vocal cord polyps and jet vent

[Skip2myLou]

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we do quite a few of these in the surgi center and the surgeons prefer jet ventilation. curious to what technique everyone uses . normal polyp no airway issues or compromise.

induce with prop fent sux and roc(small dose). lma get them deep. turn the bed, lma out , jet vent in, propofil infusion, plus sux drip (300 mg in a 250 bag on a microdrip). at end of case lma back in until wake up.

 

[jwk]

we do quite a few of these in the surgi center and the surgeons prefer jet ventilation. curious to what technique everyone uses . normal polyp no airway issues or compromise.

induce with prop fent sux and roc(small dose). lma get them deep. turn the bed, lma out , jet vent in, propofil infusion, plus sux drip (300 mg in a 250 bag on a microdrip). at end of case lma back in until wake up.

We do ours with a small ETT. Granted, this is not a common procedure for us, and I can't say I've ever done a case with jet ventilation. It's just not something we do or that our ENT surgeons ask for.

I have no problem with your technique, except for the four extra steps I see, which would be placing and removing an LMA twice. Why do you need the LMA at all? Just mask them till they're deep, use the jet, and when done, mask them until they're awake.

 

[rsgillmd]

We do ours with a small ETT. Granted, this is not a common procedure for us, and I can't say I've ever done a case with jet ventilation. It's just not something we do or that our ENT surgeons ask for.

I have no problem with your technique, except for the four extra steps I see, which would be placing and removing an LMA twice. Why do you need the LMA at all? Just mask them till they're deep, use the jet, and when done, mask them until they're awake.

The jet cases I did during residency, I did as jwk described. One of them we intubated at the end and let him wake up slowly, but it was a longer case and wasn't for a simple polyp (I forget the details).

 

[Robert Loblaw]

we did this in residency quite a bit...

(1) surgeon in room for induction
(2) table turned 90 degrees
(3) good preox
(4) prop/remi bolus/infusions
(5) operate
(6) wake

 

[Idiopathic]

many of the polyps we do are HPV, so we typically avoid jet venting those patients, 5.0 uncuffed tube, bag bag bag, pull the tube, laser some polyps...lather, rinse, repeat.

ive also done the OPs method (sux drip can be fun), but i do more jet ventilation for tracheal stenosis cases than anything else.

 

[Mman]

For cases in the trachea that the ENT surgeon wants jet ventilation for, typically induce with prop and ensure good mask ventilation. Then go with repeated doses of succinylcholine if it will be quick or crank up the remifentanyl drip if it will take a little longer and just jet ventilate through their rigid scope. Will usually have propofol drip running for anesthesia throughout instead of just bolusing propofol. I find having to bolus too many agents while jet ventilating can be confusing. When they are done, make sure the patient has 4 good twitches, get the propofol off, and mask ventilate until they start breathing spontaneously.

 

[Skip2myLou]

I agree extra steps but much easier to ventilate with lma.

also, I thought jet vent is used because of hpv. I always thought Introducing ett through cords could seed viral particles. also better view of the cords for the surgeon. ever do a microlarungoscopy on someone with anterior cords and small opening, the combo of ett and ent equipment makes a real tight space to work for the surgeon.

 

[Mman]

I agree extra steps but much easier to ventilate with lma.

also, I thought jet vent is used because of hpv. I always thought Introducing ett through cords could seed viral particles. also better view of the cords for the surgeon. ever do a microlarungoscopy on someone with anterior cords and small opening, the combo of ett and ent equipment makes a real tight space to work for the surgeon.

No, we do jet vent DLs on any case the surgeon is going to be lasering the trachea, not just HPV. Basically they can't have an ETT in place because they are trying to laser just below the cords and you can't be constantly stopping to oxygenate/ventilate. Room air jet vent will maintain your sats pretty well and our surgeons are used to listening to the tone of the pulse ox and when it starts falling below 90 they stop for a minute to let us catch up on the ventilation/oxygenation.

 

[Arch Guillotti]

induce with propofol, sux
mask a minute, scope in, jet
propofol, remi, sux drips
finish case
resumption of spontaneous ventilation

I don't understand the need for an LMA at all😕

 

[Oggg]

If your surgeon is fast, then alfentanil, PPF, sux boluses. A 45min+ procedure I will consider 0.3mg/kg Roc, fentanyl, PPF. I use facemask and OPA, to not waste a disposable LMA

 

[Skip2myLou]

sorry dudes. no remi or alfent.

 

[Oggg]

You can use a little fent, but it's not a painful procedure

 

[Mman]

sorry dudes. no remi or alfent.

my might want an esmolol drip to help attenuate the hemodynamics, that's what I use the remi for. The problem is you need something to keep their HR/BP under control without having to give mega doses of propofol. Because if you give that much propofol your wake up will take longer than the 30 minute case duration.

Run a propofol gtt at maybe 150 mcg/kg/min and then paralyze them in whatever fashion you see fit and titrate esmolol up or down to keep hemodynamics in check. Let's you wake them up on a dime.

 

[dhb]

Run a propofol gtt at maybe 150 mcg/kg/min and then paralyze them in whatever fashion you see fit and titrate esmolol up or down to keep hemodynamics in check. Let's you wake them up on a dime.

Are you aware of any data regarding propofol doses that guarantee the absence of awareness?

 

[Mman]

Are you aware of any data regarding propofol doses that guarantee the absence of awareness?

I'm not aware of any data regarding any drug at any dose that guarantees the absence of awareness. An end tidal Sevo concentration of 5 doesn't really guarantee it. I find that dose is sort of a starting point for GA on a TIVA case. You could always throw a BIS on if you want (I usually do for TIVAs).


That's why I never promise any patient they will not have any awareness. However, I do tell them I will be fairly amazed if they remember anything.

 

[Idiopathic]

You can use a little fent, but it's not a painful procedure

suspension laryngoscopy and laser airway surgery is very stimulating. the remi attenuates that. you could use esmolol as well, as long as you have enough sedative on board. i do these cases with prop/remi qtt, full paralysis and a BIS. they all wake up fairly quickly.

 

[Mman]

suspension laryngoscopy and laser airway surgery is very stimulating. the remi attenuates that. you could use esmolol as well, as long as you have enough sedative on board. i do these cases with prop/remi qtt, full paralysis and a BIS. they all wake up fairly quickly.

Correct, the key is to attenuate the hemodynamic response without dramatically extending your wake up time. Remi is great for it because it isn't a painful procedure, but it is extremely stimulating.

 

[Arch Guillotti]

Are you aware of any data regarding propofol doses that guarantee the absence of awareness?

I am not, and I don't think it matters.

This is about the dose I start with.

 

[Idiopathic]

Are you aware of any data regarding propofol doses that guarantee the absence of awareness?

does any anesthetic agent guarantee the absence of awareness?

edit: okay besides like 2.5 MAC of volatile or burst suppression with pentothal/propofol...outside of that, though, we are guaranteed nothing