RSI and myasthenia gravis, induction drugs?

[Noyac]

I’m surprised that we have all of these comments and nobody has asked (unless I missed it)if this pt takes anticholinesterase medications and if he took it today?

How might this effect succinylcholine and NMB meds?
-succ action can be prolonged
- NMB possibly could be antagonized but I haven’t seen this.

What if he is non-compliant?
-profound responses to NMB can be found.

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[Arch Guillotti]

Just something to think about. It is well known that inducing without muscle relaxants, propofol and remi alone, will make an airway more difficult. The dose of remi is important.

This is nonsense.

Troll

So you now need to give more meds to counter the effects of your poorly chosen induction.

Give me prop and a nmb and I’m done while you are resuscitating.

Why is the airway more difficult? Please provide a reference or something other than anecdote.

For you it may be a poorly chosen induction. Not for me. Never had to resuscitate a patient with this induction.

The point of discussion is that intubation can be safely and reliably done without muscle relaxant, not just "prop and a nmb".

 

[Arch Guillotti]

Larnygnospasm aka "chest wall rigidity" from a big slug of remi isn't helpful either.

I miss having alfentanil available. I used to use propofol + alfentanil + atropine a lot for eyeball cases with retrobulbar blocks, or for other super brief stimulating procedures.

Have you ever seen ""larnygnospasm aka "chest wall rigidity"" from alfentanil (or remi for that matter)?

 

[Arch Guillotti]

Most patients can be intubated without muscle relaxants on the first attempt. The conditions may not be optimal as with NMB but it is still consistently and reliably doable. You have good reason to avoid NMB in a patient with MG. If the airway exam is benign, I say just go for it using whatever cocktail you like without NMB. You can always paralyze if you need to but more than likely it won't be necessary.

Mostly they can but mostly it is sort of ugly a lot of the time and not a good situation if they are a full stomach.

 

[vector2]

Drunk, combative, full stomach takes precedence over MG here. Prop + roc 20mg Rsi here. Switch him to dex infusion at end of case. Let ICU attending know to keep him sedated for another etoh half life and to give him some sugammadex if his NIF is still piss poor when trying to extubate

 

[Twiggidy]

Can someone explain the rationale for remi during airway management?

I never encountered any attending using remi for airway management as a resident or as an attending. It seems like overkill to me, or at the very least a waste of remi.

 

[pgg]

Have you ever seen ""larnygnospasm aka "chest wall rigidity"" from alfentanil (or remi for that matter)?

No.

But enough people have told me that they have seen it after boluses of the synthetic fents that I'm reluctant to dismiss it as complete dogma.

 

[Arch Guillotti]

No.

But enough people have told me that they have seen it after boluses of the synthetic fents that I'm reluctant to dismiss it as complete dogma.

Maybe not. I think that if it exists it is pretty doggone rare though.

 

[BeatriZZ]

I'm enjoying this thread...I heard of using remi for intubation during residency but never have tried it myself or seen it used

But please explain why you are all so hesitant to use sux in this patient. So hesitant to use it that you prefer expensive remi. I genuinely want to know because I don't understand why

 

[Noyac]

Why is the airway more difficult? Please provide a reference or something other than anecdote.

For you it may be a poorly chosen induction. Not for me. Never had to resuscitate a patient with this induction.

The point of discussion is that intubation can be safely and reliably done without muscle relaxant, not just "prop and a nmb".

Statement: 4th National Audit Project (NAP4): investigated complications of airway management in United Kingdom for 1 yr; suggested early use of additional anesthetic agent and/or NMB if anesthesia by face or laryngeal mask complicated by failed ventilation; “no anaesthetist should allow airway obstruction and hypoxia to develop to the stage where emergency surgical airway is necessary without having administered a muscle relaxant“.
Most of the literature I’ve read on this comes from Britain.
If you look at image#2 plan C you will see that the recommendation a difficult mask ventilation is to paralyze. I know this isn’t exactly saying that remi will make things more difficult but what I am saying is that the dose of remi rally matters and that the way to fix the problem isn’t remi but paralysis. Therefore, paralysis gives us the best opportunity at the airway.
So having an administrator of this site state that this is nonsense should actually concern the others on this site about the agenda of said administrator. You of all people should be educated on the things to admonish.

 

[deleted697535]

Mate what was nap4?
A self reported email survey.

It's good info but not exactly level 1 evidence for anything.

