.3 degrees.

 

[Planktonmd]

When a surgeon comes up with a silly idea and feels strongly about it, and provided it does not really hurt the patient, the best plan of action is to just do it and avoid the drama.
Nasal intubation is not a bad thing and many smart old people would tell you that is better tolerated than oral intubation and requires less anesthesia.

 

[urge]

Anyone's vascular surgeons requesting this for "high" carotids? The vascular surgery folks say that it is well described in their textbooks, but after digging around I really couldn't find much outside of a few old studies.

Thinkig is that with a high carotid bifurcation, distal exposure is improved if they can close the mouth (i.e., necessitating nasal intubation) they can gain quite a bit of exposure and make surgery quicker, safer, etc. They also can avoid the mandibular subluxation (which I've never seen).

Obviously many of these patients are on platelet inhibitors not to mention intraop heparinization.

The original "study" in 1986 reported 120 cases with 0 complications and only a couple minor epistaxis 3-5 days post-op.

Thoughts? Experiences?

http://www.ncbi.nlm.nih.gov/pubmed/3748355

Haven't heard of it.

Echoing others, how much can it change the expusure? Feeling it on myself, not much.

Edentulous patients or those without front teeth should not be an issue.

 

[pgg]

When a surgeon comes up with a silly idea and feels strongly about it, and provided it does not really hurt the patient, the best plan of action is to just do it and avoid the drama.

I don't entirely disagree ...

Nasal intubation is not a bad thing and many smart old people would tell you that is better tolerated than oral intubation and requires less anesthesia.

If you were going in for surgery, would you really rather have a nasal intubation than an oral one? I wouldn't. And I don't think I could find any smart old people who would, either! 😉

 

[drmwvr]

I don't entirely disagree ...




If you were going in for surgery, would you really rather have a nasal intubation than an oral one? I wouldn't. And I don't think I could find any smart old people who would, either! 😉

If I were going into surgery, I'd want the surgeon to have what he asked for

 

[Crash cart]

Place a red rubber catheter over the tip of the ETT and pass the catheter through the nose and into the posterior pharynx. Then use the catheter to "pull" the ETT through the nasal cavity into the back of the throat. Remove the catheter and intubate the patient. Zero to very minimal bleeding every time.

I agree it sounds utterly ridiculous. Just a matter of how much you want to get into a pissing match with an egotistical vascular surgeon.

By the time you finish discussing / arguing the tube could be in, the case underway and you're that much closer to heading home for the day.


Sent from my iPhone using SDN mobile app

 

[Shimmy8]

Appreciate the responses.

Ive done two of these cases in last six months. We have a very high acuity and high volume vascular program, and my attendings for both said they had never heard of it or done it before. But we obliged.

Both bled like stink. One was on placix, one not.

One required ENT to place Rhino Rockets post op and one aspirated a fair amount of blood that led to O2 requirement 48 hrs post op and definitely prolonged hospital stay. Both ended up being packed with cocaine pledgets upon
extubation.

Nonetheless, our issue is with heparinization and patients on plavix getting a nasal tube.

Maybe just bad luck on our part? I did both intubations myself, lubed up warm tube, very smooth and no bleeding at time of intubation for either case.

Just curious about others' experiences.

 

[Crash cart]

Well, with your N of 2, the risk clearly seems to outweigh the benefit.


Sent from my iPhone using SDN mobile app

 

[Planktonmd]

I don't entirely disagree ...




If you were going in for surgery, would you really rather have a nasal intubation than an oral one? I wouldn't. And I don't think I could find any smart old people who would, either! 😉

Nasal intubation is just another way to do the same thing! And it is very well tolerated in the short term, actually I think in England they used to intubate every ICU patient nasally because it is better tolerated and requires less sedation.
So your emergence will be smoother with a nasal tube, how about that for motivation???

 

[Planktonmd]

Appreciate the responses.

Ive done two of these cases in last six months. We have a very high acuity and high volume vascular program, and my attendings for both said they had never heard of it or done it before. But we obliged.

Both bled like stink. One was on placix, one not.

One required ENT to place Rhino Rockets post op and one aspirated a fair amount of blood that led to O2 requirement 48 hrs post op and definitely prolonged hospital stay. Both ended up being packed with cocaine pledgets upon
extubation.

