Trache's, PEG's and cystos....

[interleukin2]

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Here is a post I hope generates some good discussion. As a newly minted CA-1 I have been finding myself in the tracheotomy/PEG and Cysto rooms. So far I have found these to at times be the most challenging and difficult cases I have dose so far. I find that this is usually a result of the fact that most patients requiring tracheotomies, and to a lesser extent the cysto peeps, do so largely because they are sick. I dont mean the morbidly obese with PNA that is now vent dependent...no I mean the 89 y/o EF 15% with recent h/o cardiogenic shock and SAM, s/p CABG and MVR two weeks ago who now comes for a trache or any other myriad of co-morbidities for which you ( in my case me) dont have the experience and knowledge that comes with 3y of residency, you have at this point 3 months! Oh and did I mention you are in an open room so no cheating by knowing and reading about your cases the night before 🙂 Basically I am asking the well seasoned, the experienced in this forum to maybe share some wisdom as to how to approach these deceptively simple cases which can turn into nightmares on a dime. Any pearls of wisdom any drips, drugs, questions to ask, equipment ( aside from ur phone with your attending # on speed dial) you guys would advise to have ready to go? Any particularly hairy situations you encountered in these "20 min" cases BP management strategies? save ur ass tools? Basically, I would like to initiate a discussion to help us inexperienced CA-1's that may get duped by believing the surgeon and thinking these cases are simple, the case may be, from the surgeon's POV , not so much for us because we deal with the whole package not just what needs to be cut out or into!
thanks in advance!

 

[Idiopathic]

Here is a post I hope generates some good discussion. As a newly minted CA-1 I have been finding myself in the tracheotomy/PEG and Cysto rooms. So far I have found these to at times be the most challenging and difficult cases I have dose so far. I find that this is usually a result of the fact that most patients requiring tracheotomies, and to a lesser extent the cysto peeps, do so largely because they are sick. I dont mean the morbidly obese with PNA that is now vent dependent...no I mean the 89 y/o EF 15% with recent h/o cardiogenic shock and SAM, s/p CABG and MVR two weeks ago who now comes for a trache or any other myriad of co-morbidities for which you ( in my case me) dont have the experience and knowledge that comes with 3y of residency, you have at this point 3 months! Oh and did I mention you are in an open room so no cheating by knowing and reading about your cases the night before 🙂 Basically I am asking the well seasoned, the experienced in this forum to maybe share some wisdom as to how to approach these deceptively simple cases which can turn into nightmares on a dime. Any pearls of wisdom any drips, drugs, questions to ask, equipment ( aside from ur phone with your attending # on speed dial) you guys would advise to have ready to go? Any particularly hairy situations you encountered in these "20 min" cases BP management strategies? save ur ass tools? Basically, I would like to initiate a discussion to help us inexperienced CA-1's that may get duped by believing the surgeon and thinking these cases are simple, the case may be, from the surgeon's POV , not so much for us because we deal with the whole package not just what needs to be cut out or into!
thanks in advance!

Three types of patients exist
1) Healthy patients that will tolerate anesthesia
2) Sick patients that will tolerate anesthesia
3) Sick patients that will not tolerate anesthesia

If you are doing quite a few cases like you describe above, you should get very comfortable for inotropic support, stealthily placing arterial lines and interpreting PAC data. I would imagine that case was an anomaly, however, and that most of your trach patients are just "regular sick". In that case, many of them are already intubated and on some sort of sedation in the ICU, which implies some basic level of tolerance. Often with these cases I plan on remaining on ventilator support upon completion, so a little extra paralytic is reasonable. this will help with your anesthetic needs, since you can keep the patient at more of a MAC-aware level (0.3-0.5 MAC).

the big mental hurdle to jump over here is to rationalize how sick the patients look on paper with how stable they are in person. for instance, you may hear about the patient described above and imagine them to be on deaths door, but when you see them in person, they are off inotropes, without a PAC, minimal PEEP and no coagulopathy. they are probably much better than their history would suggest, and this is key. patients on epi and milrinone with EF of 10% should be getting bedside tracheostomy rather than going to the OR.

"emergency" drugs should be the same as you would have for any case, with the realization that recent hearts/lungs/transplants, etc may have an increased need for cardiovascular support in the way of epi/norepi/dobutamine so familiarize yourself with the upper tier drugs there (i.e. probably will not be very responsive to neo/ephedrine).

