What did you learn today?

[Noyac]

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I learned how effective BiPaP can be. I was called to the cath lab to help sedate a gentleman for pacer placement. he was well known to me and my colleagues since he spent 6 weeks in our ICU maxed out on levophed and suffering from SIRS just 1 yrs ago. He has since lost 140 lbs and is now down to about 450 lbs. He has built up a tolerance to benzos and narcotics since then and they feel they can't handle the sedation in the lab. When I first see him he asks for some benzos and narcotics for his back pain and anxiety I love these pts. His OSA is so severe that he is suffering from long cardiac pauses and now needs a pacer. We get him on the ironing board the cath lab calls a table and this guy hangs over the edges so far that I can't even see the table under him. He immediately starts complaining of back pain and screaming for some narcotics. What an arse. I slap the Bipap on him hit him with 5 mg versed and start the propofol at some rate. I have no idea what the propofol dose was since the pump only went up to 100 kgs and this guy is somewhere over 200 kgs. The I proceeded to put him in a K hole. It was a beautiful thing. He breathed like a champ for the whole 90 min of the procedure with only a rare mown. I was pretty amazed at how well that bipap worked.

 

[bigdan]

I learned that even though someone is young and doing GREAT on post-op day #6 (up and walking, eating, and making plans to go home), he can still just get up and die.

What a sh*tty fu*king day.

dc

 

[badasshairday]

I learned that even though someone is young and doing GREAT on post-op day #6 (up and walking, eating, and making plans to go home), he can still just get up and die.

What a sh*tty fu*king day.

dc

Damn. Do you know what it was? Pulmonary embolism?

 

[lfesiam]

I learned that even though someone is young and doing GREAT on post-op day #6 (up and walking, eating, and making plans to go home), he can still just get up and die.

What a sh*tty fu*king day.

dc

I learned that even though you think you are good at a certain procedure... you may have done 100, or 1000s.... one may walk in the door where you just can't get it done right!

 

[fastosprintini]

i learned today during our airway course that in a pinch (lost airway , can't intubate , can't ventilate , no cric kit around) the drip chamber of an iv set can be cut off about 3/4 " from the bottom of the drip chamber and attached to a standard ambubag, it has a very good seal and the 1" long spike is sharp enough to penetrate the cricothyroid membrane
hope you never have to use it but it's a neat idea....
fasto

 

[Gern Blansten]

i learned today during our airway course that in a pinch (lost airway , can't intubate , can't ventilate , no cric kit around) the drip chamber of an iv set can be cut off about 3/4 " from the bottom of the drip chamber and attached to a standard ambubag, it has a very good seal and the 1" long spike is sharp enough to penetrate the cricothyroid membrane
hope you never have to use it but it's a neat idea....
fasto

Never would have thought of that one.

 

[Gern Blansten]

I learned that even though someone is young and doing GREAT on post-op day #6 (up and walking, eating, and making plans to go home), he can still just get up and die.

What a sh*tty fu*king day.

dc

Man, that IS a bad day. Sorry.

 

[fastosprintini]

neither would have i , but one of our er docs actually used it once and it worked very well ....
my $0.02 , fasto

 

[cchoukal]

I learned how effective BiPaP can be... I was pretty amazed at how well that bipap worked.

I've used plenty of bipap (including intra-op, as you mentioned), but I'd never seen such a dramatic response to it as I did a couple nights ago on call in the unit. 80 yo F w/ a CHF exacerbation, breathing 30, satting 92%, HR 120s, in obvious distress, did not want to be intubated. Within 2 minutes on 10/5, RR 17, SpO2 99%, HR 70s, and a more satisfying decrease in her distress I've never seen.

 

[proman]

i learned today during our airway course that in a pinch (lost airway , can't intubate , can't ventilate , no cric kit around) the drip chamber of an iv set can be cut off about 3/4 " from the bottom of the drip chamber and attached to a standard ambubag, it has a very good seal and the 1" long spike is sharp enough to penetrate the cricothyroid membrane
hope you never have to use it but it's a neat idea....
fasto

If you've done a cric with a 14ga you can also take the ET connector from a 3.0 tube and connect that to an ambu bag.

