Oral Board Thread/case Scenarios, Let's Discuss

[TecmoBowl]

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Hey folks,
As I prepare for my Oral board exams, I sometimes pose questions to myself that neither my friends or myself can answer, at least convincingly. So I thought why not present my questions here and generate discussion. So maybe we can all post some questions and concerns about possible scenarios in our practice? Anyways, here are two recent thoughts.

1) 35 yo obese female with MP4 airway for emergent c-section. Placed a spinal, it doesn't work after waiting for heaven forbid 10 minutes. Options?

My thoughts/options were this: A) Awake Fiberoptic- I don't have time for topicalization so I'd proceed with nerve blocks (recurrent laryngeal only as I would want some airway protection left) with small doses of benzos/narcs/ketamine. B) I could redo the spinal with the possibility of a resultant high spinal or, another failed spinal.

I'm thinking are my surgeons going to be waiting around while I'm palpating hyoid bones in layers of soft tissue? Even if I could, probably not. Now let's say she starts puking as I try the fiberoptic, or goes into laryngospasm that I can't break- Great! Now it's DL time, no view, ILMA, aspiration, ICU. Or, she's now sedated and can't sit up for a repeat spinal.

So I'd take the risk of a high spinal and try again. What would you guys do?
This has happened to me before (despite 4 quadrant CSF flow) but without the airway issues, and so I did GA.


2) Another C-section scenario: Labor epidural placed by colleague, now emergent c-section. Bolused 30 ml of 2%lidocaine with epi/bicarb. Patchy level/No level. Again let's make it an MP4
Replacing and re-dosing epidural catheter would take us into toxic doses possibly. Attempting awake fiberoptic has the same risks as above, not to mention time. I know mom comes first but still...Can I place an intrathecal catheter? We don't have the ones designed for intrathecal use, but my thoughts were- place the epidural catheter intrathecally- dose it slowly- deal with the headache and possible cranial nerve palsies after. This way, we get a quick and reliable level, avoid local anesthetic toxicity and possibly avoid airway compromise.

What do you think? Jet? UT?

Sorry about the long one...thoughts appreciated. I'll keep them short next time but it's midnight...geez late nights these days! Can't wait till I'm done with these hurdles!

 

[coprolalia]

For what it's worth, I'd sit her up and try the spinal again. Back up airway equipment (intubating LMA, GlideScope, etc.) and ready to treat high spinal. All else fails, be ready to do emergency trach.

-copro

 

[urge]

1 You are in a tough spot. Most likely somebody will have to die. Either baby or mom. Medical ethics say do everything for the mom and forget about the baby. I would not induce her. I would take my time doing an epidermal or an awake fiberoptic. If nothing works do a trach. You can try your luck with an LMA but you might end up killing both. You can also try straight local infiltration by surgeon with a lot of ketamine iv. It ain't pretty but it works. This is a very stressful scenario with a very simple answer. Keep your cool.

2 Seems reasonable. I would probably do another epidural and dose it with chloroprocaine. IV ketamine if still patchy.

 

[Noyac]

You are on target with these cases as is almost everyone that walks into Orals. The thing is that you are not going to see these cases most likely. What you will see however, is the regular everyday case that goes south. They will try to shake you with random questions like the ones you just mentioned but will not dwell on them and then go back to the case of record. Have a plan of attack for something like these cases whether you choose awake Intubation or spinal or epidural and be ready for what will happen next but they will most likely give you a straight forward case and then have something go wrong with it.

 

[TecmoBowl]

Hey,
Thanks. I realize there are no right or wrong answers for these things, just how you would defend the answer/choice I guess! Its funny though....was walking into my OR this afternoon and a colleague came up to me with this exact scenario! Epidural...loaded, no level. Elective C-section...so I told him to hold off (unless he wanted to risk GA), wait for an hour and repeat case with spinal...whatever. It all works...safety and preparedness...is that even a word? Anyways, thanks for the answers.
-ST

 

[Planktonmd]

Hey folks,
As I prepare for my Oral board exams, I sometimes pose questions to myself that neither my friends or myself can answer, at least convincingly. So I thought why not present my questions here and generate discussion. So maybe we can all post some questions and concerns about possible scenarios in our practice? Anyways, here are two recent thoughts.

1) 35 yo obese female with MP4 airway for emergent c-section. Placed a spinal, it doesn't work after waiting for heaven forbid 10 minutes. Options?

My thoughts/options were this: A) Awake Fiberoptic- I don't have time for topicalization so I'd proceed with nerve blocks (recurrent laryngeal only as I would want some airway protection left) with small doses of benzos/narcs/ketamine. B) I could redo the spinal with the possibility of a resultant high spinal or, another failed spinal.

I'm thinking are my surgeons going to be waiting around while I'm palpating hyoid bones in layers of soft tissue? Even if I could, probably not. Now let's say she starts puking as I try the fiberoptic, or goes into laryngospasm that I can't break- Great! Now it's DL time, no view, ILMA, aspiration, ICU. Or, she's now sedated and can't sit up for a repeat spinal.

