yet another airway...

[Licoricestick]

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Just got back from doing a pre-an on my case for tomorrow.

38yo male with locally advanced SCC L tonsil (T4aN0M0) for L mandibulotomy, completion of L tonsillectomy, excision of L base of tongue and lateral oropharyngeal wall, L neck dissection, tracheostomy and a radial free forearm flap for reconstruction of oropharynx.

BMI 25, 80kg, ex smoker (quit 2 months ago), otherwise fit & well.

Airway Ax:
MO ~2cm
reduced tongue protrusion
unable to protrud lower teeth beyond level of upper incisors
MP IV
all own teeth, no caps/crowns/loose
Normal neck movement, thyromental distance ~8cm
thin, easily palpable neck anatomy
looks like an easy mask ventilation

Airway findings at biopsy/partial L tonsillectomy/panendoscopy (a month ago - anaesthetic by a experienced consultant anaesthetist):
C&L Gd IV
MO not improved by anaesthesia + muscle relaxation (200mg propofol 50mg rocuronium + fentanyl for induction)
iLMA attempted - not successful
eventually intubated blindly over bougie after 4 attempts
no specific comment on mask ventilation (but electronic charting shows no desaturation)

I'm hoping the boss will let me do an AFOI (I need more practice!), and so far the patient seems agreeable enough. But the one thing that does worry me is that the descripton of the tumour at the time of Bx was that it was highly vascular and they needed to place surgicel on the tonsillar bed to get haemostasis as it still had very friable tumour. There is also at least one consultant where I work who thinks that fibreoptics in the presence of airway tumours are evil and asking for trouble - due to the bleeding risk, whereupon you have blood in the airway and can't see a thing.

We don't have a videolaryngosope at the moment, although that was my first thought given that they got a Mac 3 in before and he appears maskable.

So - other alternatives?

 

[jwk]

FOI clearly the best choice here. The key is doing it slowly and deliberately. Cooperative patient, plenty of sedation, Afrin or cocaine spray and/or pledgets to the nares, EXCELLENT airway numbing, including nebulized/spray/gargled lidocaine, gradual dilation of the preferred nare with nasal airways, liberally coated with lidocaine jelly, and allowed to remain in place for a couple minutes before going to the next size up. Consider trans-tracheal lidocaine a few minutes prior to going in with the FOB.

Glidescope or similar also a great choice, but if you don't have one, that's not an option.

 

[Planktonmd]

Awake fiberoptic intubation is the only reasonable option here IMHO.
You do good topical anesthesia (maybe atomized Lido 4%) + transtracheal block and if you want to be elegant you could also do a superior laryngeal block.
Don't forget to give Glyco and some light sedation.
Your attending who is claiming that awake fiberoptic intubation causes more bleeding obviously does not know how to do a smooth awake FOB.

Just got back from doing a pre-an on my case for tomorrow.

38yo male with locally advanced SCC L tonsil (T4aN0M0) for L mandibulotomy, completion of L tonsillectomy, excision of L base of tongue and lateral oropharyngeal wall, L neck dissection, tracheostomy and a radial free forearm flap for reconstruction of oropharynx.

BMI 25, 80kg, ex smoker (quit 2 months ago), otherwise fit & well.

Airway Ax:
MO ~2cm
reduced tongue protrusion
unable to protrud lower teeth beyond level of upper incisors
MP IV
all own teeth, no caps/crowns/loose
Normal neck movement, thyromental distance ~8cm
thin, easily palpable neck anatomy
looks like an easy mask ventilation

Airway findings at biopsy/partial L tonsillectomy/panendoscopy (a month ago - anaesthetic by a experienced consultant anaesthetist):
C&L Gd IV
MO not improved by anaesthesia + muscle relaxation (200mg propofol 50mg rocuronium + fentanyl for induction)
iLMA attempted - not successful
eventually intubated blindly over bougie after 4 attempts
no specific comment on mask ventilation (but electronic charting shows no desaturation)

I'm hoping the boss will let me do an AFOI (I need more practice!), and so far the patient seems agreeable enough. But the one thing that does worry me is that the descripton of the tumour at the time of Bx was that it was highly vascular and they needed to place surgicel on the tonsillar bed to get haemostasis as it still had very friable tumour. There is also at least one consultant where I work who thinks that fibreoptics in the presence of airway tumours are evil and asking for trouble - due to the bleeding risk, whereupon you have blood in the airway and can't see a thing.

