Spine Case

[GassYous]

60 yo M pmh throat cancer, diabetes, hypertension, hyperlipidemia, hypothyroid with worsening neck pain and unilateral arm weakness. Imaging shows atlantoaxial instability. Surgeon booked a suboccipital craniectomy and decompression/fusion to c5 due to cord compression and is itching to get to the OR. What's your next step?

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[Arch Guillotti]

Do the case?

Big question is how to manage the airway.

 

[deleted162650]

I’d probably bump up to an LMA Supreme for this one.

 

[MirrorTodd]

Prior Radiation treatment to throat? I would expect the board answer to be awake fiberoptic after good topicalization. Document excellent neuro exam and remind the surgeons that no matter how fast they want to get slicing, their surgery won't matter for **** if he gets paralyzed during intubation.

 

[DocVapor]

Prior Radiation treatment to throat? I would expect the board answer to be awake fiberoptic after good topicalization. Document excellent neuro exam and remind the surgeons that no matter how fast they want to get slicing, their surgery won't matter for **** if he gets paralyzed during intubation.

A real team player Anesthesiologist would go ahead and DL this guy so he can take the fall for the surgeon.

 

[Arch Guillotti]

"Throat cancer" can mean a bunch of things. More relevant information is needed about the airway. Awake intubation may be prudent if the airway is bad or medicolegal considerations.

 

[Lecithin5]

If you do an awake intubation, it better be the smoothest one you’ve ever done, with no coughing or bucking... If I am not concerned about the airway (ie radiation etc), I would just do a ‘gentle’ video laryngoscopy with MIS. Yes, I know, glidescope manipulates the neck almost as much as direct laryngoscopy... but so does someone flailing and not tolerating afoi

Could consider an asleep fiberoptic- but you have to be pretty quick and slick -most of us don’t do these often enough

 

[Arch Guillotti]

Could consider an asleep fiberoptic- but you have to be pretty quick and slick -most of us don’t do these often enough

Agree this is a lost art. Depending on how bad the airway is because of the throat cancer the patient may be impossible to ventilate though.

 

[GassYous]

He doesn't know what kind of throat cancer but he has had chemotherapy and radiation. Marginal mouth opening but you probably could fit a mcgrath in there. Maybe not a glide. He's a little nervous but seems like a reasonable guy overall. BMI is about 35 but neck looks okay, not micrognathic and he looks like he would be mask ventilatable. Decision was made to go with awake fiberoptic. Do you agree and if so how would you want to go about it? Of note, the patient came up in a hard collar.

 

[Hoya11]

He doesn't know what kind of throat cancer but he has had chemotherapy and radiation. Marginal mouth opening but you probably could fit a mcgrath in there. Maybe not a glide. He's a little nervous but seems like a reasonable guy overall. BMI is about 35 but neck looks okay, not micrognathic and he looks like he would be mask ventilatable. Decision was made to go with awake fiberoptic. Do you agree and if so how would you want to go about it? Of note, the patient came up in a hard collar.

Leave the collar on. Awake (ish) glidescope.

Versed 6-10mg
Ketamine 30mg boluses.
Maintain SV.
Maybe a little propofol like 20-50 before VL.

Look with the glidescope while spontaneously breathing.
Pass the tube if able on that first look.

If good view but unable to pass due to patient movement or uncooperative, prop and sux before second attempt.

If no view at all despite some looking, no more sedation and do a nasal fiberoptic. If that fails call ENT for the trach.

There is no known history of difficult airway here, despite the radiation. Highly likely to be able to pass tube with glidescope on that first awake(ish) look.

 

[coffeebythelake]

He doesn't know what kind of throat cancer but he has had chemotherapy and radiation. Marginal mouth opening but you probably could fit a mcgrath in there. Maybe not a glide. He's a little nervous but seems like a reasonable guy overall. BMI is about 35 but neck looks okay, not micrognathic and he looks like he would be mask ventilatable. Decision was made to go with awake fiberoptic. Do you agree and if so how would you want to go about it? Of note, the patient came up in a hard collar.