 

[psychbender]

i learned today during our airway course that in a pinch (lost airway , can't intubate , can't ventilate , no cric kit around) the drip chamber of an iv set can be cut off about 3/4 " from the bottom of the drip chamber and attached to a standard ambubag, it has a very good seal and the 1" long spike is sharp enough to penetrate the cricothyroid membrane
hope you never have to use it but it's a neat idea....
fasto

http://www.bioone.org/doi/abs/10.1580/PR20-05.1?cookieSet=1&journalCode=weme

I heard about this first in my Advanced Wilderness Life Support class several years ago. Since then, I've heard a lot of people mention that it can be done, but never heard of someone actually doing it. I'm wondering in what situation you would find yourself with a patient requiring an emergent surgical airway, an IV drip set and ambu bag, but no other equipment necessary to secure an airway of any sort.

 

[Narcotized]

Can someone remind me what size syringe and ET tube connector makes a nice McGyver type cric kit (I'm thinking 5cc and maybe the above mention 3.0?). Anybody know?

 

[Narcotized]

Can someone remind me what size syringe and ET tube connector makes a nice McGyver type cric kit (I'm thinking 5cc and maybe the above mention 3.0?). Anybody know?

I learned today to Google first before asking questions to strangers.

http://www.templejc.edu/dept/ems/Pdf/Tip Sheets/Surgical Cric tip.pdf

1. Assemble all necessary equipment. This should include a 14 gauge 1 ½ inch over the needle IV catheter, 5 cc syringe with luer fitting, 3.0 endotracheal tube connector (if using BVM), high pressure oxygen source, jet ventilation device (if not using BVM), and BVM with oxygen tubing.

 

[proman]

With a 3.0 adapter you don't need the syringe. Should fit directly from ambu to adapter to catheter hub.

Oh, and the horizontal incision in that tip sheet from Temple is dangerous. We're taught vertical midline based on previous misadventures with horizontal cuts.

 

[Noyac]

With a 3.0 adapter you don't need the syringe. Should fit directly from ambu to adapter to catheter hub.

Oh, and the horizontal incision in that tip sheet from Temple is dangerous. We're taught vertical midline based on previous misadventures with horizontal cuts.

But the syringe is more secure.

I was taught to use a 3cc syringe and a connector from whichever ETT fit snuggly. I think it was a 7.0 or 7.5 ETT connector. I'll have to check again.

Another trick is to wipe the connector down with alcohol b/4 inserting. THis allows it to slip into place easily and then quickly evaporate creating a tight secure connection.

 

[Planktonmd]

If you've done a cric with a 14ga you can also take the ET connector from a 3.0 tube and connect that to an ambu bag.

You can not use an ambu bag to ventilate through a 14ga catheter, it will not work.
You can use a jet ventilator but not an ambu bag.

 

[Arch Guillotti]

You can not use an ambu bag to ventilate through a 14ga catheter, it will not work.
You can use a jet ventilator but not an ambu bag.

I would think that the amount of air you could squeak in would be negligible.

 

[proman]

You can not use an ambu bag to ventilate through a 14ga catheter, it will not work.
You can use a jet ventilator but not an ambu bag.

And if you don't have a jet ventilator?

 

[Planktonmd]

And if you don't have a jet ventilator?

Then you are screwed!

 

[cfdavid]

I learned the other day that there's a thing called propofol infusion syndrome. Seriously, this never came up on any of my (only 2) anesthesiology rotations (probably because it's more relevant in the ICU). It was mentioned in a medicine grand rounds I sat in on. Here's a brief from PubMed.




The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome.
Vasile B, Rasulo F, Candiani A, Latronico N.

Institute of Anesthesiology-Intensive Care, University of Brescia, Piazzale Ospedali Civili 1, 25125 Brescia, Italy.

Comment in:

Intensive Care Med. 2004 Mar;30(3):522.

Propofol infusion syndrome (PRIS) is a rare and often fatal syndrome described in critically ill children undergoing long-term propofol infusion at high doses. Recently several cases have been reported in adults, too. The main features of the syndrome consist of cardiac failure, rhabdomyolysis, severe metabolic acidosis and renal failure. To date 21 paediatric cases and 14 adult cases have been described. These latter were mostly patients with acute neurological illnesses or acute inflammatory diseases complicated by severe infections or even sepsis, and receiving catecholamines and/or steroids in addition to propofol. Central nervous system activation with production of catecholamines and glucocorticoids, and systemic inflammation with cytokine production are priming factors for cardiac and peripheral muscle dysfunction. High-dose propofol, but also supportive treatments with catecholamines and corticosteroids, act as triggering factors. At the subcellular level, propofol impairs free fatty acid utilisation and mitochondrial activity. Imbalance between energy demand and utilisation is a key pathogenetic mechanism, which may lead to cardiac and peripheral muscle necrosis. Propofol infusion syndrome is multifactorial, and propofol, particularly when combined with catecholamines and/or steroids, acts as a triggering factor. The syndrome can be lethal and we suggest caution when using prolonged (>48 h) propofol sedation at doses higher than 5 mg/kg per h, particularly in patients with acute neurological or inflammatory illnesses. In these cases, alternative sedative agents should be considered. If unsuitable, strict monitoring of signs of myocytolysis is advisable.