 

[nap$ter]

you've asked about two very different subsets of pts - cysto pts and trach n peg.

we call trach n peg pts "plug and play". you'll get used to the acuity soon enough. i used to do em like this: make sure the tube feeds have been OFF!! go up to the icu myself for transport (helps with OR flow, check out the icu nursing scenery, get a better grip on what's happening with the pt), bring em to OR, plug circuit to tube first, turn on gas (just a lil bit is usually needed) and push paralytic (or paralytic + versed). then transfer to OR table (or better yet talk surgeons into doing procedure on ICU bed). straightening the lines and re/placing the aline will win you adoration of icu nurses. keep all gtt's running. before they drape loosen/remove RT's clamp/zip tie/padlock ett fixation device so you don't have to goat rodeo it and look silly when ent gets in. the only dicey part is when they get into the trachea and you pull the tube back - have plan a,b,c,etc ready to go for airway management - i have had to reintubate a cuppla pts cuz ent intern couldn't get into trachea - and most of these pts have low reserves.

the best piece of advice i can give about plug n play pts is to make them look better when you bring them back to the icu nurses than they looked when you received em. re/place alines/IV's, redress lines if they look messy, bundle tubing and monitor cables; wash blood off of face/arms/fingers. the patient deserves it and nurses will be enamored of you and may invite you to their potluck days, very nice.

cysto pts are an entirely different story and deserve a new thread.

 

[Monty Python]

you've asked about two very different subsets of pts - cysto pts and trach n peg.

we call trach n peg pts "plug and play". you'll get used to the acuity soon enough. i used to do em like this: make sure the tube feeds have been OFF!! go up to the icu myself for transport (helps with OR flow, check out the icu nursing scenery, get a better grip on what's happening with the pt), bring em to OR, plug circuit to tube first, turn on gas (just a lil bit is usually needed) and push paralytic (or paralytic + versed). then transfer to OR table (or better yet talk surgeons into doing procedure on ICU bed). straightening the lines and re/placing the aline will win you adoration of icu nurses. keep all gtt's running. before they drape loosen/remove RT's clamp/zip tie/padlock ett fixation device so you don't have to goat rodeo it and look silly when ent gets in. the only dicey part is when they get into the trachea and you pull the tube back - have plan a,b,c,etc ready to go for airway management - i have had to reintubate a cuppla pts cuz ent intern couldn't get into trachea - and most of these pts have low reserves.

the best piece of advice i can give about plug n play pts is to make them look better when you bring them back to the icu nurses than they looked when you received em. re/place alines/IV's, redress lines if they look messy, bundle tubing and monitor cables; wash blood off of face/arms/fingers. the patient deserves it and nurses will be enamored of you and may invite you to their potluck days, very nice.

cysto pts are an entirely different story and deserve a new thread.

👍


.

 

[Idiopathic]

yeah thats what i was trying to say

 

[dhb]

nurses will be enamored of you

for doing their freakin job so they can sit on their fat a**

 

[rsgillmd]

for doing their freakin job so they can sit on their fat a**

If you need to do it, obviously they haven't done it. As slavin said, you do it for the patients, not for the nurses.

 

[gtb]

Agree with everything above for trachs.

Ensure the surgeons are using generous amounts of local anesthetic over the incision site, and consider squirting some 2% lidocaine into the trachea using a suction catheter through the ETT. Then, optimally, you'll only need just enough anesthetic agent to keep the patient asleep. Remember we do these at the bedside using a remarkably brutal dilation technique, so you can go light on the anesthetic agents when needed.

Also consider dialing down the O2 fraction early so you can evaluate whether the patient will tolerate FiO2 anywhere near room air. Do it early, and then if necessary you'll have some time to try and optimize (maybe w/ recruitment breaths, PEEP, etc.) oxygenation before you need to drop the FiO2. For cardiovascular cripples, odds are good that the patients will transport with all the necessary drips already running, so you'll just need to titrate agents prn.

