Three Airway Disasters

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The unusual anatomy was later described by the forensic pathologist: "the neck was significantly reduced in length, with the left ear 2cm below the left shoulder and the right ear lobe resting on the right shoulder. The neck showed no mobility and was deviated to the right." In addition, her trachea was deviated to the left and covered anteriorly by a large goitre. The surgeon, who was to have operated that day, described co-morbidities for anaesthesia as including dysmorphia, torticollis of the neck and flexion deformity of the neck, as a result of operative cervical spinal fusion. In theatre the consultant anaesthetist administered atracurium, a non- depolarising muscle relaxant. The anaesthetist was unable to ventilate her using a bag and mask or laryngeal mask airway (LMA). He removed and repositioned the LMA but was still unable to ventilate. A Guedel airway and another LMA were tried, to no avail.
At this point, the anaesthetist called for help and another anaesthetist offered assistance. He too was unable to ventilate the patient or secure the airway and an arrest was called. Various attempts were made to establish an airway by those in theatre, including further LMAs, nasal fibre-optic intubation, cricothyroidotomy and tracheostomy. None was successful. Despite the efforts of those in theatre, the patient remained unventilated and, tragically, died.
 
fakin' the funk said:
WOW.
Case #1 - preoxygenate. WTF?! There are people who don't preoxygenate?!
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There are many people who do not routinely preoxygenate healthy patients with no predictors of difficult mask ventilation/ laryngoscopy. I witnessed this first hand when I was interviewing for jobs. I am aware of at least one senior and well respected member of this board (think JPP/MilMD/Blade caliber) who does not routinely preoxygenate.

My impression of case one is that they persisted too long. Don't F around with the airway. Go through your algorithm quickly and efficiently then wake the patient up and do a spontaneously breathing FOB.

- pod
 
periopdoc said:
There are many people who do not routinely preoxygenate healthy patients with no predictors of difficult mask ventilation/ laryngoscopy. I witnessed this first hand when I was interviewing for jobs. I am aware of at least one senior and well respected member of this board (think JPP/MilMD/Blade caliber) who does not routinely preoxygenate.

My impression of case one is that they persisted too long. Don't F around with the airway. Go through your algorithm quickly and efficiently then wake the patient up and do a spontaneously breathing FOB.

- pod
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It takes time and experience to know who you do not have to preoxygenate or more importantly, those who you MUST preoxygenate. This comes with clinical experience and thousands of cases.

As for losing an airway in 2011 the question will be asked over and over again by the attorneys: Why? How? I've had 2 airways which could not be intubated without an awake fiberoptic intubation. In one of these cases the patient was allowed to wake up and explained the problem. The case was rescheduled for a later date (awake intubation).

Over my career at least a dozen suspected or known airways with difficulty were approached in the correct manner: with caution and the FOB. Now trauma is another story altogether. Those airways with facial, tracheal injury may need a surgical airway.
 
BLADEMDA said:
It takes time and experience to know who you do not have to preoxygenate or more importantly, those who you MUST preoxygenate. This comes with clinical experience and thousands of cases.
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I preO2 everybody. Even in the skinny young healthy MP1 patients I don't skip it entirely.

That said, I'm certainly more diligent about a good mask seal, sufficient time, and a high end-tidal O2 in patients with sketchier airways.

Maybe calling it a standard of care is too rigid, but if anything were to happen, I would absolutely look askance at anyone who didn't bother.
 
pgg said:
I preO2 everybody. Even in the skinny young healthy MP1 patients I don't skip it entirely.

That said, I'm certainly more diligent about a good mask seal, sufficient time, and a high end-tidal O2 in patients with sketchier airways.

Maybe calling it a standard of care is too rigid, but if anything were to happen, I would absolutely look askance at anyone who didn't bother.
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I fully expected you to say that.😉 I understand your reasons but haven't found the population you mention to be a problem. Perhaps, another decade or two of practice will alter the way you do things.
 
BLADEMDA said:
It takes time and experience to know who you do not have to preoxygenate or more importantly, those who you MUST preoxygenate. This comes with clinical experience and thousands of cases.
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The real key. I did not mean to sound critical of the individuals whom I observed as I do not feel that they were unsafe. My own preoxygenation habits trend more this way than to the one size fits all approach although I try not to get into hazardous specifics of my own techniques on a board like this.

- pod
 
I'm amazed at the husband and his attitude about the situation. Most people see $$ signs...but to him, this was an opportunity to learn from the situation.
 
