Urgently Intubating Massively Obese

[gtb]

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Called by an overhead page to an ICU at midnight. Walked into the ICU room, saw a whale-sized patient laying on the bariatric bed getting bag masked. "Holly crap," the first thing popping into my brain. This is a 497 pound (225kg) woman who self extubated 20 minutes before the call (ICU team wanted to see if she would fly w/o mech ventilation. Other complications: septic, ARDS, already intubated for 11 days, and also Down's syndrome with a tongue approximating the size and shape of a Volkswagen Beetle. No spontaneous respirations, but seemed to be getting ventilated okay with SpO2 94%, although no EtCO2 monitoring. No signs of rapidly spiraling down. Intubated at "outside hospital" with no record of airway management except for the tube in the trash can and a note by RT that the intubation depth was 20cm. She is completely supine, there is absolutely no neck to visualize, her chin is merging with what I think are the breasts, the cheeks are drooping onto the pillow and nearly spilling over the edges of her bariatric bed. Central venous access in situ. No gas values but electrolytes from earlier in the day WNL. No worrisome platelet count, Hct 33.

Heres what I did since she's ventilating adequately.
1. Continue bag mask (why screw up what's working at present?).
2. Called the attending, requesting help and somebody to bring up the difficult airway cart.
3. Started building a ramp trying to get a position where I might actually see vocal cords. This took 5 ICU nurses, and they also utilized the electrical lift. Still not a great position but her SpO2 went up to 96%. Maybe progress?
4. I asked for ENT to come stand by. Originally got a junior ENT resident, she called a talented R4 general surgery resident when she walked into the room. When he saw the patient, he made a call for an ENT senior resident to come by, although that never happened.
5. Gave 0.2 glycopyrolate to try and dry up secretions in case FOB needed. This was only 0.9 micrograms per kilo, a ridiculous small dose in retrospect, but her heart rate was already 120, and I worried about furthering myocardial O2 demand.
5. Lined up drug & airway tools: airways, DL blades, Glidescope, Fastrach, turned on and focused FOB.
6. Attending arrives and options for the following:
a. Go straight to Fastrach instead of RSI.
b. Etomidate induction, no neuromuscular blockade.

Outcome, easy Fastrach placement, good ventilation w/ +EtCO2, sats improve to 98%. Super copious secretions out of nose & mouth. Wondering about regurgitation. Suctioned mouth. Placed ETT through Fastrach, inflated balloon, +EtCO2, Sats to 100%, Bilateral, symmetric sounds (horrible sounding). Successful removal of Fastrach LMA and the tube adjusted to depth, CXR confirmed placement.

Outcome, patient is intubated and back on the ventilator. I still don't feel completely comfortable about the next time this happens. This was my original plan - looking for ideas & critical evaluation. Since ventilating okay, next time I'd spend a few more minutes building a ramp for best position possible. Since no spontaneous (or completely inadequate) respirations in the first place, I would have gone with a RSI. Cricoid pressure (pretty much just a pretense since none of us could locate the cricoid. Etomidate, low dose for her mass, to help minimize anxiety but I'm not going to give more than 10 - 20mg even though she weighs 225 kg. Also, I only have 40mg in my bag. Given a 100mg of Roc (all I have with me) as paralytic. Suctioned. Quick look with DL (tube if possible) followed by immediate Glidescope attempt if no clear path to cords. Reserve Fastrach as my emergency airway.

Post analysis. Glycopyrolate 0.2mg did nothing for her volume of distribution. Scopolamine patch(s)? Maybe I'd give more glycopyroloate for secretions (0.2 mg x 2 or maybe 3 rounds) if tolerated while waiting for the FOB. Drop an NG tube to evacuate stomach of the air stuffed in after 35 minutes of bagging. Faster ramp time. And RSI as per the original plan.

As said, looking for looking for ideas & critical evaluation of this case.