 

[NotAMD]

i unfortunately also do a lot of trachs - cardiac issues aside here is my usual recipe:

pick up from unit with my own microdrip carrier, neo gtt stop-cocked to it, minimize other meds and number of pumps running, prior to leaving they get midaz 4, fentanyl 200, roc 50, propofol 20-40 that i carry in my pocket..

enter or, first priority is hook up circuit and run gas - theyll do a lot better respiratory wise than they had been in the unit now that they are paralyzed and on your vent - use their own monitor cables if possible for transfer to your monitor.. thats pretty much it for every unit tubed unit pickup .. for trachs in particular i just have a pair of scissors handy to cut off the strap and i run a lower fio2 and communicate with the surg about tube movement

 

[Ignatius J]

i unfortunately also do a lot of trachs - cardiac issues aside here is my usual recipe:

pick up from unit with my own microdrip carrier, neo gtt stop-cocked to it, minimize other meds and number of pumps running, prior to leaving they get midaz 4, fentanyl 200, roc 50, propofol 20-40 that i carry in my pocket..

enter or, first priority is hook up circuit and run gas - theyll do a lot better respiratory wise than they had been in the unit now that they are paralyzed and on your vent - use their own monitor cables if possible for transfer to your monitor.. thats pretty much it for every unit tubed unit pickup .. for trachs in particular i just have a pair of scissors handy to cut off the strap and i run a lower fio2 and communicate with the surg about tube movement

Agree with all above but for sick patients I would swap out Propfol for Etomidate. Pushing phenylephrine in elevators on the way to the ICU is not fun.

 

[Arch Guillotti]

i have had to reintubate a cuppla pts cuz ent intern couldn't get into trachea - and most of these pts have low reserves.

Has anyone else ever had this happen? I have been a part of many trachs inclusing some very difficult ones and I have never even come close to having to reintubate.

 

[Arch Guillotti]

we call trach n peg pts "plug and play". you'll get used to the acuity soon enough. i used to do em like this: make sure the tube feeds have been OFF!!

Does the feeding tube position matter to you?

 

[nap$ter]

Does the feeding tube position matter to you?

nope. gi motility and sphincter tone is f-ed in the icu - post-pyloric yields no guarantees. risk of turning off feeds < risk of aspiration.

 

[nap$ter]

for doing their freakin job so they can sit on their fat a**

it's your job when you have the patient.

don't be a dansko-wearin d-bag 😀

 

[Arch Guillotti]

nope. gi motility and sphincter tone is f-ed in the icu - post-pyloric yields no guarantees. risk of turning off feeds < risk of aspiration.

Motility is surely messed up but there are some who would argue that having a post-pyloric feeding tube with a secure airway isn't that big of a deal.

 

[interleukin2]

Thanks for the replies, the reason I grouped both types of cases is because at my institution, and I am sure nationwide, these cases are typical of CA-1's and one may underestimate the complexity of the case as well as not give them the fear they deserve due to a pushy surgeon who only cares that the patient doesn't move until he throws that last stitch and that the turnover is lightning fast...

 

[Fah-Q]

Has anyone else ever had this happen? I have been a part of many trachs inclusing some very difficult ones and I have never even come close to having to reintubate.

They should never be extubated. The surgeon should have you pull the tube back just far enough to put the trach tube in. Leave the ETT in place until you have definitely re-established ventilation through the trach tube and the trach tube has been secured. Extubating the patient should be the last step in the case. If the surgeon can't get the trach tube in for some reason then you just advance the ETT again and re-inflate the cuff and ventilate.

 

[ssmallz]

The key to trach's and sick pts in general - less is more. The most stimulating part of any surgery is usually induction and intubation. For intubated pts you don't really have to deal w/that. Plug em in, turn on a touch of gas, push the roc and run em light. They're so zonked out of the minds that they won't remember much and they're old so their MAC is way low to begin with so they don't need too much gas. Just do as little as possible, don't turn off drips, don't get too exotic w/your anesthetic techniques keep it simple

 

[Arch Guillotti]

They should never be extubated. The surgeon should have you pull the tube back just far enough to put the trach tube in. Leave the ETT in place until you have definitely re-established ventilation through the trach tube and the trach tube has been secured. Extubating the patient should be the last step in the case. If the surgeon can't get the trach tube in for some reason then you just advance the ETT again and re-inflate the cuff and ventilate.

That's what I have always done. Occasionally I will get a trach with a difficult airway. Extubating them prematurely would be a disaster.