And as for their recommendations, you are assuming this will be a difficult airway.

And as for rigidity or Brady's with remi I've done quite a bit of intubations with it and usually 40 or 50 mcg boluses don't cause this.

I have seen some spectacular rigidities but only with much higher doses over 150 to 200mcg quickly.


I don't think anyone argues that 100 or roc or sux gives you best conditions, but best conditions are rarely needed. Especially with a glidescope.

Now this guy is drunk so it's a definite RSI with roc and then ICU post-op. But if it was elective, I wouldn't paralyse him

 

[Onefellswoop87]

Statement: 4th National Audit Project (NAP4): investigated complications of airway management in United Kingdom for 1 yr; suggested early use of additional anesthetic agent and/or NMB if anesthesia by face or laryngeal mask complicated by failed ventilation; “no anaesthetist should allow airway obstruction and hypoxia to develop to the stage where emergency surgical airway is necessary without having administered a muscle relaxant“.
Most of the literature I’ve read on this comes from Britain.
If you look at image#2 plan C you will see that the recommendation a difficult mask ventilation is to paralyze. I know this isn’t exactly saying that remi will make things more difficult but what I am saying is that the dose of remi rally matters and that the way to fix the problem isn’t remi but paralysis. Therefore, paralysis gives us the best opportunity at the airway.
So having an administrator of this site state that this is nonsense should actually concern the others on this site about the agenda of said administrator. You of all people should be educated on the things to admonish.

I couldn’t find the specific image you referenced, but I do find the contrast between what you mentioned and the ASA Diffcult Airway Algorithm interesting. Nowhere in the ASA’s are NMBDs mentioned but they are here to facilitate difficulty with mask ventilation and then intubation.

 

[Noyac]

I couldn’t find the specific image you referenced, but I do find the contrast between what you mentioned and the ASA Diffcult Airway Algorithm interesting. Nowhere in the ASA’s are NMBDs mentioned but they are here to facilitate difficulty with mask ventilation and then intubation.

I forgot the link.
PubMed Central Image Viewer.

 

[Noyac]

Mate what was nap4?
A self reported email survey.

It's good info but not exactly level 1 evidence for anything.

And as for their recommendations, you are assuming this will be a difficult airway.

And as for rigidity or Brady's with remi I've done quite a bit of intubations with it and usually 40 or 50 mcg boluses don't cause this.

I have seen some spectacular rigidities but only with much higher doses over 150 to 200mcg quickly.


I don't think anyone argues that 100 or roc or sux gives you best conditions, but best conditions are rarely needed. Especially with a glidescope.

Now this guy is drunk so it's a definite RSI with roc and then ICU post-op. But if it was elective, I wouldn't paralyse him

No. I was not talking about this case. It was a general statement.

The dose you describe has an even lower chance of giving an adequate view. Some studies describe an 80% chance. This is improved with 3-5mcg/kg bolus of remi. I would agree that 80% is a pretty good chance but in that means 20% of the time you are not getting a good view. If I didn’t get a good view this frequently then I’d change what I was doing.
Now, with this large of a dose of remi you will need to address other issues from time to time. So I ask why deal with all of this when in this guy you could get by with a small dose of roc and prop and call it good?

 

[deleted162650]

We must live in different worlds then.

We probably do in that I don't 'call' people to my ICU to tube when I'm on call and I also dont leave to go back to the OR 5 mins later. I stay and look after them after them. And the ones without Roc do better mostly.

And the tube always goes in. First time. No big deal

Can you please elaborate on your statement that those that did not get Roc "do better mostly". I'm geuinely curious but also wildly skeptical that a single intubating dose of NMB has any negative clinical significance.

 

[deleted171991]

As I mentioned in my previous post, the dose of remi is important.
When someone calls it nonsense, they must be more clear. Don’t be an ass.

Let me ask this, if you are struggling to intubate and even mask the pt,what are you going to do. You just gave a 10min dose of remi. Is this pt going to start breathing and come back around in time? What are you going to do?

Give narcan?

 

[WholeLottaGame7]

I think every student, resident, and new attending should soak this line in because he’s correct. Give yourself the best opportunity to win when called to intubate. CC-IM docs and ER docs shy away from relaxants because they’re afraid of the point of no return, but we’re airway experts and live our lives at the point of no return. Make it easy and relax these people (unless they’re a difficult airway and in that case be smart)

At least in my training institution, ICUs did not use much NMB because non-anesthesia staffed ICUs couldn't give NMB without an attending or someone from anesthesia being present (or something like that). Apparently one too many etomidate/100 roc/no tube incidences. I'm sure that had something to do with the number of failed intubations (as well as poor positioning, suboptimal patient condition, lack of equipment, etc).