 

[huktonfonix]

your attending probably did what he should have. Take your best shot with your favorite difficult airway tool. Rapid sequence is an option, but you risk losing any spontaneous activity and muscle tone although it doesnt sound like there was much to begin with and you also run the risk of hyperkalemia with a bed bound patient when using succ. Your favorite tool may be the glidescope which would have been the right tool for you. Its usually not the wrong thing to do to take a quick DL although with a downs patient extreme hyperextension of the neck may not be advised. Did you ask your attending for his train of thought? Most are more than happy to give their rationale. The fastrach also give the advantage of being able to ventilate since in this case your ventilation may have been questionable and the risk of losing the airway likely outweighs the aspiration risk (which probably already happened anyway) in this case

 

[deleted126335]

.

 

[aredoubleyou]

Outcome, patient is intubated and back on the ventilator. I still don't feel completely comfortable about the next time this happens. This was my original plan - looking for ideas & critical evaluation. Since ventilating okay, next time I'd spend a few more minutes building a ramp for best position possible. Since no spontaneous (or completely inadequate) respirations in the first place, I would have gone with a RSI. Cricoid pressure (pretty much just a pretense since none of us could locate the cricoid. Etomidate, low dose for her mass, to help minimize anxiety but I'm not going to give more than 10 - 20mg even though she weighs 225 kg. Also, I only have 40mg in my bag. Given a 100mg of Roc (all I have with me) as paralytic. Suctioned. Quick look with DL (tube if possible) followed by immediate Glidescope attempt if no clear path to cords. Reserve Fastrach as my emergency airway.

Post analysis. Glycopyrolate 0.2mg did nothing for her volume of distribution. Scopolamine patch(s)? Maybe I'd give more glycopyroloate for secretions (0.2 mg x 2 or maybe 3 rounds) if tolerated while waiting for the FOB. Drop an NG tube to evacuate stomach of the air stuffed in after 35 minutes of bagging. Faster ramp time. And RSI as per the original plan.

As said, looking for looking for ideas & critical evaluation of this case.

I think the plan that happened was a good plan cause no muscle relaxant was used on a lady that could obstruct and become very difficult to ventilate. Biggest disadvantage is dealing with one of those crappy prone-to-kink fast track tubes in the icu.

An RSI with Roc would NOT be my plan. Just cause shes ventilating ok now doesnt mean she will be after you DL her a bunch of times, and the Roc gives you no hope of recovery before she dies from suffication. Also, if your ventilating her now, why stop after you give her a paralytic agent and all of a sudden convert to RSI - doesnt make sense to me. And 20 mg etomidate wont even phase her, if your gunna give a long acting muscle relaxant you should properly induce her or give high dose versed. Given what you presented I prolly wouldnt even use sux, or try a DL. So my critical evaluation of the case is that you had everything ready for multiple plans (excellent), but your plan A....not for this patient, especially given you have all the equipment available.

Fast track is a fine chice, I would probably use etomidate and glydescope w/o sux instead ..... cause I use that more often....or "awake" FOB (nasal - dont see oral having a high chance of working in this situation). I might DL her in the OR in a more controlled fashion, but not this pt in this setting.

 

[Jeff05]

1. DL an awake patient? that can't be slick. actually, it's not cause i've seen that magic before.

2. she's Down's
you must worry about AA instability (don't mess with her neck too much), smaller trachea - use a size smaller tube (PRVC setting on the icu vent should be able to deal with that). large tongue. cardiac abnormalities?

3. scopolamine patch?! just give her more glyco. she doesn't have a history of CAD, but if you're worried give her esmolol/metoprolol.

4. even though she is not making an effort to breathe (WHY?- i mean she self extubated so she must have muscle strength) i would not give her ROC as she still has some degree of pharyngeal muscle tone keeping her airway patent. if that collapses you may lose your ability to ventilate.

