what do you make of this ekg?

[VentdependenT]

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We have a Lap Band/Lap Gastric bypass guy who goes APE$hiT if we don't do a rapid sequence or an awake.

We did an elective FOI on a dude. I blew it. I needed a jaw thrust with tongue pull not a friggen ovasapian. Anyhoots, Had difficult 2 person mask ventilate. My attending wanted to retry FO. I said lets just look and get it over with the DL. He tried. Bagged him up again. I gave the dude a jawthrust and pulled his tongue out then he tried FOI again. Got it.

But the dude's guts were all filled with air. Surgeon went nuts. Said we ruined his surgery.

So......the point of me asking was to see if these are done in some sort of routine fashion at his institution. Awake FOI vs Paralytic and DL vs Glidescope DL. I know that nothing should be done routinely, but surgeons get comfortable with us doing one style of anesthesia and then sort of "demand" that be done.

I'm putting on my flak jacket now.

 

[Noyac]

First of all, never let surgeons demand anything.

They don't know our business as well as we do. They can monday morning QB all they want after the fact but it doesn't change anything.

 

[Tenesma]

well i can understand the lap gastric bypass surgery dude's point of view --- when those morbidly obese people aspirate it is a disaster --- it is an even bigger disaster to do the surgery and then find out the patient aspirated...

the air in the stomach is a joke because they do an upper endoscopy most of the time anyway - not to mention that you usually place an NGT to decompress the stomach...

 

[VentdependenT]

well i can understand the lap gastric bypass surgery dude's point of view --- when those morbidly obese people aspirate it is a disaster --- it is an even bigger disaster to do the surgery and then find out the patient aspirated...

the air in the stomach is a joke because they do an upper endoscopy most of the time anyway - not to mention that you usually place an NGT to decompress the stomach...

There was assloads of air in the small bowel. It totally ruined his visualization.

I know to always do the right thing for the patient, no matter what the surgeon thinks. But his request is not a demand and he does have a point.

 

[UTSouthwestern]

How you intubating these folks UT?

Missed your reply earlier Vent. Rarely have to use a FOB and I've done more than 500 bariatric cases in the last 2.5 years. RSI with back of the table up, assistant present for cricoid and most importantly to pull the breasts of the women and men down and out of the way, occasionally the Troop pillow if they are supermorbidly obese (twice on 600+ pounders). Always expect the disaster, but rarely use even a bougie.

Most of the time, good cephalad, NON-PINCHING cricoid is all that you need to intubate ANYONE. I've walked into can't intubate situations in several different hospitals and just slapped down good cricoid pressure to help out the struggling intubater.

As for your patient with the air in the small bowel, your surgeon can guide your NGT into the small bowel and decompress it by manually compressing the bowel with the NGT on suction.