Nonetheless, our issue is with heparinization and patients on plavix getting a nasal tube.

Maybe just bad luck on our part? I did both intubations myself, lubed up warm tube, very smooth and no bleeding at time of intubation for either case.

Just curious about others' experiences.

You need to use a lot of afrin to prepare the nose, then use gradually increasing sizes of well lubricated nasal trumpets after induction, and while you are ventilating, also make sure your tube is sitting in warm water prior to insertion and if they bleed use more Afrin.

 

[pgg]

Nasal intubation is just another way to do the same thing! And it is very well tolerated in the short term, actually I think in England they used to intubate every ICU patient nasally because it is better tolerated and requires less sedation.
So your emergence will be smoother with a nasal tube, how about that for motivation???

ICU is a totally different scenario. For a patient who's intubated but awake/sedated, having a less mobile tube in the nose is probably significantly more comfortable.

But an OR case, where the discomfort from being intubated is experienced after extubation, nasal is the clear loser by a large margin IMO. Nosebleeds, congestion, tissue trauma ... some percent of the time you need to try both nares.

Smoother emergence? I'm not buying that dragging the tube and that wrinkly cuff through the nasopharynx is less stimulating than coming out the mouth. Especially since some of these cases last longer than the Afrin or local you put in the nose at intubation. If your nasal emergences are better it's surely because of something else you're doing, and maybe you should do that for oral intubations too.


For my nasal intubations I mix up a 10 mg vial of phenylephrine with some 2% lidocaine jelly and use that after an Afrin prep. Bleeding and postop discomfort is usually minimal, but not always. I still think nasal intubations for CEAs are stupid.

 

[Planktonmd]

ICU is a totally different scenario. For a patient who's intubated but awake/sedated, having a less mobile tube in the nose is probably significantly more comfortable.

But an OR case, where the discomfort from being intubated is experienced after extubation, nasal is the clear loser by a large margin IMO. Nosebleeds, congestion, tissue trauma ... some percent of the time you need to try both nares.

Smoother emergence? I'm not buying that dragging the tube and that wrinkly cuff through the nasopharynx is less stimulating than coming out the mouth. Especially since some of these cases last longer than the Afrin or local you put in the nose at intubation. If your nasal emergences are better it's surely because of something else you're doing, and maybe you should do that for oral intubations too.


For my nasal intubations I mix up a 10 mg vial of phenylephrine with some 2% lidocaine jelly and use that after an Afrin prep. Bleeding and postop discomfort is usually minimal, but not always. I still think nasal intubations for CEAs are stupid.

Ok... then don't do it!! 😀

 

[Planktonmd]

For a patient who's intubated but awake/sedated, having a less mobile tube in the nose is probably significantly more comfortable.

Smoother emergence? I'm not buying that dragging the tube and that wrinkly cuff through the nasopharynx is less stimulating than coming out the mouth.

You do know that emergence and extubation are two different things don't you?

 

[cchoukal]

Retro molar oral ETT placement on the contra lateral side and the mouth will close.

 

[sevoflurane]

Nasal tube for a CEA is on the far far left of the surgeon spoiled-ness bell curve.

 

[pgg]

Nasal intubation is just another way to do the same thing! And it is very well tolerated in the short term, actually I think in England they used to intubate every ICU patient nasally because it is better tolerated and requires less sedation.
So your emergence will be smoother with a nasal tube, how about that for motivation???

Just to be clear, your argument is that because a nasal tube requires less sedation in an ICU, it's smoother for emergence from general anesthesia?

And that overcomes the downsides of extubating through the nose (discomfort & bleeding, postop swelling & congestion), enough to make nasal intubations a reasonable routine approach for OR cases?

 

[deleted162650]

Next time he asks for a nasal tube say something passive aggressive like: "Oh really? All of your colleagues seem to get adequate exposure with an oral tube."

 

[caligas]

Next time he asks for a nasal tube say something passive aggressive like: "Oh really? All of your colleagues seem to get adequate exposure with an oral tube."

"And all of YOUR colleagues put in the nasal tube without giving me any crap about it"

 

[scudrunner]

If I were going into surgery, I'd want the surgeon to have what he asked for

There is so much wrong with this statement I'm not sure where to begin.