For some of the old timer's here who feel they "know who needs to be preoxygenated and who doesn't"

Why would you not preoxygenate everybody regardless of what you think? I don't think everyone needs the full 5 minutes of TV breathing of 100% O2 but at least 5 VC breaths. The maneuver takes less than 30 seconds and really has no downside. Regardless of how much experience you have, what's the point of skipping it?
 
ssmallz said:
For some of the old timer's here who feel they "know who needs to be preoxygenated and who doesn't"

Why would you not preoxygenate everybody regardless of what you think? I don't think everyone needs the full 5 minutes of TV breathing of 100% O2 but at least 5 VC breaths. The maneuver takes less than 30 seconds and really has no downside. Regardless of how much experience you have, what's the point of skipping it?
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Not every patient enjoys the mask over his/her face prior to induction. Of course, you can talk most patients easily through the process but a few still get anxious. I'm amazed at just how many still remember the pre-induction process even after getting midazolam in holding.

By all means continue to preoxygenate your patients as usual. I'll continue to practice the way my experience has shown to be safe.
 
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When I visited Blade's group, I was like WTF. Thought about it on the flight home. My current technique is a lot more similar to his than to the way I was trained in residency.

- pod
 
ssmallz said:
For some of the old timer's here who feel they "know who needs to be preoxygenated and who doesn't"

Why would you not preoxygenate everybody regardless of what you think? I don't think everyone needs the full 5 minutes of TV breathing of 100% O2 but at least 5 VC breaths. The maneuver takes less than 30 seconds and really has no downside. Regardless of how much experience you have, what's the point of skipping it?
Click to expand...

Remember, some of the people that trained us had been putting people to sleep decades before the invention of pulse ox and capnography. Back in the day, you didn't preoxygenate because there was no pulse ox to tell you how low the sat was. But time has changed.
 
DrN2O said:
Remember, some of the people that trained us had been putting people to sleep decades before the invention of pulse ox and capnography. Back in the day, you didn't preoxygenate because there was no pulse ox to tell you how low the sat was. But time has changed.
Click to expand...

Uh...FYI the SAT rarely drops below 92-93% in the ASA1 young, healthy subgroup without preoxygenation. ASA1 gets to OR. Monitors placed. A few deep breaths on room air then drugs (propofol). LMA placed and patient quickly re-oxygenated. No problem. Or, if you prefer, once the ASA1 is asleep place face mask and assist bringing SAT to 100%.

Contrast the above stated approach with your ASA3 morbidly obese, sleep apnea, Diabetic, GERD, HTN for LAp. Gastric Bypass. That patients gets full, by the book, preO2 prior to induction.
 
DrN2O said:
Remember, some of the people that trained us had been putting people to sleep decades before the invention of pulse ox and capnography. Back in the day, you didn't preoxygenate because there was no pulse ox to tell you how low the sat was. But time has changed.
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Ummm.....if you don't have a pulse ox, its even more important to preoxygenate because you can't tell what the sat is and preoxygenation will delay desaturation in the even that you can't/aren't ventilating. I'm sure in the days before the pulse ox, preoxygenating was even more important than it is today.
 
For one of the replys about patients not liking the mask over their face, I don't like wearing a seatbelt either in the car, but I figure in the case of something going wrong, it is a good idea. Just give them versed and they won't even remember the mask over their face.
 
cincincyreds said:
For one of the replys about patients not liking the mask over their face, I don't like wearing a seatbelt either in the car, but I figure in the case of something going wrong, it is a good idea. Just give them versed and they won't even remember the mask over their face.
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Really? What's your next analogy? Wearing a parachute when jumping from a plane?

Being fully monitored and having Certified Providers standing over you during induction (with or without a face mask strapped to your head) has nothing to do with seat belts.

By the way some patients DO REMEMBER Induction. Think of all the patients that recall the fact that propofol can "burn" on induction.
 
Acta Anaesthesiol Scand. 1993 Jan;37(1):23-5.
Preoxygenation techniques: the value of nitrous oxide.

Khoo ST, Woo M, Kumar A.
Source

Department of Anaesthesia, National University of Singapore.

Abstract

Changes in arterial oxygen saturation during induction of anaesthesia and intubation were studied using the pulse oximeter. Seventy-five young ASA I patients undergoing elective uncomplicated surgery were divided equally into three groups. The patients were preoxygenated with 100% oxygen, 50% oxygen: 50% nitrous oxide or 30% oxygen: 70% nitrous oxide for 1 min. All were then induced with thiopentone, paralysed with suxamethonium and orally intubated. Arterial oxygen saturations were continuously recorded by a separate investigator. All groups showed similar arterial desaturation during suxamethonium-induced apnoea and intubation, but the degree of desaturation was not clinically significant and no patient showed clinical signs of hypoxaemia. Preoxygenation with mixtures of oxygen and nitrous oxide can hasten the build-up of alveolar nitrous oxide concentration and help to smooth induction without compromising oxygenation of patients.
 