Goals:
1. position for intubation and to maximize FRC - ramp it - and sit her up as much as you can
2. minimize neck manipulation - poss. AA instability: use glide or FO
3. avoid aspiration - likely full stomach: awake or RSI. sux may cause hyperkalemia in this critically ill bedbound patient.
4. avoid a can't ventilate/can't intubate situation: awake FOI.

i would have given her lotsa glyco. let it work. suction her out. nebulize some 4% lido in her mouth - if she aspirates some of it, great. then awake FOI or awake glidescope.

 

[Planktonmd]

1. DL an awake patient? that can't be slick. actually, it's not cause i've seen that magic before.
.

What if I told you that you can do awake DL very nicely as long as you do good topical anesthesia and airway blocks?
Actually this is what people did in the past for anticipated difficult intubations.

i would have given her lotsa glyco. let it work. suction her out. nebulize some 4% lido in her mouth - if she aspirates some of it, great. then awake FOI or awake glidescope.

Why is an awake Glidescope more "slick" than an awake DL?

 

[Arch Guillotti]

Awake nasal intubation.

 

[Frank Rizzo]

1. DL an awake patient? that can't be slick. actually, it's not cause i've seen that magic before.

Depends just how awake... the majority of the time when I'm called to one of the ICU's to emergently intubate someone, they're not that awake, they're trying to die.

 

[Frank Rizzo]

What if I told you that you can do awake DL very nicely as long as you do good topical anesthesia and airway blocks?
Actually this is what people did in the past for anticipated difficult intubations.

Have only done this once before, and it was on a healthy, male with a known difficult airway... it worked well. Would have been interesting with this patient though!

 

[Planktonmd]

Awake nasal intubation.

Sure, why not?
I tend to keep nasal intubation as a backup plan though in most situations since once you cause a nose bleed you might make a simple situation more complex.

 

[Jeff05]

with a glidescope, especially with a disposable handle (smaller) there is minimal stimulation of the patient's tongue and posterior pharynx/epiglottis (you don't have to lift any tissue out of the way like with DL). you also can get a great view of even the most anterior glottic opening.

What if I told you that you can do awake DL very nicely as long as you do good topical anesthesia and airway blocks?
Actually this is what people did in the past for anticipated difficult intubations.

Why is an awake Glidescope more "slick" than an awake DL?

 

[Planktonmd]

with a glidescope, especially with a disposable handle (smaller) there is minimal stimulation of the patient's tongue and posterior pharynx/epiglottis (you don't have to lift any tissue out of the way like with DL). you also can get a great view of even the most anterior glottic opening.

You are right in that a Glidescope could be more gentle but Glidescopes are not everywhere (yet), and it is good to know how to do an awake intubation without any advanced toys.
There is nothing wrong about lifting the soft tissue out of the way if that soft tissue is properly topicalized.
Try it sometimes, you will be amazed.

 

[jwk]

Anyone else think "the ramp" is overrated? I do tons of bariatric patients (no pun intended), and I have yet to see any real benefit. And in a 500 pounder already flailing, I'd see even less benefit to trying to get one in place.

 

[DrN2O]

Anyone else think "the ramp" is overrated? I do tons of bariatric patients (no pun intended), and I have yet to see any real benefit. And in a 500 pounder already flailing, I'd see even less benefit to trying to get one in place.

So you stopped doing the ramp and see no difference? Is it possible that the view would be worse without the ramp? Any study out there with MRI that compares airway anatomy with and without ramping?

 

[cchoukal]

1

 

[pillowhead]

Just want to say this is my absolute nightmare night time scenario. At one of the hospitals I rotate frequently through (with a very very busy, sick, and bariatric population) there are no attendings in house at night, no ENT in house, and no gen surg. in house. We had an anesthesia resident cric a patient once but there's no way I would ever even attempt such a thing in a patient like this. It's this scenario that keeps me from sleeping well on call.

Whenever I've been called to the ICU for some total disaster patient like this, it's always because they've self-extubated as well. I feel murderous rage when the nurse tries to tell me some ridiculous reason the wrist restraints were barely on and the sedation off. 😡

 

[Planktonmd]

Just want to say this is my absolute nightmare night time scenario. At one of the hospitals I rotate frequently through (with a very very busy, sick, and bariatric population) there are no attendings in house at night, no ENT in house, and no gen surg. in house. We had an anesthesia resident cric a patient once but there's no way I would ever even attempt such a thing in a patient like this. It's this scenario that keeps me from sleeping well on call.