We don't have a videolaryngosope at the moment, although that was my first thought given that they got a Mac 3 in before and he appears maskable.

So - other alternatives?

 

[Boujee]

why dont you have the ENT folks do an awake tracheostomy since pt is going to wake up with one....

 

[sevoflurane]

why dont you have the ENT folks do an awake tracheostomy since pt is going to wake up with one....

What he said. If an experienced anesthesiologist had a hard time with the airway and there is suspicion of a rapidly advancing ca invading the oropharynx I think that an awake trach is a reasonable approach... especially if this guy has a skinny neck and is going to get one anyways. What does the CT show regarding the trachea and surrounding tissues? Awake fiberoptic is another choice but it may prove to be more difficult and time consuming...

 

[hoyden]

AFI via nasal route. Will need a lot of topicalization all over - nasal and oral as well.

And get a good heap of articles for tomorrow 😉

 

[Mister J]

AFI via nasal route. Will need a lot of topicalization all over - nasal and oral as well.

And get a good heap of articles for tomorrow 😉

M3 here. I was wondering about this. Is there a reason not to choose a nasal approach?

I've seen it done for plastics cases where they were reconstructing the mandible. It seems like the easiest way past the tumor and the least obstructive way to maintain the airway during the surgery.

 

[2win]

why dont you have the ENT folks do an awake tracheostomy since pt is going to wake up with one....

I will suggest the same. Better surgical field for them too....

 

[hoyden]

M3 here. I was wondering about this. Is there a reason not to choose a nasal approach?

I've seen it done for plastics cases where they were reconstructing the mandible. It seems like the easiest way past the tumor and the least obstructive way to maintain the airway during the surgery.

You mean in this particular situation? In this situation I dare to think it is the only possible approach, or straightforward awake trach.

Or your question is about any head surgery?

 

[Mister J]

You mean in this particular situation? In this situation I dare to think it is the only possible approach, or straightforward awake trach.

Or your question is about any head surgery?

I was asking about this particular situation. Perhaps I was just misreading above, I don't have all the acronyms down yet but I was under the impression that others may have been suggesting oral intubation.

 

[nap$ter]

You mean in this particular situation? In this situation I dare to think it is the only possible approach, or straightforward awake trach.

Or your question is about any head surgery?

think ms3 missed the part where everyone was suggesting awake nasal FOI..

awake trach or awake FOI for this guy (or awake glidescope if that's your thing, plank). and NO sedation for awake FOI from me - if your topicalization and bedside manner/lullaby is good enough, you won't need any - only creates potential trouble.

we had this same case in a room that was not mine yesterday, except patient had also had neck radiation (neck felt like a plank of wood). for some reason attg let CRNA convince him that she could mask him, and they tried asleep nasal FOI. CRNA didn't do her job with the Afrin and glycopyrrolate, and no surprise she couldn't mask after induction, couldn't drive the scope in, and caused a massive nosebleed to join his copious secretions. sats down to 30's with bradycardia, attg finally steps in and is able to mask with great difficulty back up to 90's (mouth opening was too small to even try an LMA, even after anesthesia/relaxant). ENT attending apparently wasn't in the room for induction(!!!!!), called in STAT, crike kit placed on patient's chest, blind nasal intubation by feel completed successfully by attending, surgeon proceeded with case.

oropharyngeal cancer s/p radiation with small mouth opening = automatic AWAKE tube or AWAKE trach in my hands + ENT attending at the bedside (most of them know better and will be hovering anyway).

cannot overemphasize importance of vasoconstriction - patients love it when you tell 'em you're gonna have 'em snort a little coke. and glyco...