The point is young, healthy patients can go to sleep without a mask over their face. After induction (immediately) place the LMA or bag/assist the patient.

Of course, the data is clear that 100% pre-oxygenation allows the provider much more time before desaturation occurs. This means if you have any doubt about your ability to ventilate the patient immediately after induction NEVER skip pre-oxygenation. Also, "skipping" the face mask is only an option for your healthiest subgroup of patients.

This debate reminds me of the subject of waiting to give the muscle relaxant AFTER you have proven mask ventilation. I NEVER do that any longer unless I have an airway concern or some other concern.
 
Anaesth Intensive Care. 1991 May;19(2):192-6.
Arterial desaturation during induction in healthy adults: should preoxygenation be a routine?

Kung MC, Hung CT, Ng KP, Au TK, Lo R, Lam A.
Source

Department of Anaesthesia, Queen Elizabeth Hospital, Hong Kong.

Abstract

We studied the haemoglobin saturation of one hundred healthy patients equally divided into two groups. Group 1 patients received three minutes of preoxygenation prior to thiopentone induction followed by inhalational anaesthetics. Group 2 patients breathed room air prior to induction. None of the patients in Group 1 showed any arterial oxygen desaturation during the five minutes of the induction period, whereas 21 patients in Group 2 showed definite desaturation (P less than 0.005), of which fifteen patients had a saturation of 90% or less (P less than 0.005) and six had a saturation of 85% or less. Since those were healthy patients and the anaesthetics were given by experienced anaesthetists, we concluded that some form of preoxygenation should be used in all patients receiving general anaesthesia.
 
For patients who dislike the mask over their face, but whom I feel the need to pre-oxygenate, I detach the mask and have them breath out of the elbow connector like a snorkel. Works great for those PTSD/ claustrophobic patients.

- pod
 
BLADEMDA said:
This debate reminds me of the subject of waiting to give the muscle relaxant AFTER you have proven mask ventilation. I NEVER do that any longer unless I have an airway concern or some other concern.
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Agree 100%. For a normal patient the test ventilation is bunk.
 
I'm a junior guy in this thread, but my 2 cents is that
a) patients rarely mind the mask (and I ALWAYS use the headstrap), and if they do, they don't mind it if they hold it themselves
b) preoxygenation takes no extra time and provides a substantial safety margin.

From a medicolegal standpoint, if you know "expert witnesses" who would be willing to testify that preoxygenation isn't the standard of care, I certainly know some bigwigs who would argue that it is.

I would also argue that relying on "my ability to tell someone who doesn't need preoxygenation versus someone who does" is very, very fallible and smacks a little of arrogance.
 
DrN2O said:
Remember, some of the people that trained us had been putting people to sleep decades before the invention of pulse ox and capnography. Back in the day, you didn't preoxygenate because there was no pulse ox to tell you how low the sat was. But time has changed.
Click to expand...

This seems like 100% backwards thinking.

In fact, some of the old-timers at my institution feel the exact opposite about how they used to do things. They will scold a resident for not bagging with 100% oxygen fast enough or big enough TV's for this very reason. "Back in the day we didn't have SpO2, so we preoxygenated and bagged like crazy since we never knew."
 
BLADEMDA said:
It takes time and experience to know who you do not have to preoxygenate or more importantly, those who you MUST preoxygenate. This comes with clinical experience and thousands of cases.
Click to expand...

As this pertains to this particular case (Case #1), we can never know if the outcome would have been different with her ~20 minutes of profound hypoxemia/hypoxia vs. the ~16 minutes of hypoxemia/hypoxia she wouldve had with full preoxygenation. And certainly the C-spine issue would've raised most people's red flags.

But if it was me, I would certainly want the "bonus" 4-5 minutes of full cerebral oxygenation time in exchange for wearing a tight-fitting mask for a few minutes.
 
fakin' the funk said:
I'm a junior guy in this thread, but my 2 cents is that
a) patients rarely mind the mask (and I ALWAYS use the headstrap), and if they do, they don't mind it if they hold it themselves
b) preoxygenation takes no extra time and provides a substantial safety margin.

From a medicolegal standpoint, if you know "expert witnesses" who would be willing to testify that preoxygenation isn't the standard of care, I certainly know some bigwigs who would argue that it is.