Whenever I've been called to the ICU for some total disaster patient like this, it's always because they've self-extubated as well. I feel murderous rage when the nurse tries to tell me some ridiculous reason the wrist restraints were barely on and the sedation off. 😡

First thing to do when you are faced with a situation like this to to check your own pulse.
Always remember that they should not expect you to perform above your level of training just because they want to save money by not having appropriate coverage.
Optimize the conditions before you do anything: suction secretions, sit the patient up, give more oxygen, even try non-invasive ventilation if possible.
Do not allow the panic atmosphere around you to force you into a more complicated situation.

 

[gtb]

I'm grateful for ideas and the analysis. Given that she might have had just enough "awake" in her to keep her airway patent, I appreciate the general consensus that neuromuscular blockade is probably the wrong approach. I am curious about DL blade choices you might use. I've just not used a miller enough on obese adults, but it seems for her the tongue would have just folded over the edges of the blade and obscured my view.

I've never really evaluated the onset for the antisialogogue effect of glycopyrolate. How fast would you expect it to dry up her secretions? Fast enough to be useful in an urgent intubation in a massively obese patient?

I regret that I did not perform a DL once the tube was in. Then I would have been able to document a view, and a point of reference for future cases. A lost opportunity.

Interestingly, ICU stated the extubation occurred not from her grabbing the tube, but instead because the neck tissue was so wiggly-jigglly that the rigid tube securing device used by RT eventually moved superiorly and pulled the tube with it. ICU nurses reported that patient was adequately sedated and did not approach it with her hands. Who knows what really happened. Once getting the tube in, resecured it with lots of tape (360 degrees) and mastisol, not the RT device. Seemed more stable.

These are the papers I've read about positioning. The first recommends ramping so the tragus is horizontal to the sternal notch. The second recommends 30 degrees reverse trendelenburg.

Positioning the morbidly obese patient for anesthesia. Brodsky JB. Obes Surg. 2002 Dec;12(6):751-8. Review.

A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Boyce JR, Ness T, Castroman P, Gleysteen JJ. Obes Surg. 2003 Feb;13(1):4-9

Thanks again.

 

[LongSnow]

We have this thing cal the troupe pillow, I think it rocks! I use it for all of our mobidly obese. A lot easier than making that ramp.

I would have handled this similarly except that I would have put in an intubating lam and advance a tube through the lma into the trachea using a fiberoptic scope. Would use hardly any drugs, probobly just versed, etomidate, propofol, just whatever I could give at the moment.

 

[periopdoc]

IMHO the ramp may increase FRC but does not improve laryngoscopy. I mean how can it since it does not affect spino-cephalic alignment? It just bends the patient at the waist.

I either reverse-T the bed or flex the bed with the bed controller to (maybe) increase FRC. Works great whether in the ICU or the OR and you don't have to worry about pulling out tubes or lines as you do with removing the ramp.

Ramp vs bed flex

If you have one of those folks with a c-shaped neck while lying flat I think a shoulder roll is a better choice to open up that neck for laryngoscopy.

- pod

 

[ProRealDoc]

I'm grateful for ideas and the analysis. Given that she might have had just enough "awake" in her to keep her airway patent, I appreciate the general consensus that neuromuscular blockade is probably the wrong approach. I am curious about DL blade choices you might use. I've just not used a miller enough on obese adults, but it seems for her the tongue would have just folded over the edges of the blade and obscured my view.

I've never really evaluated the onset for the antisialogogue effect of glycopyrolate. How fast would you expect it to dry up her secretions? Fast enough to be useful in an urgent intubation in a massively obese patient?

I regret that I did not perform a DL once the tube was in. Then I would have been able to document a view, and a point of reference for future cases. A lost opportunity.

