PACU Intubation

[aredoubleyou]

This discussion came up a while back at work, could reach no consensus on a plan of action.

Basically heres the case: 40 yr old BMI 30ish, no pmh, big neck, lap chole (i think), was a grade 2 intubation per record. Pt was given roc and reversal given at the end of the case with one weak twitch. In the pacu he's desating on facemask and appeard floppy. DBS shows inadequate reversal. More reversal given (neo or edro, doesnt matter), still desating, now in low 80's. No bronchospasm, pneumo, significant atalectasis, a lot of upper airway obstruction even with nasal canula, shallow rapid breathing. 250 mcg fentanyl given in case, 6 mg neostigmine altogether. You decide to intubate him in the PACU. No glidescope, or other video airway device available.

Ok, so heres the question: Challenging airway, pacu intubation....do you in addition to an induction agent:
A) Intubate w/out more relaxant
B) More roc, shove the tube in
C) Sux, tube.
D) Other? (suga is not an option)

The discussion centered around whether or not to give sux after recent reversal agents.

What if he was a grade 3 intubation?

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[Gern Blansten]

Not too much is lost by trying a blind nasal, unless you stir up too much bleeding

 

[Idiopathic]

Im okay with sux tube but id also be okay with no hypnotic and no paralytic, DL, and an LMA if I cant get a view. I do most of my urgent floor laryngoscopy without paralytic, at least taking a look. I do think that you sedate and try to mask, etc. following some algorithm, ideally.

 

[jetproppilot]

You've got 2 choices.

1) Flatten the bed, then reverse Trendelenberg the bed at a pretty good angle. Give a little midazolam to smooth the dude out. Assist-mask ventilate him until the nondepolarizer wears off enough. Use an airway adjunct (oral or nasal) if tolerated. Count on losing your availability to the operating room/PACU/day surgery/life itself for at least thirty minutes.

2) No mention of difficult mask airway so give a low dose of propofol (40-50mg) followed by a low dose of sux (40mg). Chances are, if you routinely yield The Force, you will at least be able to slide an Eschmann (sic?) in followed by your tube. Then mildly sedate the dude and allow the residual nondepolarizer to be metabolized.

I'd personally go with 2).

 

[jetproppilot]

Not too much is lost by trying a blind nasal, unless you stir up too much bleeding

Thats an awesome, almost lost art I wish I was good at.

I remember my days as a med student at The U where I witnessed several of those, all on my ER rotation where the ER doc called the anesthesiologist for airway management.

This was circa 1990, and the anesthesiologists I saw who were deft at blind nasals were 50ish. In 1990.

Blind nasals are great if you're really good at them.

They're a waste of time if, like me, you suck at them.

 

[Licoricestick]

Most important question - easy facemask ventilation or not?

I don't think it matters what you do as long as you position the patient as best you can - as Jet says, some reverse trendelenburg will be a great help regardless of FM or tube.

As for giving sux after anticholinesterases - yes, you may get a phase 2 block, but isn't that irrelevant in the situation? With a BMI of 40 and sats in the 80s, this patient is going to be dead before an induction dose of sux wears off (even if there is no phase 2 block, and potentially still dead even with a smaller dose) if you can't oxygenate. So as long as you acknowledge the possibility of a phase 2 block and don't depend on sux's duration of action to get you out of trouble if you end up in a CICV scenario, I don't think it matters what you do.

As for if it'd been a grade 3 - I don't think that makes much of a difference if you decide to tube, but could you consider trying BiPAP?

 

[drccw]

I'm sorry..
I might be missing something...
are we afraid of a grade II airway.
or a grade III airway...

eschmann stylet....
induce with drug of choice.. if he's really that weak then you might not need muscle relaxant...

drccw

 

[Fastrach]

Dunk w/ a little propofol, stick in an LMA, leave on pressure support til the LMA gets spit out. Avoids the muscle relaxant and further manipulation of an already tenuous airway. Might try bipap first.

 

[sevoflurane]

Dunk w/ a little propofol, stick in an LMA, leave on pressure support til the LMA gets spit out. Avoids the muscle relaxant and further manipulation of an already tenuous airway. Might try bipap first.

If the patient is able to generate 2-3ml/kg I would try bipap + time. If the patient is moving less air and has the wondering zombie eyes, then I'd tube with only a little jackson juice and extubate when ready.

 

[Planktonmd]

If you decide to reintubate a patient in the PACU then I am not sure why you are concerned about the prolonged effect of Sux?
So what if he needs to remain intubated 30 extra minutes? Why is that such a big deal?
If you decide that the patient needs to be tubed especially if the patient has a marginal airway then give yourself the best conditions possible, give a real induction dose of an induction agent + SUX, put the tube in and call it a day.
Many airway disasters are easily traceable to suboptimal muscle relaxation and crappy intubation conditions as a result.
I am not saying that you need to intubate every patient that is still a little weak in the PACU but if you decide to intubate then do it right.