 

[Fastrach]

ditto for awake trach

 

[pd4emergence]

"Awake" FOI would be the way I approached this. Glyco as soon as he gets into the room. Afrin, lidocaine sprayed into each nare, nebulized lidocaine and viscous lidocaine to gargle. Versed, fentanyl, ketamine sedation. At least you know that you should be able to ventilate him if you give too much. If you stir up some bleeding you can always get the ENT guys to do the trach. Go to the trach early if you can't see. Don't wait until you get significant bleeding after multiple attempts at FOI. In residency we used to do alot of preemptive transtracheal jet ventilation using a vessel dilator in people with head and neck cancers. We would put the dilator in and then go to sleep and jet ventilate the patient until we could get a more secure airway (usually FOI). It worked well but If I had to do it now I would do a FOI with the patient spontaneously breathing. Check out this link if you are interested in the above http://www.ncbi.nlm.nih.gov/pubmed/16103392.

 

[Noyac]

Awake trach is a good approach.

And Plank, do you really have to insult someone in every post you write?

 

[nap$ter]

"Awake" FOI would be the way I approached this. Glyco as soon as he gets into the room. Afrin, lidocaine sprayed into each nare, nebulized lidocaine and viscous lidocaine to gargle. Versed, fentanyl, ketamine sedation. At least you know that you should be able to ventilate him if you give too much. If you stir up some bleeding you can always get the ENT guys to do the trach. Go to the trach early if you can't see. Don't wait until you get significant bleeding after multiple attempts at FOI. In residency we used to do alot of preemptive transtracheal jet ventilation using a vessel dilator in people with head and neck cancers. We would put the dilator in and then go to sleep and jet ventilate the patient until we could get a more secure airway (usually FOI). It worked well but If I had to do it now I would do a FOI with the patient spontaneously breathing. Check out this link if you are interested in the above http://www.ncbi.nlm.nih.gov/pubmed/16103392.

versed, fentanyl, ketamine for awake FOI? this sounds like a recipe for disaster. the goal is to be awake and dry - fentanyl + versed + ketamine = suppression of spontaneous ventilation + copious secretions from ketamine. I know you likely give ginger amounts, but in the words of southpark, beware the ginger kids. i wouldn't even go down this road.

if i'm doing awake FOI, no sedation from me unless they have a full-on panic attack, and only then do they get small amounts of versed, just versed, never fentanyl or ketamine. if you need to give fentanyl you haven't topicalized sufficiently.. verbal reassurance with confidence goes a long way..

 

[sevoflurane]

oropharyngeal cancer s/p radiation with small mouth opening = automatic AWAKE tube or AWAKE trach in my hands + ENT attending at the bedside (most of them know better and will be hovering anyway).

👍

Radiation to the neck always has me on high alert.

 

[militarymd]

if easy mask...and it appears that he is...

put him to sleep....asleep fiber.....

when I used to train residents...I didn't let rookies monkey with an airway like this......unless I knew the patient was going to hold stilll.......ie asleep.

 

[pd4emergence]

versed, fentanyl, ketamine for awake FOI? this sounds like a recipe for disaster. the goal is to be awake and dry - fentanyl + versed + ketamine = suppression of spontaneous ventilation + copious secretions from ketamine. I know you likely give ginger amounts, but in the words of southpark, beware the ginger kids. i wouldn't even go down this road.

if i'm doing awake FOI, no sedation from me unless they have a full-on panic attack, and only then do they get small amounts of versed, just versed, never fentanyl or ketamine. if you need to give fentanyl you haven't topicalized sufficiently.. verbal reassurance with confidence goes a long way..

Remember from his previous anesthetic they could mask ventilate him. Think about if it was you. With appropriate management you can give some sedation to this pt. and make it better for him. This is not how I do every patient, some get no sedation, some go to sleep, some get pretty heavily sedated, it depends on the situation. To make a rule that you will never do sedation for an awake FOI is short sighted. Verbal reassurance when you have a big endotracheal tube being rammed through your nose doesn't go very far. It may make you feel better but I can tell you that the patient doesn't really hear what you are saying (even if you have good topicalization). In this case, with the known fact that you can ventilate if he gets overly sedated, there is no reason not to give sedation other than you are following your own unreasonable dogmatic rule.