So I'd take the risk of a high spinal and try again. What would you guys do?
This has happened to me before (despite 4 quadrant CSF flow) but without the airway issues, and so I did GA.


2) Another C-section scenario: Labor epidural placed by colleague, now emergent c-section. Bolused 30 ml of 2%lidocaine with epi/bicarb. Patchy level/No level. Again let's make it an MP4
Replacing and re-dosing epidural catheter would take us into toxic doses possibly. Attempting awake fiberoptic has the same risks as above, not to mention time. I know mom comes first but still...Can I place an intrathecal catheter? We don't have the ones designed for intrathecal use, but my thoughts were- place the epidural catheter intrathecally- dose it slowly- deal with the headache and possible cranial nerve palsies after. This way, we get a quick and reliable level, avoid local anesthetic toxicity and possibly avoid airway compromise.

What do you think? Jet? UT?

Sorry about the long one...thoughts appreciated. I'll keep them short next time but it's midnight...geez late nights these days! Can't wait till I'm done with these hurdles!

For the oral boards the best answer you can give is the answer you can defend the most, and in my opinion you can never be blamed for an awake intubation.
So, my answer would be awake fiberoptic intubation for both cases.
And by the way: it's not a "recurrent laryngeal nerve block" that you are trying to do, it is a superior laryngeal block, but you really don't need it:
Just do a transtracheal block then tell her to stick her tongue out and hold it with a piece of gauze then pour a generous amount of Lido 4% in the mouth and ask her to try to swallow while you are still holding the tongue, she will most likely aspirate the lido and anesthetize most of her airway.

 

[Gas4Life]

Just do a transtracheal block then tell her to stick her tongue out and hold it with a piece of gauze then pour a generous amount of Lido 4% in the mouth and ask her to try to swallow while you are still holding the tongue, she will most likely aspirate the lido and anesthetize most of her airway.

Wow, great call. I hope I end up in an Anesthesia program with attendings that make calls like that. I am very impressed with how you think. Not that you or anyone else should care, I guess. Man, am I ever looking forward to getting started in Anesthesia residency wherever the match sends me.

 

[epidural man]

Hey folks,
As I prepare for my Oral board exams, I sometimes pose questions to myself that neither my friends or myself can answer, at least convincingly. So I thought why not present my questions here and generate discussion. So maybe we can all post some questions and concerns about possible scenarios in our practice? Anyways, here are two recent thoughts.

1) 35 yo obese female with MP4 airway for emergent c-section. Placed a spinal, it doesn't work after waiting for heaven forbid 10 minutes. Options?

My thoughts/options were this: A) Awake Fiberoptic- I don't have time for topicalization so I'd proceed with nerve blocks (recurrent laryngeal only as I would want some airway protection left) with small doses of benzos/narcs/ketamine. B) I could redo the spinal with the possibility of a resultant high spinal or, another failed spinal.

I'm thinking are my surgeons going to be waiting around while I'm palpating hyoid bones in layers of soft tissue? Even if I could, probably not. Now let's say she starts puking as I try the fiberoptic, or goes into laryngospasm that I can't break- Great! Now it's DL time, no view, ILMA, aspiration, ICU. Or, she's now sedated and can't sit up for a repeat spinal.

So I'd take the risk of a high spinal and try again. What would you guys do?
This has happened to me before (despite 4 quadrant CSF flow) but without the airway issues, and so I did GA.


2) Another C-section scenario: Labor epidural placed by colleague, now emergent c-section. Bolused 30 ml of 2%lidocaine with epi/bicarb. Patchy level/No level. Again let's make it an MP4
Replacing and re-dosing epidural catheter would take us into toxic doses possibly. Attempting awake fiberoptic has the same risks as above, not to mention time. I know mom comes first but still...Can I place an intrathecal catheter? We don't have the ones designed for intrathecal use, but my thoughts were- place the epidural catheter intrathecally- dose it slowly- deal with the headache and possible cranial nerve palsies after. This way, we get a quick and reliable level, avoid local anesthetic toxicity and possibly avoid airway compromise.

What do you think? Jet? UT?

Sorry about the long one...thoughts appreciated. I'll keep them short next time but it's midnight...geez late nights these days! Can't wait till I'm done with these hurdles!

I would do an intrathecal catheter in case #1. Maybe in #2 also. I like Noyac's idea of an awake fiber.

Since we are asking questions that are hard to answer, I have one. How come sometimes when a patient is sitting, the CVP can read 1 or maybe even negative (correctly zeroed of course)?

 

[Idiopathic]

Since we are asking questions that are hard to answer, I have one. How come sometimes when a patient is sitting, the CVP can read 1 or maybe even negative (correctly zeroed of course)?

because the transducer is above the level of the right atrium?