Glyco, nebz lidocaine, dealers choice for sedation

 

[Arch Guillotti]

Leave the collar on. Awake (ish) glidescope.

Versed 6-10mg
Ketamine 30mg boluses.
Maintain SV.
Maybe a little propofol like 20-50 before VL.

Look with the glidescope while spontaneously breathing.
Pass the tube if able on that first look.

If good view but unable to pass due to patient movement or uncooperative, prop and sux before second attempt.

If no view at all despite some looking, no more sedation and do a nasal fiberoptic. If that fails call ENT for the trach.

There is no known history of difficult airway here, despite the radiation. Highly likely to be able to pass tube with glidescope on that first awake(ish) look.

No offense but I think "awakeish" looks are crazy and a recipe for disaster if you are really that concerned about the airway. I am not sure the airway as described here requires AFOI but I feel that if you do an intubation "awake" the pt. should basically only have mild sedation.

 

[Hoya11]

No offense but I think "awakeish" looks are crazy and a recipe for disaster if you are really that concerned about the airway. I am not sure the airway as described here requires AFOI but I feel that if you do an intubation "awake" the pt. should basically only have mild sedation.

What does awake buy you that carefully titrated spontaneously breathing patient does not? or even a patient spontaneously breathing under sevo?

i dont care if the person is awake or asleep, i care that they are breathing well on their own

 

[Arch Guillotti]

What does awake buy you that carefully titrated spontaneously breathing patient does not? or even a patient spontaneously breathing under sevo?

i dont care if the person is awake or asleep, i care that they are breathing well on their own

I just think that it increases the potential of going downhill. I don't want them wide awake, just sedated - maybe drifting off to sleep but arousable. Exception would be small bumps of ketamine.

 

[Arch Guillotti]

Versed 6-10mg
Ketamine 30mg boluses.
Maintain SV.
Maybe a little propofol like 20-50 before VL.

That seems like a lot of versed.

 

[Lecithin5]

What does awake buy you that carefully titrated spontaneously breathing patient does not? or even a patient spontaneously breathing under sevo?

i dont care if the person is awake or asleep, i care that they are breathing well on their own

I hear you and agree with you in principle. But there is a certain amount of risk that you are taking by titrating drugs to affect- the question is how much of a risk are you willing to take that either you inadvertently: oversedate (then you are scrambling...), or undersedate (and pt becomes sort of disinhibited and is flailing with an unstable neck..).

 

[Arch Guillotti]

I hear you and agree with you in principle. But there is a certain amount of risk that you are taking by titrating drugs to affect- the question is how much of a risk are you willing to take that either you inadvertently: oversedate (then you are scrambling...), or undersedate (and pt becomes sort of disinhibited and is flailing with an unstable neck..).

Agree. I have helped out in a disaster caused by sedation becaming too much with a difficult airway.

 

[nimbus]

After all our machinations, the surgeon will crank the patient’s head and neck every which way to get him in optimal position for surgery.

 

[abolt18]

After all our machinations, the surgeon will crank the patient’s head and neck every which way to get him in optimal position for surgery.

But we can clearly document that the spinal cord transection was NOT because of us.

 

[Volatile]

What does awake buy you that carefully titrated spontaneously breathing patient does not? or even a patient spontaneously breathing under sevo?

i dont care if the person is awake or asleep, i care that they are breathing well on their own

One concern here is cord compression so an “awake” buys you a Neuro exam after intubation.... might buy you a dismissal from a court case if they wake up with a deficit

Do it awake, madgic atomizer with 4%. By the time you get to the room you’ll be able to slide a fiberoptic scope back, spray the cords under visualization. Transtracheal block. By the time you’ve loaded the ETT they’ll be numb. Pass tube, get Neuro exam. Tell the surgeon not to **** it up as you walk out.

 

[Arch Guillotti]

But we can clearly document that the spinal cord transection was NOT because of us.