I figured there were enough "muscle relaxation provides the best intubating condition/initial success rate" papers out there that it would be unnecessary to post some, but now I'm wondering.

If this case were elective, prop/remi for sure. As is, prop/NMB/tube/ICU. Also, @Twiggidy, don't bring that cricoid pressure crap in here! I put my hand on the neck to help with the view and to say that I did it in the chart, not because it prevents aspiration.

 

[vector2]

I figured there were enough "muscle relaxation provides the best intubating condition/initial success rate" papers out there that it would be unnecessary to post some, but now I'm wondering.

You're right, it's much sparser than what I would've imagined, but to be fair I didn't go looking back 20-30 years. Most of the papers are from ICU/ED/paramedic literature. Even the Canadian and American difficult airway papers give dosing/re-dosing NMB a weak recommendation / C level evidence.

http://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-517OC

Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents - ScienceDirect

Paramedic-Administered Neuromuscular Blockade Improves... : Journal of Trauma and Acute Care Surgery

The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient

 

[facted]

Can someone explain the rationale for remi during airway management?

I never encountered any attending using remi for airway management as a resident or as an attending. It seems like overkill to me, or at the very least a waste of remi.

We used it VERY frequently in training and in lieu of paralytics (much of the time it was academic and clearly not necessary). Works very well. So any case where you don't want to paralyze for whatever reason, you could use remi in it's place for intubation.

 

[facted]

No.

But enough people have told me that they have seen it after boluses of the synthetic fents that I'm reluctant to dismiss it as complete dogma.

I gave 1mg of remi bolus to probably over 100 patients in residency for inductions (we had some attendings that were very fond of it). Didn't once see laryngospasm or chest wall rigidity. Can't recall any colleagues telling me any stories about their issues with it either.

 

[Twiggidy]

We used it VERY frequently in training and in lieu of paralytics (much of the time it was academic and clearly not necessary). Works very well. So any case where you don't want to paralyze for whatever reason, you could use remi in it's place for intubation.

Cool. Never thought of the replacement for NMB aspect. Now I've learned something which makes this thread useful now. Cheers

 

[Twiggidy]

Also, @Twiggidy, don't bring that cricoid pressure crap in here! I put my hand on the neck to help with the view and to say that I did it in the chart, not because it prevents aspiration.

 

[Noyac]

We used it VERY frequently in training and in lieu of paralytics (much of the time it was academic and clearly not necessary). Works very well. So any case where you don't want to paralyze for whatever reason, you could use remi in it's place for intubation.

This is the most important point, “any case that you don’t want to paralyze.”

 

[deleted59964]

I gave 1mg of remi bolus to probably over 100 patients in residency for inductions (we had some attendings that were very fond of it). Didn't once see laryngospasm or chest wall rigidity. Can't recall any colleagues telling me any stories about their issues with it either.

1 mg? Really ?
I dilute 1 mg in 20 ml (50mcg/ml) and give about 1-2 mcg/kg ie 1 -4 ml

Otherwise my experience echoes yours ... works great as replacement for neuromuscular blockade for intubation. If you underdose you still get reasonable conditions, but they cough a bit on passing the tube into the trachea

 

[dhb]

No.

But enough people have told me that they have seen it after boluses of the synthetic fents that I'm reluctant to dismiss it as complete dogma.

Difficult or impossible ventilation after sufentanil-induced anesthesia is caused primarily by vocal cord closure. - PubMed - NCBI

Upper airway closure: a primary source of difficult ventilation with sufentanil induction of anesthesia. - PubMed - NCBI

 

[Ezekiel2517]

Has any experienced attending here, since the glidescope, had a floor patient that they were unable to intubate?