 

[pgg]

That's what I have always done. Occasionally I will get a trach with a difficult airway. Extubating them prematurely would be a disaster.

My first intraop death as a new-ish CA1 was a trach.

Horrible airway, with a difficult intubation, now with an even thicker more edematous face/tongue/neck after some time in the ICU. Surgeon was attempting a percutaneous trach with a new (to him) device. Long story short, I pulled the tube back a bit (maybe too far, but who knows?) as he declared he was into the trachea, they didn't actually get into the trachea, in the ensuing flail all the tracheal stimulation vagal'd the patient down the 20s, the ETT cuff was torn, we readvanced the ETT but couldn't deliver PPV, patient desaturated, PEA, CPR, DRT.

Sick, sick patient who had a very poor prognosis to start with, but he didn't need to die in the OR ... It's the case I think of every time I've done a trach since.

 

[Arch Guillotti]

My first intraop death as a new-ish CA1 was a trach.

Horrible airway, with a difficult intubation, now with an even thicker more edematous face/tongue/neck after some time in the ICU. Surgeon was attempting a percutaneous trach with a new (to him) device. Long story short, I pulled the tube back a bit (maybe too far, but who knows?) as he declared he was into the trachea, they didn't actually get into the trachea, in the ensuing flail all the tracheal stimulation vagal'd the patient down the 20s, the ETT cuff was torn, we readvanced the ETT but couldn't deliver PPV, patient desaturated, PEA, CPR, DRT.

Sick, sick patient who had a very poor prognosis to start with, but he didn't need to die in the OR ... It's the case I think of every time I've done a trach since.

Was your attending there? I hope so.

 

[pgg]

Was your attending there? I hope so.

He was.

 

[Arch Guillotti]

He was.

Wow, that makes it all the more brutal. I can remember a couple of trachs early in my CA1 year when the attending was not there and it was not fun. Trachs are normally a simple straightforward procesdure but many of the patients are sick as heck and the procedure itself is fraught with danger. I have seen experienced ENT attendings struggle with them.

 

[Fah-Q]

My first intraop death as a new-ish CA1 was a trach.

Horrible airway, with a difficult intubation, now with an even thicker more edematous face/tongue/neck after some time in the ICU. Surgeon was attempting a percutaneous trach with a new (to him) device. Long story short, I pulled the tube back a bit (maybe too far, but who knows?) as he declared he was into the trachea, they didn't actually get into the trachea, in the ensuing flail all the tracheal stimulation vagal'd the patient down the 20s, the ETT cuff was torn, we readvanced the ETT but couldn't deliver PPV, patient desaturated, PEA, CPR, DRT.

Sick, sick patient who had a very poor prognosis to start with, but he didn't need to die in the OR ... It's the case I think of every time I've done a trach since.

The only trach deaths I have ever heard of were percutaneous trachs. It is a horrible procedure and there is just no reason to ever do one, in my opinion. It is even more ridiculous that a surgeon was doing a perc trach...these are usually done by non-surgeons in the ICU's. Not your fault in the least. The surgeon has to get into the trachea...no excuses. Good lesson though. Always keep your butthole tight when dealing with the airway. $hit hits the fan before you know it.

 

[proman]

I know of one lost airway when the attending surgeon (driving the bronchoscope) got pissed off at his fellow doing the trach and went to scrub in. He apparently whipped the bronch out of the patient and took the tube with it. Obviously the person holding the tube should have had a better grip but it's not like you can anticipate something like that.

 

[pgg]

I know of one lost airway when the attending surgeon (driving the bronchoscope) got pissed off at his fellow doing the trach and went to scrub in. He apparently whipped the bronch out of the patient and took the tube with it. Obviously the person holding the tube should have had a better grip but it's not like you can anticipate something like that.

Temper, temper. And I bet he never acknowledged his fault in losing the airway ...

 

[Fah-Q]

I know of one lost airway when the attending surgeon (driving the bronchoscope) got pissed off at his fellow doing the trach and went to scrub in. He apparently whipped the bronch out of the patient and took the tube with it. Obviously the person holding the tube should have had a better grip but it's not like you can anticipate something like that.

Scrub in for a trach? That's like scrubbing in for a rectal exam.