No. We can say that the neurological exam was unchanged from prior and document that the surgeon agreed though.

 

[Arch Guillotti]

Leave the collar on. Awake (ish) glidescope.

Versed 6-10mg
Ketamine 30mg boluses.
Maintain SV.
Maybe a little propofol like 20-50 before VL.

Look with the glidescope while spontaneously breathing.
Pass the tube if able on that first look.

If good view but unable to pass due to patient movement or uncooperative, prop and sux before second attempt.

If no view at all despite some looking, no more sedation and do a nasal fiberoptic. If that fails call ENT for the trach.

There is no known history of difficult airway here, despite the radiation. Highly likely to be able to pass tube with glidescope on that first awake(ish) look.

Do you numb them up first?

 

[Volatile]

That seems like a lot of versed.

Do you numb them up first?

Probably won’t matter since they’re under GA from the 10 versed, 30 ketamine, 50 propofol :/

 

[Hoya11]

I hear you and agree with you in principle. But there is a certain amount of risk that you are taking by titrating drugs to affect- the question is how much of a risk are you willing to take that either you inadvertently: oversedate (then you are scrambling...), or undersedate (and pt becomes sort of disinhibited and is flailing with an unstable neck..).

like all things, its an art.

i could describe a silky smooth fiber optic intubation awake - we all know it doesnt always go like that.. its stimulating no matter what you do to pass an ETT through the cords - unless you give propofol or heavy sedation right before, which is doing the same thing i am doing. so when they buck on the tube that you have passed with the FOB, is that not "flailing" or that never happens to you?

sedation to a level of spontaneous ventilation before you insert the glidescope blade, once the blade is in, they are definitely breathing, and you can see it.

of all the different ways to do "awake" intubations this has been the easiest/most reliable in my opinion, the awake-ish glidescope. this has been my go to technique for difficult airway scenarios in the ER and outside of the OR also..

 

[Hoya11]

Agree. I have helped out in a disaster caused by sedation becaming too much with a difficult airway.

with versed and ketamine though? very unlikely to get you into trouble. very unlikely for the patient to remember anything.

 

[Arch Guillotti]

with versed and ketamine though? very unlikely to get you into trouble. very unlikely for the patient to remember anything.

propofol was given at some point along the way. Slippery slope became untenable.

 

[GassYous]

Thanks for the replies.

I've done awake looks with glide and I do think they have a place but for this patient an awake fiberoptic intubation is my go to. I prefer not to glide since it can take some effort to get into the mouth and the tube may have limited space to get past that big blade. Also you may be able to get a really nice view but be unable to pass the tube and I don't want to mess around with this patient.

I think that the awakeish look is a bad idea. I want my patient to be able to follow commands because as people said, you need to CYA. Document the neuro exam after you intubate and make sure that it matches the preop exam. If the patient has a worse deficit after surgery is over, I want that note in place so that no sleezy lawyer can try to catch me. I let the surgeon control the head after they pin prior to the turn while I watch the tube.

What would you do if the patient stopped breathing from all that sedation? I've had patients go apneic from just 2 of versed. I have given 10 of versed with no problem as well. What about if all that ketamine caused them to have a ton of secretions so you can't see anything with your scope or caused airway reactivity? Would you guys put an lma as a temporizing measure for this kind of patient?

 

[Hoya11]

One concern here is cord compression so an “awake” buys you a Neuro exam after intubation.... might buy you a dismissal from a court case if they wake up with a deficit

Do it awake, madgic atomizer with 4%. By the time you get to the room you’ll be able to slide a fiberoptic scope back, spray the cords under visualization. Transtracheal block. By the time you’ve loaded the ETT they’ll be numb. Pass tube, get Neuro exam. Tell the surgeon not to **** it up as you walk out.

right but once the tube is in you can let everything else wear off and do the "neuro exam"

 

[Katheudontas parateroumen]