 

[hoyden]

Remember from his previous anesthetic they could mask ventilate him. Think about if it was you. With appropriate management you can give some sedation to this pt. and make it better for him. This is not how I do every patient, some get no sedation, some go to sleep, some get pretty heavily sedated, it depends on the situation. To make a rule that you will never do sedation for an awake FOI is short sighted. Verbal reassurance when you have a big endotracheal tube being rammed through your nose doesn't go very far. It may make you feel better but I can tell you that the patient doesn't really hear what you are saying (even if you have good topicalization). In this case, with the known fact that you can ventilate if he gets overly sedated, there is no reason not to give sedation other than you are following your own unreasonable dogmatic rule.

Things change pretty fast in these pts and ability to mask ventilate him previously is absolutely not a guarantee you will be able to do so again.
Which doesn't mean I would avoid any sedation, but I would dilute everything as if I have a neonate. Or a 100 y.o.

 

[Planktonmd]

Who the Fuk did I insult???
Noyac, I like you but it seems that the low FIO2 in the mountains is starting to affect your brain.

Awake trach is a good approach.

And Plank, do you really have to insult someone in every post you write?

 

[Frank Rizzo]

i would have a discussion with ENT about awake trach also

 

[Noyac]

Who the Fuk did I insult???
Noyac, I like you but it seems that the low FIO2 in the mountains is starting to affect your brain.

"Your attending who is claiming that awake fiberoptic intubation causes more bleeding obviously does not know how to do a smooth awake FOB."


I know you are just being funny with the FiO2 thing but the insults seem to be a theme in your posts lately.

 

[coprolalia]

Who the Fuk did I insult???
Noyac, I like you but it seems that the low FIO2 in the mountains is starting to affect your brain.

Congratulations! You are working your way to becoming the most hated poster on the SDN Anesthesiology forum.

My work is almost done...

-copro

 

[Noyac]

Congratulations! You are working your way to becoming the most hated poster on the SDN Anesthesiology forum.

My work is almost done...

-copro

Your not working for anything different.

 

[Planktonmd]

"Your attending who is claiming that awake fiberoptic intubation causes more bleeding obviously does not know how to do a smooth awake FOB."


I know you are just being funny with the FiO2 thing but the insults seem to be a theme in your posts lately.

Well, I am sorry that my posts seem offensive to you!
But I truly think that it is STUPID to tell a resident that he should not do an awake FOB on a patient with confirmed terrible airway and known difficult intubation because it might cause bleeding!
And for those who are interested to know: There is no reason why you should restrict yourself to nasal intubation in this patient.
You can do an oral awake fiberoptic intubation and the surgeon can work around your tube.
I do apologize in advance but anyone who tells a resident to not do an awake fiber optic intubation here is simply stupid and abviously does not know how to do it right.

 

[coprolalia]

I know you are just being funny with the FiO2 thing but the insults seem to be a theme in your posts lately.

I don't think he's being funny. I think it's demonstrative of his unchecked arrogance that's finally beginning to consume him.

-copro

 

[Planktonmd]

I knew Nancy would also have an opinion on this, and why not?
Nancy is a person after all.

 

[coprolalia]

Your not working for anything different.

Eh... you're probably right and I'm probably already there. 🙂

-copro

 

[2win]

Well, I am sorry that my posts seem offensive to you!
But I truly think that it is STUPID to tell a resident that he should not do an awake FOB on a patient with confirmed terrible airway and known difficult intubation because it might cause bleeding!
And for those who are interested to know: There is no reason why you should restrict yourself to nasal intubation in this patient.
You can do an oral awake fiberoptic intubation and the surgeon can work around your tube.
I do apologize in advance but anyone who tells a resident to not do an awake fiber optic intubation here is simply stupid and abviously does not know how to it right.