However, in the case of a requested nasal intubation, for the very slight possibility of increased exposure, I'd oblige... unless I saw a contraindication.

 

[Planktonmd]

Just to be clear, your argument is that because a nasal tube requires less sedation in an ICU, it's smoother for emergence from general anesthesia?
Not only because it requires less sedation in the ICU, also because if you pay attention you will notice that during emergence time patients buck less and don't gag when the tube is nasal. There is a huge advantage to having the tube not touching the uvula and the back of the tongue.

And that overcomes the downsides of extubating through the nose (discomfort & bleeding, postop swelling & congestion), enough to make nasal intubations a reasonable routine approach for OR cases?
For some reason you still seem to think that emergence means pulling the tube out!!! and I did not say for routine OR cases, but if a surgeon really wants a nasal tube it's not such a big deal... unless you are an academic guy who wants to add some drama to your day!

 

[deleted682700]

Sorry, not heard of advantage of nasal intubation. One surgeon used to do them awake and he had a squeaky ball that he would have the pt on the opposite hand and make them squeeze it to test for adequacy of collateral blood flow.

The pain was doing the superficial and deep cervical plexus blocks, because he wanted them awake. In retrospect it was a good technique and that surgeon never had a stroke post op

 

[sevoflurane]

Sorry, not heard of advantage of nasal intubation. One surgeon used to do them awake and he had a squeaky ball that he would have the pt on the opposite hand and make them squeeze it to test for adequacy of collateral blood flow.

The pain was doing the superficial and deep cervical plexus blocks, because he wanted them awake. In retrospect it was a good technique and that surgeon never had a stroke post op

I was going to do one awake last friday, but an emergent heart came in and I got pulled off that case. They are easy. You just need the SCPB (ideally under USD) and some good local by the surgeon. You don't need to do the DCPB.
Checked in on the case after I dropped my patient in the ICU. The case was under way and everyone was chatty... including the patient after carotid clamp. We didn't have a rubber ducky.

 

[sevoflurane]

Agree though. Nasal for a CEA is voodoo medicine.

 

[divinemsm]

Do something because another doctor says to ? Were that the case , I'd place spinals in critical aortic stenosis patients, do prone 2 hour ERCPs in obese OSA patients with spontaneous ventilation, place epidurals in patients with ITP and no heme follow up to speak of , take ex IVdA patients back for elective c section with a single 22 gauge IV ....and on and on and on. So many " doctors " out there are hacks, that it makes me tremble. And we all are well aware who gets blamed when ish hits the fan.

 

[Consigliere]

I the surgeon wants a nasal tube youre giving them one. A potential nose bleed is better than worse surgical exposure. Even if there is no literature, but the surgeon likes it youre giving them one. A nose bleed can be dealt with.

Now this guy's experienced!

 

[drmwvr]

Do something because another doctor says to ? Were that the case , I'd place spinals in critical aortic stenosis patients, do prone 2 hour ERCPs in obese OSA patients with spontaneous ventilation, place epidurals in patients with ITP and no heme follow up to speak of , take ex IVdA patients back for elective c section with a single 22 gauge IV ....and on and on and on. So many " doctors " out there are hacks, that it makes me tremble. And we all are well aware who gets blamed when ish hits the fan.

There is no equivalency between a vascular surgeon asking for a nasal tube for his carotid and placing a spinal in a patient with critical AS or any other outrageous scenario.

Honestly.

Especially if the guy is a respected, skilled colleague (they are where I am) asking for something I can do/have done as easily as not...what is the big deal?

 

[Planktonmd]

There is no equivalency between a vascular surgeon asking for a nasal tube for his carotid and placing a spinal in a patient with critical AS or any other outrageous scenario.

Honestly.

Especially if the guy is a respected, skilled colleague (they are where I am) asking for something I can do/have done as easily as not...what is the big deal?

Exactly!!!

 

[fakin' the funk]

Anyone's vascular surgeons requesting this for "high" carotids? The vascular surgery folks say that it is well described in their textbooks, but after digging around I really couldn't find much outside of a few old studies.

Oh please. Your surgeon should focus on the aspects of their technique/exposure on THEIR end that are REASONABLE to achieve.