I would also argue that relying on "my ability to tell someone who doesn't need preoxygenation versus someone who does" is very, very fallible and smacks a little of arrogance.
Click to expand...

I haven't used a headstrap in 20 years and I'd slap you if you tried to put one on me. Totally unnecessary and uncomfortable for the patient - the only person it helps the inexperienced provider who doesn't have their act together yet. If preoxygenation is THAT important in a given patient, then you need to be holding the mask, not diverting your attention to all the other stuff you think you need to be doing.
 
fakin' the funk said:
This seems like 100% backwards thinking.

In fact, some of the old-timers at my institution feel the exact opposite about how they used to do things. They will scold a resident for not bagging with 100% oxygen fast enough or big enough TV's for this very reason. "Back in the day we didn't have SpO2, so we preoxygenated and bagged like crazy since we never knew."
Click to expand...

If I had Residents then EVERY patient would get 100% pre-oxygenation.
 
jwk said:
I haven't used a headstrap in 20 years and I'd slap you if you tried to put one on me. Totally unnecessary and uncomfortable for the patient - the only person it helps the inexperienced provider who doesn't have their act together yet. If preoxygenation is THAT important in a given patient, then you need to be holding the mask, not diverting your attention to all the other stuff you think you need to be doing.
Click to expand...

Good post.👍
 
jwk said:
I haven't used a headstrap in 20 years and I'd slap you if you tried to put one on me. Totally unnecessary and uncomfortable for the patient - the only person it helps the inexperienced provider who doesn't have their act together yet. If preoxygenation is THAT important in a given patient, then you need to be holding the mask, not diverting your attention to all the other stuff you think you need to be doing.
Click to expand...

I get that you don't like a headstrap. I also get you think you would slap someone if they tried to put it on you.

But don't you think that saying - someone that uses a head strap means they are inexperienced and don't have their act together - is a little dogmatic and perhaps a little arrogant? Maybe just a little?

Also there are a ton of things that we could do without - so of course MANY things are unnecessary, but we choose to use them for various reasons.

I don't know a single person that only does what is necessary - or only uses the necessary equipment, and leaves everything else out. What fun would that be?

I would say that in general - life goes better for people that can offer up opinions and advice and personal experience and try to avoid spewing forth piss and venom and blackness that is in the form of ridicule.

I use the mask all the time. I rarely have my act together. So at least you are correct in that with regards to myself.
 
I have a pre-oxygenation question - maybe a savy resident could figure this out.

Regarding all the recent discussion in our anesthesia world about 100% oxygenation (either on pre-induction or extubation) being a bad thing because you get absorption atelectasis that may persists for days after....

It maybe be better to NOT pre-oxygenate with 100% - maybe 80 or 90% is better.

The question then is, assuming many factors - like a healthy person with a reasonable and predictable FRC - how much time do you gain (before sats drop to maybe 85%) in an apneic patient if you take them from 80% alveolar O2 content to 100%. Does the gain matter that much?
 
epidural man said:
I have a pre-oxygenation question - maybe a savy resident could figure this out.

Regarding all the recent discussion in our anesthesia world about 100% oxygenation (either on pre-induction or extubation) being a bad thing because you get absorption atelectasis that may persists for days after....

It maybe be better to NOT pre-oxygenate with 100% - maybe 80 or 90% is better.

The question then is, assuming many factors - like a healthy person with a reasonable and predictable FRC - how much time do you gain (before sats drop to maybe 85%) in an apneic patient if you take them from 80% alveolar O2 content to 100%. Does the gain matter that much?
Click to expand...

If you REALLY pre-oxygenate well using 80% FiO2, like 3 minutes, which most people never do then a healthy patient could go several minutes completely apneic without any desaturation.

By the way, Today I put to sleep an ASA1 patient. Thin. Young. No mask. NO O2 via mask. Induction then LMA 20 seconds later. Saturation NEVER dropped below 99%. Of course, he was 100% SAt on room air prior to induction. I was thinking of this thread the entire time.

My usual course of action is to pre-oxygenate with a blend of O2/Air for 60 seconds or so. Again, the 60 seconds is for the NORMAL airway and case. The BIG lap. Gastric Bypass patients doesn't get induced until the saturation is 100% and he/she has taken BIG BREATHS/TV plus 60 seconds ( I use 100% FiO2 here).
 
epidural man said:
I get that you don't like a headstrap. I also get you think you would slap someone if they tried to put it on you.