Always appreciate the replies and discussion. These cases happen not often enough. I would do AFOI. The reason is I want to keep the collar on given his unstable spine. The collar usually makes it difficult to intubate traditional methods and even glidescope/D-blade, also has that history of neck radiation which might further decrease ability. Having said that, it is important to have the patient not move or cough/buck as much as possible as that increases risk to the cord as well. My cocktail is glyco 10-15 min before, zofran 4mg (has some small evidence of decreasing gag reflex), atomized 4% lidocaine all over until i can place the tip of the atomized down without them moving, sedation with precedex and remifentanil. Bolus of precedex for anxiolysis without respiratory depression, remifentanil is super short acting so easier to walk back if over done. When the view of cords in place, I'll spray lidocaine, bolus remifentanil and then pass the cords.

 

[Planktonmd]

Any one thought it might be a good idea to look at the neck CT (which is likely already done) to see what the airway looks like before discussing intubation techniques?
Also patients who had radiation to the head and neck usually have little or no saliva and decreased sensation of the mucosa which makes awake intubation much easier.

 

[GassYous]

CT and MRI of the head and neck were done, airway looks okay from what I remember. Can't access the images right now. I guess the radiation damages the salivary glands? That's a nice pearl though, the patient's mouth was definitely a lot more dry than I expected and that explains it.

The point about trying to prevent coughing is well taken but I think it's hard to avoid. Transtracheal block or lido to the cords will cause coughing. I give fentanyl upfront and in training I also used remi infusions but I feel like you can do without the remi.

I like to make sure the glossopharyngeal is included, either with injections or lidocaine paste. I think you can inject right behind the tonsillar pillars as long as you don't go too deep and risk hitting vessels. I think nebulized lidocaine takes too long and is more prone to failure, especially when the mouth isn't totally dry.

Another thing we did was leave the tube and scope in some warm water before intubation. Keeps the screen from fogging and makes the tube easier to get in over the corniculates.

 

[lobelsteve]

Not an anesthesiologist, but where is the guy on here who used to say: " Pent, sux, tube"
No matter what the thread was about. Kinda like "That's what she said".

 

[ranvier]

Is this the one time the annoying neuromonitoring people can be helpful to us? Let them needle him up and document no changes. A little precedex and topicalization and awakish glide.

 

[GassYous]

You have them needle before induction/intubation?

Of note there was a paper in anesthesiology in 2019 saying that precedex has similar effects on upper airway collapsability to propofol and there's evidence for precedex having a similar effect on reaction to hypoxia as propofol.

Upper Airway Collapsibility during Dexmedetomidine and Propofol Sedation in Healthy Volunteers: A Nonblinded Randomized Crossover Study

At comparable levels of light to moderate sedation, dexmedetomidine and propofol exhibit similar degrees of pharyngeal collapsibility and reductions in ventilatory drive. The findings suggest that sedation with dexmedetomidine does not offer inherent protection against upper airway obstruction...

pubs.asahq.org

Sedation with Dexmedetomidine or Propofol Impairs Hypoxic Control of Breathing in Healthy Male Volunteers: A Nonblinded, Randomized Crossover Study

In this randomized crossover healthy volunteer study, sedation with dexmedetomidine and propofol significantly reduced hypoxic ventilation to 59 and 53% and the hypercapnic ventilation to 82 and 86%, respectively. Clinicians should recognize respiratory-depressant effects of dexmedetomidine.

pubs.asahq.org

I think a short remi infusion is better than precedex because it is more titratable and is better at decreasing coughing. Maybe 0.1 or so.

 

[coffeebythelake]

You have them needle before induction/intubation?

Of note there was a paper in anesthesiology in 2019 saying that precedex has similar effects on upper airway collapsability to propofol and there's evidence for precedex having a similar effect on reaction to hypoxia as propofol.