PMID: 12904852 [PubMed - indexed for MEDLINE]

 

[cfdavid]

I've used plenty of bipap (including intra-op, as you mentioned), but I'd never seen such a dramatic response to it as I did a couple nights ago on call in the unit. 80 yo F w/ a CHF exacerbation, breathing 30, satting 92%, HR 120s, in obvious distress, did not want to be intubated. Within 2 minutes on 10/5, RR 17, SpO2 99%, HR 70s, and a more satisfying decrease in her distress I've never seen.

I've learned the benefit of BiPap in such instances as well. Use it EARLY in a dude with a COPD or CHF exacerbation with dyspnea. This can preempt a trip to the unit and ETT. Kind of a clinical judgement, but don't be afraid to bring it out early if someone just doesn't look well on a non-rebreather etc.

 

[Trisomy13]

I learned a neurosurgeon can cause a pneumothorax during an L1-2 decompression.

 

[proman]

Then you are screwed!

No you're not:

 

[bigdan]

Damn. Do you know what it was? Pulmonary embolism?

Autopsy results back; guy did indeed catch a "huge saddle embolus" (their words).

dc

 

[Planktonmd]

I did not say it doesn't look pretty I said it does not work!
Have you ever tried to ventilate someone with your gadget and an ambu bag as you suggested?

No you're not:

 

[Licoricestick]

And if you don't have a jet ventilator?

Regarding this there is an interesting article in this month's BJA looking at MV obtained in a lung model using different methods of ventilation through different sized cannulas through the cricothyroid membrane. Both with unobstructed upper airway and partially obstructed upper airway.

Essentially the findings were:
In absence of upper airway obstruction
# self inflating bag or oxygen flush : MV 0L/min regardless of cannula diameter
# 3 way tap improvised system or ENK flow modulator: MV >1L/min only through 13G cannula
#manujet jet ventilator: MV ~10L/min through 13G cannula. MV 2.4L/min through 16G cannula (only one to acheive detectable MV through 16G)

In presence of simulated upper aoirway obstruction (2.5mm diameter)

#self inflating bag: only able to achieve any ventilation torugh 13G cannula, MV 2L/min
# oxygen flush: MV 3L/min through 14G cannula
#ENK flow modulator and 3 way tap: MV 3-6L/min with 16 G to 13G cannulas respectively
#Manujet: 10L/min through 16G, 15L/min through 13G

Bottom line when ventilating through cicothyroid membrane - if you have a jet ventilator, use it.
If you don't have a jet then cannula size gets even more important, and your best improvised option is likely to be a 3 way tap.

Br J Anaesth. 2009 Dec;103(6):891-5.

 

[tucker27705]

1. during my workout listening to a podcast of a great lecture I learned for the first time what "on the road to Damascus" means and the origin from the bible (not a biblical scholar here)
2. learned while taking care of a pt what general dystonia is. learned about how deep brain stimulators are used to alleviate some of the horrible symptoms. figured out how to handle the stimulator during anesthesia/surgery. then saw a "dystonic storm" after the procedure. learned how to calm the storm. ativan is your friend.
bonus learning point no. 3: google and wikipedia are sometimes better resources than our standard anesthesia textbooks for esoteric conditions.

 

[lfesiam]

Just an intern's crazy idea: How about hooking up more than one Cri site and linking it up to a single ambubag for ventilation. Increasing the total area that the air can be ventilated, would that decrease the resistance?

 

[Eta Carinae]

Boehner has a night job!

 

[proman]

I did not say it doesn't look pretty I said it does not work!
Have you ever tried to ventilate someone with your gadget and an ambu bag as you suggested?

You're hopeless, and wrong. It works. I've done it on a cadaver.

 

[proman]

Just an intern's crazy idea: How about hooking up more than one Cri site and linking it up to a single ambubag for ventilation. Increasing the total area that the air can be ventilated, would that decrease the resistance?

Some advocate placing 2 14ga catheters. 1 is used from inspiration, the other supposedly helps increase exhalation. Not sure well that works.

 

[proman]

You mean you got chest rise?

Some. Try this: assemble like in the picture: 14 ga catheter, 3.0 ET adapter plugged in. Breath through it. Inhalation is not that bad, it's exhalation that's the issue, but that's also a problem with jet ventilation through a catheter.