 

[rsgillmd]

Is this patient a candidate for BiPaP? If so, use it. Why mess with the airway if you don't need to? If not, I'm with Plank on this one. Worst case scenario you can't get the tube, so you stick in an LMA. The phase II block is more of an academic concern than a practical concern.

You haven't mentioned he was a difficult ventilation before, so he should be ventilatable now, especially with an LMA, even if you can't get the tube.

If you're cautious, have the LMA you select as your backup be an intubating LMA, like Fastrach. I've had excellent success with it.

 

[rsgillmd]

.......if you decide to intubate then do it right.

My viewpoint exactly. Picture yourself taking a course of action and something going wrong. You will ask yourself if you could have done anything differently. Why wait to ask that question? Address the potential problem now so you don't have to ask the question.

On my oral boards as a grab bag I was given a non-cooperative trauma patient with a suspected full stomach and antiicipated difficult airway who needed a CT scan. When it go to the point of how I would intubate the patient I said: RSI with Glidescope, backup equipment available. Prep the neck and have surgeon ready to cut. There were only a few followup questions. I passed.

 

[sevoflurane]

So you would give sux to every patient that needs an AW in the PACU? I've done plenty of intubations w/o any paralytics or propofol in the pacu w/o sequela.... especially the old ones with the Q sign.

This is my take, you are welcome to disagree:

GDII, GDIII shouldn't be a big deal. He is already partially paralyzed. I would start with propofol and have sux ready. If I need it (very unlikely), I will have intubating conditions in 30 sec., but if I don't have to give it, then why would I?
I don't like my patients intubated in the pacu longer than they have to be. Even if it's 30 minutes.

As soon as the tube is out I check them off in my head.

 

[rsgillmd]

So you would give sux to every patient that needs an AW in the PACU? I've done plenty of intubations w/o any paralytics or propofol in the pacu w/o sequela.... especially the old ones with the Q sign.

This is my take, you are welcome to disagree:

GDII, GDIII shouldn't be a big deal. He is already partially paralyzed. I would start with propofol and have sux ready. If I need it (very unlikely), I will have intubating conditions in 30 sec., but if I don't have to give it, then why would I?
I don't like my patients intubated in the pacu longer than they have to be. Even if it's 30 minutes.

As soon as the tube is out I check them off in my head.

I'm not sure if your post was directed at me or someone else. Like everyone else I take the whole picture into account. Being that this is the internet where I can't see/examine the patient, I'm making certain assumptions given the information I have on this particular patient.

One of the assumptions I was making was this patient is alert enough to resist me. I don't want to cause trauma to a questionable airway and make subsequent laryngoscopies more difficult.

I was just trying to make a general point with my posts -- don't handicap yourself if you don't have to.

 

[sevoflurane]

I'm not sure if your post was directed at me or someone else. Like everyone else I take the whole picture into account. Being that this is the internet where I can't see/examine the patient, I'm making certain assumptions given the information I have on this particular patient.

One of the assumptions I was making was this patient is alert enough to resist me. I don't want to cause trauma to a questionable airway and make subsequent laryngoscopies more difficult.

I was just trying to make a general point with my posts -- don't handicap yourself if you don't have to.

Nah... not directed at anyone... just a little healthy debating.

If he is weak enough from the lingering ROC, is not moving a lot of air, floppy fish, no head lift.... I would sneak in a little prop and tube. He is already partially paralyzed. It won't take much to get intubating conditions. If I need sux, I have it cocked and ready to fire.

If the patient is strong enough to resist me and the TV were 2-3ml/kg I'd use bipap and spare the man an ETT as he gains strength.

 

[Planktonmd]

There is nothing wrong with wanting to have people intubated for a shorter time.
This patient according the first post is not a little old lady that you can intubate with your fingers, it's a patient that seems to be strong, big and was not very easy to intubate.
If a paitent was grade 2 or 3 WITH good muscle relaxation then I can assure you that your laryngoscopy now is not going to be easier with partial or no muscle relaxation and possibly swollen airway.
So, I like to give myself the best conditions on the first attempt in such a patient but you could always try a few times and see what happens
Again, I am not saying we should intubate every patient that is a little weak in the PACU but if a patient needs to be intubated then I would give myself the best intubating conditions.