True - you can do whatever intubation you want. I'll stick with the awake trach. I will offer the chance for residents to do a fiberoptic for their training.

 

[coprolalia]

By the way, Mike... what time is it out there in Durango? A little after 2:00 PM? Man, that is a pretty "cush" job.

-copro

 

[coprolalia]

I knew Nancy would also have an opinion on this, and why not?
Nancy is person after all.

Hey, why not? Opinions are like a-holes, we all got 'em and they all stink.

Or, as Justin's dad says, "It's not the size of the a-hole you gotta worry about, it's the amount of **** that comes out of it."

And, buddy, certainly a lot of **** comes outta you.

-copro

 

[nap$ter]

Remember from his previous anesthetic they could mask ventilate him. Think about if it was you. With appropriate management you can give some sedation to this pt. and make it better for him. This is not how I do every patient, some get no sedation, some go to sleep, some get pretty heavily sedated, it depends on the situation. To make a rule that you will never do sedation for an awake FOI is short sighted. Verbal reassurance when you have a big endotracheal tube being rammed through your nose doesn't go very far. It may make you feel better but I can tell you that the patient doesn't really hear what you are saying (even if you have good topicalization). In this case, with the known fact that you can ventilate if he gets overly sedated, there is no reason not to give sedation other than you are following your own unreasonable dogmatic rule.

if you re-read the OP's case, you will find that he actually said he "looked like an easy mask ventilation", and that there was no comment in the previous record about ease of mask ventilation - just no de-saturations recorded during 4!! attempts at intubation. for all we know it might have been a goat rodeo to mask this guy..

to clarify - i don't have an unreasonable dogmatic rule. on the contrary, my practice of witholding sedation unless absolutely necessary for an awake FOI (and then choosing the appropriate drug) has a lot of reasoning behind it. i did not say i will never give sedation for an awake FOI. i said that i will only give it after trying to go without first, and if i do give it, it will be only versed - no fentanyl and definitely not ketamine.

if i am certain i can mask the patient but expect difficult intubation - proceed with ASLEEP FOI.

if i am uncertain as to whether we will be able to mask the patient and expect difficult intubation - proceed with AWAKE FOI.

there is no grey area in between. I DON'T DO KINDA SLEEPY FOI's. as hoyden said, things change quickly. why burn bridges unless you have to? you can't suck the sedation out once you've given it.

i have thought about "if it was me". if it was me, i would want the safest most comfortable airway. i like my neurons, and my neurons like oxygen. topicalization done correctly ie in advance, patiently, and with verbal reassurance and confidence displayed, has in my limited experience been sufficient for safe comfortable awake FOI for most patients.

lidocaine and cocaine make things numb; numb means you can't feel... if they feel it, they're not numb enough... if limbic excitation is the problem, they get smidges of versed until they feel ok, then tube, ETCO2, propofol.

lastly, i don't ram a big endotracheal tube into patients' nares. i topicalize, vasoconstrict, dilate with smallest to largest nasal trumpets and lubrication, and place the smallest possible nasal rae with enough length to safely clear the nostril. i do this before scoping to pre-empt the necessity for ramming. perhaps the ramming technique is your problem 🙂

 

[2win]

if you re-read the OP's case, you will find that he actually said he "looked like an easy mask ventilation", and that there was no comment in the previous record about ease of mask ventilation - just no de-saturations recorded during 4!! attempts at intubation. for all we know it might have been a goat rodeo to mask this guy..

to clarify - i don't have an unreasonable dogmatic rule. on the contrary, my practice of witholding sedation unless absolutely necessary for an awake FOI (and then choosing the appropriate drug) has a lot of reasoning behind it. i did not say i will never give sedation for an awake FOI. i said that i will only give it after trying to go without first, and if i do give it, it will be only versed - no fentanyl and definitely not ketamine.

if i am certain i can mask the patient but expect difficult intubation - proceed with ASLEEP FOI.

if i am uncertain as to whether we will be able to mask the patient and expect difficult intubation - proceed with AWAKE FOI.