This is a last ditch, nothing available technique that will provide oxygen to the patient for a brief amount of time. Their CO2 will probably be 3,000.

 

[Planktonmd]

You're hopeless, and wrong. It works. I've done it on a cadaver.

How did the cadaver do?

 

[proman]

It seems like it works for temporary oxygenation but not ventilation then.

Not to put words in his mouth, but Plank was stressing ventilation.

Your point is that your not screwed and I agree with you. It's probably a great thing to use to maintain some oxygenation while waiting for the jet ventilator to arrive.

The jet ventilator actually generates enough pressure to raise the chest. When you turn the jet ventilator off, the chest falls. You can actually eliminate CO2 with a jet ventilator.

Someone correct me if I'm wrong here.

I learned of this technique as a medic. Jet ventilation is simply not an option. Your only source of PPV is an ambu bag.

 

[Planktonmd]

It seems like it works for temporary oxygenation but not ventilation then.

Not to put words in his mouth, but Plank was stressing ventilation.


The jet ventilator actually generates enough pressure to raise the chest. When you turn the jet ventilator off, the chest falls. You can actually eliminate CO2 with a jet ventilator.

Someone correct me if I'm wrong here.

You are right.
You probably can do passive oxygen insufflation through the angiocatheter and buy some time, but you can not ventilate through it using an ambu bag as he suggested.
The only way to ventialte will be using a jet ventilator or some other way to deliver high pressure oxygen.
But proman is obviously convinced that his idea will work since it worked on a cadaver!

 

[dillpickles]

How did the cadaver do?

That is hilarious.

 

[Frank Rizzo]

I'm learning RIGHT NOW, that Great Lakes Christmas Ale is pretty fuking tasty!

 

[Licoricestick]

It seems like it works for temporary oxygenation but not ventilation then.

Not to put words in his mouth, but Plank was stressing ventilation.

Your point is that your not screwed and I agree with you. It's probably a great thing to use to maintain some oxygenation while waiting for the jet ventilator to arrive.

The jet ventilator actually generates enough pressure to raise the chest. When you turn the jet ventilator off, the chest falls. You can actually eliminate CO2 with a jet ventilator.

Someone correct me if I'm wrong here.

Chest fall and CO2 elimination isn't really related to the ventilator. Whilst it's certainly true that if you aren't getting enough gas in to cause chest rise (ie you are profoundly hypoventilating, if you are ventilating at all) you are highly unlikely to clear much CO2, the acutal CO2 removal is more related to diameter through which passive exhalation can happen.

If you only have a cannula in the cricothyroid membrane and a completely obstructed upper airway you get one squirt with the jet ventilator and that's it, no CO2 elimination, no chest fall.

The larger the diameter for exhalation, the better chest fall (and less time it takes to happen and therefore the faster the RR you can have) and therefore CO2 elimination will also be better. Patent upper airway and a good ventilating system should allow near normal minute ventilation. But ultimately it isn't going to be adequate (you always have a limitation to RR due to duration of the inspiratory phase) and CO2 will rise.

If I recall correctly, even with a patent upper airway, good ventilation system and 12-14G cannula you can only do TTJV for about 30min before CO2 rises significantly.

Of course, how likely are you to be able to maintain a patent upper airway in a CICV scenario (cause I can't think of any other circumstance in which I would need to use a needle cric).

 

[Licoricestick]

How did the cadaver do?

Yeah, what'd the ABG show? Good oxygenation?

 

[Noyac]

Some advocate placing 2 14ga catheters. 1 is used from inspiration, the other supposedly helps increase exhalation. Not sure well that works.

Probably not needed in 99% of the cases. Once the air goes in it usually can find a way out through the upper airway.

 

[fakin' the funk]

I learned the other day that there's a thing called propofol infusion syndrome. Seriously, this never came up on any of my (only 2) anesthesiology rotations (probably because it's more relevant in the ICU). It was mentioned in a medicine grand rounds I sat in on. Here's a brief from PubMed.

I learned that pulm/CCM intensivists and pharmacists are SCARED S%#TLESS of it

 

[fakin' the funk]

I'm learning RIGHT NOW, that Great Lakes Christmas Ale is pretty fuking tasty!

A tad too much cinnamon for me but otherwise a winner. No why oh why would you be in Cleveland or the area at the moment?!

 

[fakin' the funk]

But yea, regarding NIPPV in acute respiratory distress...

Where I'm training I learned to use your mode of choice (CPAP vs. BiPAP) for 30-60 minutes and if ain't workin, tube time