 

[Noyac]

I would be comfortable doing any of the above approaches except the blind nasal. I'm just not that good at it. Everytime I do a nasal intubation in the OR I try it blind at first to see if i can get it and I succeed only about half the time. Granted, they are not breathing when I am inserting it which makes it more difficult.

 

[dhb]

I agree with everyone

 

[urge]

I would let the person who extubated him floppy deal with it.

 

[jwk]

I would let the person who extubated him floppy deal with it.

I get to the (current) bottom of the thread before I see this great post!

My question after the OP was, just out of curiosity, why the hell was this patient extubated in the first place?

 

[Planktonmd]

I get to the (current) bottom of the thread before I see this great post!

My question after the OP was, just out of curiosity, why the hell was this patient extubated in the first place?

This patient was extubated early for the same reason my CRNA decided to extubate a 7 Y/O yesterday after a tonsillectomy as soon as the kid started bucking!
The kid got reintubated and has negative pressure pulm. edema.

 

[urge]

The kid got reintubated and has negative pressure pulm. edema.

That was a ninja edit. I was going to call you out on the positive pressure...

 

[Planktonmd]

That was a ninja edit. I was going to call you out on the positive pressure...

If you want to know why just look at the scotch thread

 

[pgg]

This discussion came up a while back at work, could reach no consensus on a plan of action.

Basically heres the case: 40 yr old BMI 30ish, no pmh, big neck, lap chole (i think), was a grade 2 intubation per record. Pt was given roc and reversal given at the end of the case with one weak twitch. In the pacu he's desating on facemask and appeard floppy. DBS shows inadequate reversal. More reversal given (neo or edro, doesnt matter), still desating, now in low 80's. No bronchospasm, pneumo, significant atalectasis, a lot of upper airway obstruction even with nasal canula, shallow rapid breathing. 250 mcg fentanyl given in case, 6 mg neostigmine altogether. You decide to intubate him in the PACU. No glidescope, or other video airway device available.

Ok, so heres the question: Challenging airway, pacu intubation....do you in addition to an induction agent:
A) Intubate w/out more relaxant
B) More roc, shove the tube in
C) Sux, tube.
D) Other? (suga is not an option)

The discussion centered around whether or not to give sux after recent reversal agents.

What if he was a grade 3 intubation?

I'm late to this thread - but given a big fat guy who has already desatted to the low 80s, I agree with those who would use succ from the start. Optimal conditions ASAP. Succ may last a while after neostigmine, but he's already bought a reintubation - 20 minutes vs 60 minutes on a vent is not a big deal.

Others have said the above already though, so what I really wanted to add to the thread was if, while the induction drugs and a tube are being fetched/prepared, you're able to effectively assist his ventilation with a Mapleson/BVM, then I think NIPPV would be a good option. Weak people with far more significant underlying conditions avoid intubation this way in the ICU all the time. This patient would probably do well with it.

 

[aredoubleyou]

I get to the (current) bottom of the thread before I see this great post!

My question after the OP was, just out of curiosity, why the hell was this patient extubated in the first place?

My guess: pride. Didnt want to sit there with a tumb up his XXX waiting for relaxation to wear off. Also, partly because we can get away with it (reversing from barely a twitch) often, but sometimes its gunna bite you!

I am also of the sux camp. Did not like the thought of using more roc, cause theres no way to know how much you need to give at this point for intubating conditions. If the airway were easy, I'd give just propofol probably, but in this case I think plank is right, get the tube in on the first shot, dont find yourself working down the airway algorithm.

I'm a huge fan on non-invasive ventilation, but it seems I am one the few.

 

[Idiopathic]

I'm a huge fan on non-invasive ventilation, but it seems I am one the few.

every airway disaster ive been to in the last 6 months was being "bridged on BIPAP" prior to decompensating

 

[ProRealDoc]

Prop, sux, quick look with blade of choice and bougie in hand. If no success, throw in supreme LMA.

So you had no difficult airway cart around?

After the dust settles, let your nurse anesthetist know that extubating patients without properly reversing them is criminal.

 

[pgg]

every airway disaster ive been to in the last 6 months was being "bridged on BIPAP" prior to decompensating

NIPPV in the ICU sometimes just delays the inevitable (and as a resident I'd always cruise through early on my call nights looking to see if anyone was on BIPAP just to get a feel for the odds of a stat intubation call), but a postop patient whose ONLY problem is weakness from residual NMBD is exactly the patient who's going to do great with it.

 

[Idiopathic]

i know, im just saying - you really need to see the situation to get a feel for whether the patient will require reintubation and if you feel strongly, i would not use NIPPV as a bridge. i agree it should help in this case, as should assisting with a mask but you have to assume that it is what it is and that there isnt any metabolic derangement or somesuch thats forcing this issue.

should get a tube