Late to this thread but I actually did have a patient a couple months back who couldn't be tubed with any type of blade/glidescope/McGrath. Ankylosing spondylitis pt with cervical fusion, smallish mo. Grade 4 views with Mac 3, miller 2/3, glidescope, McGrath with every size blade. Attempts made by 3 different anesthesiologists including the chair of dept. Could barely even get a glimpse of epiglottis. Ultimately I went fiberoptic with scope thru ett already placed nasally. Would've went that route much sooner but took a while to get the scope at this particular hospital. Point is, there's airways out there that you can't get with any blade or glidescope

 

[propadope]

I induce and intubate with propofol and remi %95 of the time for office based dental. Most of the time you get excellent intubating conditions provided that you give enough but not too much and not too fast. Definitely not as reliable as NMB and not as stable from a cardiovascular standpoint. I do see closed cords from time to time requiring a small dose of sux. Also sometimes coughing when the tube goes in or when the cuff is inflated. I usually give 2.5ug/kg of remi in divided doses. A small dose before the propofol and the balance after.

 

[Noyac]

I induce and intubate with propofol and remi %95 of the time for office based dental. Most of the time you get excellent intubating conditions provided that you give enough but not too much and not too fast. Definitely not as reliable as NMB and not as stable from a cardiovascular standpoint. I do see closed cords from time to time requiring a small dose of sux. Also sometimes coughing when the tube goes in or when the cuff is inflated. I usually give 2.5ug/kg of remi in divided doses. A small dose before the propofol and the balance after.

This is pretty much the jest of my argument.

 

[dhb]

This is pretty much the jest of my argument.

Yes but originally we weren't talking about a potential difficult airway but a run of the mill MG patient.

 

[deleted697535]

Can you please elaborate on your statement that those that did not get Roc "do better mostly". I'm geuinely curious but also wildly skeptical that a single intubating dose of NMB has any negative clinical significance.

I very much doubt I can prove any of this to you...

But In my mind there is a difference between a medical ICU patient and a surgical ICU patient. (Maybe obvious)

The classic medical patient is the one I'm thinking of who I've seen fall apart from roc. I don't know if it's the paralysis or the positive pressure ventilation that inevitably follows...

A frail 70 to 80 yo ards neutropenic sepsis anuric patient. Failed bipap. I would prefer to avoid paralysis in that type of patient if I can

There is a type of icu patient I would always paralyse to tube and another type I would try to avoid paralysis if I can...

I don't have great evidence for it (I don't think there will ever be a decent trial on who to paralyse and who not to) so I can be shot down easily but it works well for me this last few years...

 

[pgg]

The classic medical patient is the one I'm thinking of who I've seen fall apart from roc. I don't know if it's the paralysis or the positive pressure ventilation that inevitably follows...

What do you mean fall apart from roc?

How are you avoiding PPV in patients you intubate without relaxant? Are you really doing spontaneous vent inductions in these floor patients?

 

[deleted162650]

I very much doubt I can prove any of this to you...

But In my mind there is a difference between a medical ICU patient and a surgical ICU patient. (Maybe obvious)

The classic medical patient is the one I'm thinking of who I've seen fall apart from roc. I don't know if it's the paralysis or the positive pressure ventilation that inevitably follows...

A frail 70 to 80 yo ards neutropenic sepsis anuric patient. Failed bipap. I would prefer to avoid paralysis in that type of patient if I can

There is a type of icu patient I would always paralyse to tube and another type I would try to avoid paralysis if I can...

I don't have great evidence for it (I don't think there will ever be a decent trial on who to paralyse and who not to) so I can be shot down easily but it works well for me this last few years...

You're not really making any sense here. PPV makes people who are teetering on the edge crump. That is well known fact. If someone has failed BiPAP, then the next step is PPV. You can avoid paralysis, but not the PP. There's a good study that shows equal rates of hypotension in ICU patients who were intubated with and without any drugs. It's not the Roc.

 

[Twiggidy]

Yes but originally we weren't talking about a potential difficult airway but a run of the mill MG patient.

Correction...OP had a run of the mill MG patient, alcoholic, with possible full stomach. I'm not liking the coughing potential in the OP situation.

 

[deleted697535]

Why not PS?

 

[pgg]

Why not PS?

What are you asking? Are you saying PS isn't PPV?

 

[Noyac]

Yes but originally we weren't talking about a potential difficult airway but a run of the mill MG patient.

If you read my post, I said, “This case is different, I understand”.
Frequently, we go off topic or off scenario to make a point that still has some value to the original post.

 

[Noyac]

I very much doubt I can prove any of this to you...

But In my mind there is a difference between a medical ICU patient and a surgical ICU patient. (Maybe obvious)

The classic medical patient is the one I'm thinking of who I've seen fall apart from roc. I don't know if it's the paralysis or the positive pressure ventilation that inevitably follows...

A frail 70 to 80 yo ards neutropenic sepsis anuric patient. Failed bipap. I would prefer to avoid paralysis in that type of patient if I can

There is a type of icu patient I would always paralyse to tube and another type I would try to avoid paralysis if I can...

I don't have great evidence for it (I don't think there will ever be a decent trial on who to paralyse and who not to) so I can be shot down easily but it works well for me this last few years...

I find this to be subjective and not worthy of stating as fact.

 

[Noyac]

Well known? By whom?

Well known by this guy:
Michael A. Phelps, MD, Clinical Instructor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

 

[deleted162650]

Well known by this guy:
Michael A. Phelps, MD, Clinical Instructor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

And here I thought he was just a swimmer.

 

[Noyac]

And here I thought he was just a swimmer.

Apparently he is a fast learner.

 

[Arch Guillotti]

Just something to think about. It is well known that inducing without muscle relaxants, propofol and remi alone, can make an airway more difficult. The dose of remi is important.

Why is the airway more difficult? Please provide a reference or something other than anecdote.

The point of discussion is that intubation can be safely and reliably done without muscle relaxant, not just "prop and a nmb".

Statement: 4th National Audit Project (NAP4): investigated complications of airway management in United Kingdom for 1 yr; suggested early use of additional anesthetic agent and/or NMB if anesthesia by face or laryngeal mask complicated by failed ventilation; “no anaesthetist should allow airway obstruction and hypoxia to develop to the stage where emergency surgical airway is necessary without having administered a muscle relaxant“.
Most of the literature I’ve read on this comes from Britain.
If you look at image#2 plan C you will see that the recommendation a difficult mask ventilation is to paralyze. I know this isn’t exactly saying that remi will make things more difficult but what I am saying is that the dose of remi rally matters and that the way to fix the problem isn’t remi but paralysis. Therefore, paralysis gives us the best opportunity at the airway.
So having an administrator of this site state that this is nonsense should actually concern the others on this site about the agenda of said administrator. You of all people should be educated on the things to admonish.

What is your point?

The original scenario involved a discussion of how to intubate a patient without using muscle relaxants, which can be easily accomplished if you know what you are doing. There is no mention of a potential difficult airway or potential difficult ventilation.

Of course muscle relaxants provide the best intubating conditions. Nobody that I can tell is disputing this fact. A CA-1 learns this on the first day! Nothing in the study from the UK that you cited is news to anyone who is a decent anesthesiologist.

Again, what about remi and propofol without muscle relaxant make the airway "more difficult"? The mythical laryngeal/chest wall rigidity? I have intubated without muscle relaxant many times and never had a problem. Sux is the "gold standard" (even though in a pt. with MG I wouldn't really know what the best dose is). Remi/prop may not be equal to prop/sux but if you do it right the chances of having crappy conditions is slim. What is my agenda anyway? I would love to know!

 

[deleted162650]

I think the main question here is:

Would you feel comfortable intubating this full stomach RSI worthy patient using any one of the "relaxant sparing" techniques?

 

[Arch Guillotti]

I think the main question here is:

Would you feel comfortable intubating this full stomach RSI worthy patient using any one of the "relaxant sparing" techniques?

Agree. I would have no issue intubating this patient without muscle relaxant.

I might use muscle relaxant if the patient had a bad bowel obstruction, etc.

 

[Noyac]

What is your point?

The original scenario involved a discussion of how to intubate a patient without using muscle relaxants, which can be easily accomplished if you know what you are doing. There is no mention of a potential difficult airway or potential difficult ventilation.

Of course muscle relaxants provide the best intubating conditions. Nobody that I can tell is disputing this fact. A CA-1 learns this on the first day! Nothing in the study from the UK that you cited is news to anyone who is a decent anesthesiologist.

Again, what about remi and propofol without muscle relaxant make the airway "more difficult"? The mythical laryngeal/chest wall rigidity? I have intubated without muscle relaxant many times and never had a problem. Sux is the "gold standard" (even though in a pt. with MG I wouldn't really know what the best dose is). Remi/prop may not be equal to prop/sux but if you do it right the chances of having crappy conditions is slim. What is my agenda anyway? I would love to know!

You know what the point is. You are being obstinate.
And no, it’s not the rigidity that I’m talking about.

 

[Twiggidy]

Agree. I would have no issue intubating this patient without muscle relaxant.

I might use muscle relaxant if the patient had a bad bowel obstruction, etc.

i mean, the reality is that in the hands of an experience anesthesiologist, if the airway is presumed easy, you can probably tube this gent with no relaxant AND avoid aspiration.

if there was any presumed difficulty, ie "maybe i need the glide" then the guy get's NMB...that's just me. honestly, how long people sit in ERs before they actually make it to us and the OR, it's likely been a few hours so I'd probably still Nimbex the guy and slip the tube in, if he's easy.

 

[Noyac]

i mean, the reality is that in the hands of an experience anesthesiologist, if the airway is presumed easy, you can probably tube this gent with no relaxant AND avoid aspiration.

if there was any presumed difficulty, ie "maybe i need the glide" then the guy get's NMB...that's just me. honestly, how long people sit in ERs before they actually make it to us and the OR, it's likely been a few hours so I'd probably still Nimbex the guy and slip the tube in, if he's easy.

Why nimbex?

 

[Maverikk]

Be practical, back to the OP...MG, full stomach (NDMB: can last longer, sometimes hours of weakness Sux: need a higher dose), either way RSI, no nimbex, no opioid, no funny stuff, KISS. This patient will go to ICU intubated postop, no reason not to for an emergent case like this, no reason to extubate this person until they're ready

Edit: to be specific: 100mg lido, 100mg Roc, 160 prop, everything quick IVP

 

[Noyac]

Be practical, back to the OP...MG, full stomach (NDMB: can last longer, sometimes hours of weakness Sux: need a higher dose), either way RSI, no nimbex, no opioid, no funny stuff, KISS. This patient will go to ICU intubated postop, no reason not to for an emergent case like this, no reason to extubate this person until they're ready

Edit: to be specific: 100mg lido, 100mg Roc, 160 prop, everything quick IVP

Finally, someone answers the question.
My question to the OP (forum) earlier was, what meds does he take for MG? Did he take them recently?
If he is on an anticholinesterase (pyridostigmine)? What Dose? More than 750mg/day?
How long has he had MG? More than 6 yrs?

I have taken care of many pts with MG and it isn’t that difficult. Monitor twitches closely.

Personally, I would consider inducing without NMB if airway looked like a slam dunk. My only comment earlier was that Remi can make the airway more difficult especially when underdosed. I’d give about 4mcg/kg and chase it with 150mcg of neo. But his belly is probably full of beer so it better be a slam dunk. If not I would give 30mg of roc immediately before the propofol and do an RSI. this case will most definitely last longer than the NMB. Extubated at the end of the case.

 

[vector2]

Late to this thread but I actually did have a patient a couple months back who couldn't be tubed with any type of blade/glidescope/McGrath. Ankylosing spondylitis pt with cervical fusion, smallish mo. Grade 4 views with Mac 3, miller 2/3, glidescope, McGrath with every size blade. Attempts made by 3 different anesthesiologists including the chair of dept. Could barely even get a glimpse of epiglottis. Ultimately I went fiberoptic with scope thru ett already placed nasally. Would've went that route much sooner but took a while to get the scope at this particular hospital. Point is, there's airways out there that you can't get with any blade or glidescope

Damn dude, I'm pretty sure the difficult airway algorithm doesn't include calling in the chair to perform the 14th DL/video attempt. Was masking this guy difficult? If not, would've definitely stopped with the attempts after the glidescope fail and just hand ventilated/LMA until the scope arrived. Also makes me wonder, have you or anyone else had situations (excluding those where someone's mouth is so small you can't get the glidescope blade in) where someone was unglidescopable but yet the McGrath worked? It would not have occurred to me to try to use a video mac 3 after a conventional mac 3 and highly angulated video blade had already failed.

 

[deleted59964]

Late to this thread but I actually did have a patient a couple months back who couldn't be tubed with any type of blade/glidescope/McGrath. Ankylosing spondylitis pt with cervical fusion, smallish mo. Grade 4 views with Mac 3, miller 2/3, glidescope, McGrath with every size blade. Attempts made by 3 different anesthesiologists including the chair of dept. Could barely even get a glimpse of epiglottis. Ultimately I went fiberoptic with scope thru ett already placed nasally. Would've went that route much sooner but took a while to get the scope at this particular hospital. Point is, there's airways out there that you can't get with any blade or glidescope

This sounds a disturbingly like what happened here ...