Upper Airway Collapsibility during Dexmedetomidine and Propofol Sedation in Healthy Volunteers: A Nonblinded Randomized Crossover Study

At comparable levels of light to moderate sedation, dexmedetomidine and propofol exhibit similar degrees of pharyngeal collapsibility and reductions in ventilatory drive. The findings suggest that sedation with dexmedetomidine does not offer inherent protection against upper airway obstruction...

pubs.asahq.org

Sedation with Dexmedetomidine or Propofol Impairs Hypoxic Control of Breathing in Healthy Male Volunteers: A Nonblinded, Randomized Crossover Study

In this randomized crossover healthy volunteer study, sedation with dexmedetomidine and propofol significantly reduced hypoxic ventilation to 59 and 53% and the hypercapnic ventilation to 82 and 86%, respectively. Clinicians should recognize respiratory-depressant effects of dexmedetomidine.

pubs.asahq.org

I think a short remi infusion is better than precedex because it is more titratable and is better at decreasing coughing. Maybe 0.1 or so.

Just make sure you don't bolus that remi inadvertently by changing your drip rate. I don't like using it for non intubated patients for that reason - it is so potent that even the little bit of dead space in the iv line can risk of medication error and apnea

 

[deleted162650]

it is so potent

Not really. It’s somewhere between 1-2x the potency of fentanyl depending on which study you look at.

 

[coffeebythelake]

Not really. It’s somewhere between 1-2x the potency of fentanyl depending on which study you look at.

Ok perhaps I said it thr wrong way. But I think the concern is still valid. It js easy to mistakenly bolus remi gtt when opening / closing drip which can lead to apnea. its happened more than a few times at my institution.

 

[Urzuz]

In the last year I had case of real-deal C-spine instability where I wanted to cover myself vis a vis a normal neuro exam post intubation. I did an AFOI the traditional way (set expectations with the patient (prob the most important thing), topicalize early and let the local anesthetic work, little glyco to dry up secretions etc) with pretty much no sedation. After the tube went in, I had everyone in the room (including the neurosurgeon and the neuromonitoring dude) see that the patient had normal motor/sensory exam before I pushed the propofol and induced him.

Regarding AFOI, I agree that it may not be utilized enough for people to feel truly comfortable with it. But the biggest issue that I think people have is that they want to get the intubation completed and start the case fast as they would an ASA 1 lap appendectomy. If you are someone who has a decent reputation who doesn't drag their feet for every case and take their sweet-ass time preoxygenating every ASA1 to an ETO2 of 90+, when you finally do say that things need to slow down in the name of patient safety, most people will actually listen and understand.

And on the topic of AFOI and how well tolerated an ETT can be if your topicalization is good, an oldie but a goodie that I am sure many of you have seen in the past -

 

[Lecithin5]

In the last year I had case of real-deal C-spine instability where I wanted to cover myself vis a vis a normal neuro exam post intubation. I did an AFOI the traditional way (set expectations with the patient (prob the most important thing), topicalize early and let the local anesthetic work, little glyco to dry up secretions etc) with pretty much no sedation. After the tube went in, I had everyone in the room (including the neurosurgeon and the neuromonitoring dude) see that the patient had normal motor/sensory exam before I pushed the propofol and induced him.

Regarding AFOI, I agree that it may not be utilized enough for people to feel truly comfortable with it. But the biggest issue that I think people have is that they want to get the intubation completed and start the case fast as they would an ASA 1 lap appendectomy. If you are someone who has a decent reputation who doesn't drag their feet for every case and take their sweet-ass time preoxygenating every ASA1 to an ETO2 of 90+, when you finally do say that things need to slow down in the name of patient safety, most people will actually listen and understand.

And on the topic of AFOI and how well tolerated an ETT can be if your topicalization is good, an oldie but a goodie that I am sure many of you have seen in the past -

Glyco is the most impt! I like working in 1 mg in divided doses with esmolol titration (also assuming no major cardiac concerns...)

 

[GassYous]

Any one thought it might be a good idea to look at the neck CT (which is likely already done) to see what the airway looks like before discussing intubation techniques?
Also patients who had radiation to the head and neck usually have little or no saliva and decreased sensation of the mucosa which makes awake intubation much easier.

Here's the ct: