What's going on with this patient?

[epidural man]

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Just finished this case.

Patient with obstructed ureter, septic and needs stent placement. She has been vomiting since presesntation. Pateint refuses regional. Surgeon would like a general anesthetic. EKG shows T-wave inversion on multiple leads which is old. In the ER, septic, HR was 130's with no apparent ischemic problems. Currently after ER treatment, she looks much better. She also has a history of moderate mitral valve regurgitation/insuffeciency. She also has moderate restrictive lung disease. Also, history of partial thyroidectomy that left her with paralysis of the right vocal cord. On physical exam, she has a very large low lying goiter that appears to be on both sides of the neck.

1. Would you treat this as an anterior mediastinal mass?
2. If so, how does that change your management?

 

[deleted171991]

When in doubt, awake fiberoptic. If one does enough of them, they become much more comfortable for both physician and patient.

Nicely deviated trachea, so no doubt (about AFOI) here.

 

[pjl]

Prop, sux, freak out

 

[bcat85]

It's a little unclear from the imaging whether this truly represents a mediastinal mass. If it's substernal, I would probably treat it as such and do an AFOI. Otherwise, I would plan for a glide scope intubation. I can't find the citation at the moment, but I recall reading a paper that suggested that a mass with <50% compression was associated with an essentially nonexistent risk of airway obstruction/collapse, which appears to be the case here. Additionally, if this did extend into the anterior mediastinum, I would be sure to have a rigid bronch in the room.

 

[Planktonmd]

Awake fiberoptic so next time she would think twice before refusing regional

 

[Wiscoblue]

this does not look like a difficult intubation to warrant awake fiber optic intubation. I'd go propofol roc tube. After doing anesthesia for hundreds of giant goiters, I can say with confidence that, based on the evidence supplied, I do not anticipate airway issues.

 

[funkyfaroh]

I would do an awake fiber. Yes, i see that in most cases with giant goiters things go fine, but the vocal cord paralysis secondary to the goiter along with the restrictive lung disease and deviated trachea gives some concern. I would also be careful with induction. This patient was recently septic although doing better now. Her pressures could tank rapidly.

 

[funkyfaroh]

Sorry, the OP mentioned the vocal cord paralysis was due to previous surgery. I'd still stick to an awake fiber and try to get that HR down. Must be doing wonders for her Mitral Regurgitation.

 

[bkell101]

does the patient have any dyspnea/cough while laying flat? any physical findings or subjective complaints concerning for SVC syndrome? if you scroll through the images on the CT is there compression at any level? What comes up when she vomits and what is her NPO status? .....I second the previous response about <50% compression + no positional dyspnea/cough = a low incidence of respiratory compromise....if the patient does not have symptoms supine and the CT shows minimal compression and the patient is NPO and now not vomiting...I'll take the bait and throw out this plan: having rigid bronch on stand by, gradual induction to maintain spontaneous breathing, gradually take over ventilation, place a reinforced ET tube over fiberoptic scope , then paralyze...

 

[urge]

Pent sux tube and let nature take its course.

 

[Sonny Crocket]

I would do an awake glidescope intubation. Trans tracheal lidocaine 4% 2mls. Then topicalize the oropharynx/larynx with the same as well as atomizer. Put in the glidescope and then tube. It takes about five minutes. And you will avoid the blood pressure drop from your induction agent.

 

[Triple AAA]

Depending on this patient's airway exam, intubation may or may not be difficult. However, based on this scan alone, I have serious concerns about my ability to ventilate once their spontaneous breathing is eliminated. I would do this awake. What is the diameter of the airway at it's most narrow point?

 

[urge]

Doesn't the thoracic aorta look enlarged also?

 

[Noyac]

I have issue with anyone willing to paralyze this pt and go for it. I have not seen a trachea this deviated in quite a while. I would be seriously concerned that tracheal malacia has set in and emenant collapse would ensue.
It's just too damn easy to either do an AFOI or if you are confident that you can mask ventilate then do as Sonny Crockett described. Personally, I wouldn't even paralyze this pt once the tube was in place. A well topicalized trachea will never know the tube is in.

 

[Triple AAA]

Doesn't the thoracic aorta look enlarged also?

I don't know if anyone can conclude that based on the CXR alone. I would certainly be interested in seeing the rest of the CT scan to evaluate that further.

 

[deleted59964]

Anaesth Intensive Care 2014; 42: 700–708 Original Papers

A cohort and database study of airway management in patients undergoing thyroidectomy for retrosternal goitre

N. GILFILLAN*, C. M. BALL†, P. S. MYLES‡, J. SERPELL§, W. R. JOHNSON**, E. PAUL††

Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria

SUMMARY

Patients undergoing thyroid surgery with retrosternal goitre may raise concerns for the anaesthetist, espec- ially airway management. We reviewed a multicentre prospective thyroid surgery database and extracted data for those patients with retrosternal goitre. Additionally, we reviewed the anaesthetic charts of patients with retrosternal goitre at our institution to identify the anaesthetic induction technique and airway management. Of 4572 patients in the database, 919 (20%) had a retrosternal goitre. Two cases of early post- operative tracheomalacia were reported, one in the retrosternal group. Despite some very large goitres, no patient required tracheostomy or cardiopulmonary bypass and there were no perioperative deaths. In the subset of 133 patients managed at our institution over six years, there were no major adverse anaesthetic outcomes and no patient had a failed airway or tracheomalacia. In the latter cohort, of 32 (24%) patients identified as having a potentially difficult airway, 17 underwent awake fibreoptic tracheal intubation, but two of these were abandoned and converted to intravenous induction and general anaesthesia. Eleven had inhalational induction; two of these were also abandoned and converted to intravenous induction and general anaesthesia. Of those suspected as having a difficult airway, 28 (87.5%) subsequently had direct laryngoscopy where the laryngeal inlet was clearly visible. We found no good evidence that thyroid surgery patients with retrosternal goitre, with or without symptoms and signs of tracheal compression, present the experienced anaesthetist with an airway that cannot be managed using conventional techniques. This does not preclude the need for multidisciplinary discussion and planning.



* I feel like BLADE

 

[Sonny Crocket]

I have issue with anyone willing to paralyze this pt and go for it. I have not seen a trachea this deviated in quite a while. I would be seriously concerned that tracheal malacia has set in and emenant collapse would ensue.
It's just too damn easy to either do an AFOI or if you are confident that you can mask ventilate then do as Sonny Crockett described. Personally, I wouldn't even paralyze this pt once the tube was in place. A well topicalized trachea will never know the tube is in.

I don't see the danger in doing an awake glidescope intubation like I described if one is concerned about mask ventilation. That is the whole point. The way I do it, the patient is breathing the whole time. Topicalize, put tube in and attach circuit to sevo. No paralytic given. I do this technique with unstable patients as well. I am amazed at how well this works. If the airway is easy, you don't even need a glidescope. Just use a miller or a Mac. Bronchoscope is only necessary if there is limited mouth opening, oral airway pathology etc....

 

[bkell101]

Have you ever had an afoi that was impossible because the patient was combative or non compliant?

 

[Noyac]

I don't see the danger in doing an awake glidescope intubation like I described if one is concerned about mask ventilation. That is the whole point. The way I do it, the patient is breathing the whole time. Topicalize, put tube in and attach circuit to sevo. No paralytic given. I do this technique with unstable patients as well. I am amazed at how well this works. If the airway is easy, you don't even need a glidescope. Just use a miller or a Mac. Bronchoscope is only necessary if there is limited mouth opening, oral airway pathology etc....

I agree. I kind of consider the Glidescope as AFOI as well as the bronchoscope. Both work well but bronchoscope remains the gold standard.

 

[Noyac]

Something else to think about, who wants to do a transtracheal injection for this case? Why?

 

[Planktonmd]

Something else to think about, who wants to do a transtracheal injection for this case? Why?

Not a bad idea... actually if the plan is awake FOI then it's a great idea and maybe leave the catheter in place just in case

 

[pgg]

Something else to think about, who wants to do a transtracheal injection for this case? Why?

If you can find it in its not-midline spot. Never done an u/s guided transtracheal injection before ... I love them for awake intubatations.


(also - retrograde wire!)

 

[okayplayer]

For those of you who do awake glidescopes, is your topicalization/sedation the same or different from AFOI? Seems very stimulating.

My usual approach is lido gel on the tongue and atomizer w/ 2% lido for post oropharynx and hypopharynx.

 

[pgg]

For those of you who do awake glidescopes, is your topicalization/sedation the same or different from AFOI? Seems very stimulating.

My usual approach is lido gel on the tongue and atomizer w/ 2% lido for post oropharynx and hypopharynx.

I do the same topicalization as for AFOI, given time. With the exaggerated curve to the Glidescope it's not super stimulating if you're gentle, and you don't need much force since you don't need that direct view. Gag reflex is the bigger problem absent good topicalization. Doesn't have to be painful.

 

[Noyac]

For those of you who do awake glidescopes, is your topicalization/sedation the same or different from AFOI? Seems very stimulating.

My usual approach is lido gel on the tongue and atomizer w/ 2% lido for post oropharynx and hypopharynx.

I do the same routine as for awake bronchoscopes as for the Glidescope and vice versa. But my routine differs some. I use viscous lido swish and swallow after some glyco. Then a transtracheal injection of 4%. That's all. The Glidescope is not that stimulating. It's more of a finess tool than a brute force tool like the laryngoscope can be. Slip it in. Use the angle and you don't need to lift so much. Pts tolerate it well.

As far as the transtracheal goes in this case, I would consider it if I was confident I wouldnt miss. US can be very helpful here.

 

[Noyac]

Oops. PGG already said all that.

 

[urge]

1. Would you treat this as an anterior mediastinal mass?
2. If so, how does that change your management?

What did you do? How did it go?

 

[Planktonmd]

What did you do? How did it go?

Pent Sux Tube!

 

[epidural man]

This is what we did.

This was a call case - middle of the night - so no one around but me and CA-3 and CA-1. Based on the CT scan, I didn't see much mass on top of the trachea - but was concerned that malacea was a problem and collapse could potentially happened.

However, I was more concerned about full stomach problems and didn't want to do sponaneous induction and place the tube with spontaneous breathing person. I wanted to create the best intubating conditions quickly. However, did want it to create conditions only for a very short time in case we needed to wake her up.

With glidescope and scope in the room - no rigid bronch unfortunately - We sat her on the bed to about 50deg, got some stepping stools to facilitate DL, then fentanyl, lidocaine, and 40mg propofol followed by sux. DL attempted by CA1 with only pink showing. CA3 takes a look and trachea was VERY deviated but with manipulation, she could get a view. Reinforced 7-0 tube used.

I mostly wanted to use the reinforced tube to teach the residents about them. Neither of them had used one before.

Case was quick - went well. BP never dipped below a systolic of 110. I was concerned about that but it turned out great.

We created a difficult airway letter for her to pass along to her next case. When presenting the letter, she happened to remember that the previous anesthesiologist at another institution really made a big deal about how difficult it was to place a tube in her. That would have been nice information to know.

 

[Planktonmd]

This is what we did.

This was a call case - middle of the night - so no one around but me and CA-3 and CA-1. Based on the CT scan, I didn't see much mass on top of the trachea - but was concerned that malacea was a problem and collapse could potentially happened.

However, I was more concerned about full stomach problems and didn't want to do sponaneous induction and place the tube with spontaneous breathing person. I wanted to create the best intubating conditions quickly. However, did want it to create conditions only for a very short time in case we needed to wake her up.

With glidescope and scope in the room - no rigid bronch unfortunately - We sat her on the bed to about 50deg, got some stepping stools to facilitate DL, then fentanyl, lidocaine, and 40mg propofol followed by sux. DL attempted by CA1 with only pink showing. CA3 takes a look and trachea was VERY deviated but with manipulation, she could get a view. Reinforced 7-0 tube used.

I mostly wanted to use the reinforced tube to teach the residents about them. Neither of them had used one before.

Case was quick - went well. BP never dipped below a systolic of 110. I was concerned about that but it turned out great.

We created a difficult airway letter for her to pass along to her next case. When presenting the letter, she happened to remember that the previous anesthesiologist at another institution really made a big deal about how difficult it was to place a tube in her. That would have been nice information to know.

Why would you think that she is going to be difficult to intubate after the goiter was removed?

 

[Planktonmd]

Why would you think that she is going to be difficult to intubate after the goiter was removed?

Sorry just realized this was not a thyroidectomy

 

[nimbus]

This is what we did.

This was a call case - middle of the night - so no one around but me and CA-3 and CA-1. Based on the CT scan, I didn't see much mass on top of the trachea - but was concerned that malacea was a problem and collapse could potentially happened.

However, I was more concerned about full stomach problems and didn't want to do sponaneous induction and place the tube with spontaneous breathing person. I wanted to create the best intubating conditions quickly. However, did want it to create conditions only for a very short time in case we needed to wake her up.

With glidescope and scope in the room - no rigid bronch unfortunately - We sat her on the bed to about 50deg, got some stepping stools to facilitate DL, then fentanyl, lidocaine, and 40mg propofol followed by sux. DL attempted by CA1 with only pink showing. CA3 takes a look and trachea was VERY deviated but with manipulation, she could get a view. Reinforced 7-0 tube used.

I mostly wanted to use the reinforced tube to teach the residents about them. Neither of them had used one before.

Case was quick - went well. BP never dipped below a systolic of 110. I was concerned about that but it turned out great.

We created a difficult airway letter for her to pass along to her next case. When presenting the letter, she happened to remember that the previous anesthesiologist at another institution really made a big deal about how difficult it was to place a tube in her. That would have been nice information to know.

Prop/sux/tube!!

 

[urge]

This is what we did.

This was a call case - middle of the night - so no one around but me and CA-3 and CA-1. Based on the CT scan, I didn't see much mass on top of the trachea - but was concerned that malacea was a problem and collapse could potentially happened.

However, I was more concerned about full stomach problems and didn't want to do sponaneous induction and place the tube with spontaneous breathing person. I wanted to create the best intubating conditions quickly. However, did want it to create conditions only for a very short time in case we needed to wake her up.

With glidescope and scope in the room - no rigid bronch unfortunately - We sat her on the bed to about 50deg, got some stepping stools to facilitate DL, then fentanyl, lidocaine, and 40mg propofol followed by sux. DL attempted by CA1 with only pink showing. CA3 takes a look and trachea was VERY deviated but with manipulation, she could get a view. Reinforced 7-0 tube used.

I mostly wanted to use the reinforced tube to teach the residents about them. Neither of them had used one before.

Case was quick - went well. BP never dipped below a systolic of 110. I was concerned about that but it turned out great.

We created a difficult airway letter for her to pass along to her next case. When presenting the letter, she happened to remember that the previous anesthesiologist at another institution really made a big deal about how difficult it was to place a tube in her. That would have been nice information to know.

I'm glad to hear that the greatest anesthetic plan known to mankind did not fail you.

Pent Sux Tube forever!