But don't you think that saying - someone that uses a head strap means they are inexperienced and don't have their act together - is a little dogmatic and perhaps a little arrogant? Maybe just a little?

Also there are a ton of things that we could do without - so of course MANY things are unnecessary, but we choose to use them for various reasons.

I don't know a single person that only does what is necessary - or only uses the necessary equipment, and leaves everything else out. What fun would that be?

I would say that in general - life goes better for people that can offer up opinions and advice and personal experience and try to avoid spewing forth piss and venom and blackness that is in the form of ridicule.

I use the mask all the time. I rarely have my act together. So at least you are correct in that with regards to myself.
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Sorry - I'm just an old fart with occasionally over the top opinions. So, let me rephrase.

I don't like head straps - I think they're uncomfortable for the patient and unnecessary. It's in the same line of thinking that I don't like the nurses strapping the patient's arms to the armboards or tucking them in by their sides with sheets prior to induction - it's uncomfortable and unnecessary.

I think for most patients, strict pre-oxygenation (or denitrogenation as several of my docs preferred to say) is probably overkill. I pay much more attention to it on cases with potentially difficult airways, especially our large bariatric population.
 
Recently I switched to doing most everything with max 80% FiO2. I didn't believe in the clinical significance of absorption atelectasis, but had several cases where persistent hypoxia in PACU had no other explanation. So far I am pretty happy with it.

Now the known difficult airway with pre-existing pulmonary issues will still likely get 100% FiO2 de-nitrogenation to buy a few extra seconds, but I still extubate on 80%

- pod
 
epidural man said:
The question then is, assuming many factors - like a healthy person with a reasonable and predictable FRC - how much time do you gain (before sats drop to maybe 85%) in an apneic patient if you take them from 80% alveolar O2 content to 100%. Does the gain matter that much?
Click to expand...

This has been studied, i think you gain 60-100 sec by going from 80 to 100% O2
 
periopdoc said:
Recently I switched to doing most everything with max 80% FiO2. I didn't believe in the clinical significance of absorption atelectasis, but had several cases where persistent hypoxia in PACU had no other explanation. So far I am pretty happy with it.

Now the known difficult airway with pre-existing pulmonary issues will still likely get 100% FiO2 de-nitrogenation to buy a few extra seconds, but I still extubate on 80%

- pod
Click to expand...

absorption atalectasis is real, i try to encourage my residents to extubate everyone on 50% FiO2. i suppose the same could apply for preop preoxygenation.
 
pgg said:
Induction 8:35
Desats at 8:37 while struggling with LMAs
First DL at 8:45
More DLs through 8:55
Intubating LMA at 9:00 with some ventilation

23 minutes! 😱 Cut her already!
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Cut to the chase. I think that you dissociate when you are in a critical situation. You loose sense of how close you are to causing real harm.
This sounds like a failure to escalate. I know that I have been lulled into thinking that the next DVL will be the one to get the intubation. We forget that DVLing is like slapping or punching someone in the mouth. Swelling soon follows multiple attempts.

The nurses were on the right track. It was unfortunate that no one listened to them.

This was a great post. It is very information and thought provoking.

Cambie
 
epidural man said:
I have a pre-oxygenation question - maybe a savy resident could figure this out.

Regarding all the recent discussion in our anesthesia world about 100% oxygenation (either on pre-induction or extubation) being a bad thing because you get absorption atelectasis that may persists for days after....

It maybe be better to NOT pre-oxygenate with 100% - maybe 80 or 90% is better.
Click to expand...

I have thought about this exact question. Edmark et al 2003 in Anesthesiology showed that you can gain roughly 100 seconds each going from preoxygenate with 60%, 80% and 100% before SpO2 drops to 90. The same group in 2011 also showed that atelectasis occurs rapidly after induction regardless of FiO2 during preoxygenation, but especially fast with 100%. So yes, preoxygenate with less than 100% may be beneficial.

However, atelectasis under anesthesia can occur quickly at various stages, but is reversible and preventable with recruitment manuver and the avoidance of 100% FiO2 intraop. A lost airway and anoxic brain injury are not. So I may preoxygenate with less than 100% if patient is healthy and my attending is chill. But with a suspect airway, full preoxygenate with 100% and deal with atelectasis later.
 
Idiopathic said:
absorption atalectasis is real, i try to encourage my residents to extubate everyone on 50% FiO2. i suppose the same could apply for preop preoxygenation.
Click to expand...


I just use a 50/50 mix at the end of a case (typical patient). It isn't EXACTLY 50% FiO2 but it's close enough for Obama/govt. work.
 
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