Interestingly, ICU stated the extubation occurred not from her grabbing the tube, but instead because the neck tissue was so wiggly-jigglly that the rigid tube securing device used by RT eventually moved superiorly and pulled the tube with it. ICU nurses reported that patient was adequately sedated and did not approach it with her hands. Who knows what really happened. Once getting the tube in, resecured it with lots of tape (360 degrees) and mastisol, not the RT device. Seemed more stable.

These are the papers I've read about positioning. The first recommends ramping so the tragus is horizontal to the sternal notch. The second recommends 30 degrees reverse trendelenburg.

Positioning the morbidly obese patient for anesthesia. Brodsky JB. Obes Surg. 2002 Dec;12(6):751-8. Review.

A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Boyce JR, Ness T, Castroman P, Gleysteen JJ. Obes Surg. 2003 Feb;13(1):4-9

Thanks again.

I personally prefer this approach as it aids with mask ventilation/oxygenation.

 

[proman]

If you have one of those folks with a c-shaped neck while lying flat I think a shoulder roll is a better choice to open up that neck for laryngoscopy.

- pod

Shoulder rolls all the way. Even a folded pillow makes life easier.

 

[aredoubleyou]

IMHO the ramp may increase FRC but does not improve laryngoscopy. I mean how can it since it does not affect spino-cephalic alignment? It just bends the patient at the waist.

I either reverse-T the bed or flex the bed with the bed controller to (maybe) increase FRC. Works great whether in the ICU or the OR and you don't have to worry about pulling out tubes or lines as you do with removing the ramp.

Ramp vs bed flex

If you have one of those folks with a c-shaped neck while lying flat I think a shoulder roll is a better choice to open up that neck for laryngoscopy.

- pod

Biggest advantage of the ramp is perhaps getting the blade into the mouth easily. Also i think its harder to know that u have good sniffing position in unramped super fat people-imho

 

[fakin' the funk]

Biggest advantage of the ramp is perhaps getting the blade into the mouth easily. Also i think its harder to know that u have good sniffing position in unramped super fat people-imho

My first-ever non-OR intubation, was fairly elective and a semi-obese person, I asked for a folded blanket to put under the head (to get a good sniffing position, on a firm surface, like in the OR), as opposed to the mushy pillow that the dude's head was resting on. The RT and RN looked at me like I had 2 heads. 😕

 

[poresofkohn]

My first-ever non-OR intubation, was fairly elective and a semi-obese person, I asked for a folded blanket to put under the head (to get a good sniffing position, on a firm surface, like in the OR), as opposed to the mushy pillow that the dude's head was resting on. The RT and RN looked at me like I had 2 heads. 😕

>
That must have been one inexperienced RT. That's usually my first move during an emergency intubation.

 

[aredoubleyou]

My first-ever non-OR intubation, was fairly elective and a semi-obese person, I asked for a folded blanket to put under the head (to get a good sniffing position, on a firm surface, like in the OR), as opposed to the mushy pillow that the dude's head was resting on. The RT and RN looked at me like I had 2 heads. 😕

Experienced nurses and Rts can keep you out of trouble half the time and get you into trouble half the time...but at the end of the day Ive been very unimpressed with eithers level of knowledge of airway and vent management. Know your stuff and know it well...just ignore them when you know youre right. They only know what theyve seen before...and when someone is especially slick, they dont realize all the little things going on around them (like folding the pillow in half to get em in position, etc, etc, etc.

 

[Jeff05]

Experienced nurses and Rts can keep you out of trouble half the time and get you into trouble half the time...but at the end of the day Ive been very unimpressed with eithers level of knowledge of airway and vent management. Know your stuff and know it well...just ignore them when you know youre right. They only know what theyve seen before...and when someone is especially slick, they dont realize all the little things going on around them (like folding the pillow in half to get em in position, etc, etc, etc.

word.
you are THE BOSS at airway parties. run the show. THINK. speak and do with confidence.