there is no grey area in between. I DON'T DO KINDA SLEEPY FOI's. as hoyden said, things change quickly. why burn bridges unless you have to? you can't suck the sedation out once you've given it.

i have thought about "if it was me". if it was me, i would want the safest most comfortable airway. i like my neurons, and my neurons like oxygen. topicalization done correctly ie in advance, patiently, and with verbal reassurance and confidence displayed, has in my limited experience been sufficient for safe comfortable awake FOI for most patients.

lidocaine and cocaine make things numb; numb means you can't feel... if they feel it, they're not numb enough... if limbic excitation is the problem, they get smidges of versed until they feel ok, then tube, ETCO2, propofol.

lastly, i don't ram a big endotracheal tube into patients' nares. i topicalize, vasoconstrict, dilate with smallest to largest nasal trumpets and lubrication, and place the smallest possible nasal rae with enough length to safely clear the nostril. i do this before scoping to pre-empt the necessity for ramming. perhaps the ramming technique is your problem 🙂

Again - I do the same. Sometimes we tend to over do it - talking about "sedation"... Useless to mention that I am called q10 minutes from pre op that a patient wants XANAX. They are "stressed" and "they need something". Straight awake trach or intubation with topical anesthesia and that's it. To much pampering....

 

[Planktonmd]

Excellent post Slavin 👍
You know what sedation I give with an awake fiberoptic?
2 mg of Versed.

 

[2win]

Excellent post Slavin 👍
You know what sedation I give with an awake fiberoptic?
2 mg of Versed.

Excellent!
Sometimes I'll go with 6 - because I know that I can reverse it fast.
Hey Plank - what's the percentage in you practice for pre op sedation?
Mine is reaching almost 90%...They ask for that.

 

[Planktonmd]

I am sorry man but I did not understand your question.
(English is not my first language) 😀

Excellent!
Sometimes I'll go with 6 - because I know that I can reverse it fast.
Hey Plank - what's the percentage in you practice for pre op sedation?
Mine is reaching almost 90%...They ask for that.

 

[2win]

I am sorry man but I did not understand your question.
(English is not my first language) 😀

🙂
Just asking what percentage of your patients get some sort of meds in order "to feel better" in the holding area pre op...
thx

 

[Planktonmd]

🙂
Just asking what percentage of your patients get some sort of meds in order "to feel better" in the holding area pre op...
thx

Everyone under 80 Y/O gets some sort of sedation, if you are above 80 you get nothing.
Don't ask me where I got these numbers from but in my personal experience people above 80 Y/O are usually more confused post-op if they got a Benzo pre-op.
There are exceptions to every rule of course.

 

[Noyac]

By the way, Mike... what time is it out there in Durango? A little after 2:00 PM? Man, that is a pretty "cush" job.

-copro

Pretty cush.

Are you still mad that nobody here wanted to hire you?

 

[2win]

Everyone under 80 Y/O gets some sort of sedation, if you are above 80 you get nothing.
Don't ask me where I got these numbers from but in my personal experience people above 80 Y/O are usually more confused post-op if they got a Benzo pre-op.
There are exceptions to every rule of course.

"Everyone under 80 Y/O gets some sort of sedation"
Seems that this is my "cultural" problem - back home THEY DIDN'T get it....
Except children and people with heart problems - and you know why.
On the other way here - when the stipend depends on patient "satisfaction" I am the "make them happy" guy...
BTW - the awake intubation is called like that because the other way it is -
"not awake intubation"
2win

 

[pd4emergence]

if you re-read the OP's case, you will find that he actually said he "looked like an easy mask ventilation", and that there was no comment in the previous record about ease of mask ventilation - just no de-saturations recorded during 4!! attempts at intubation. for all we know it might have been a goat rodeo to mask this guy..

to clarify - i don't have an unreasonable dogmatic rule. on the contrary, my practice of witholding sedation unless absolutely necessary for an awake FOI (and then choosing the appropriate drug) has a lot of reasoning behind it. i did not say i will never give sedation for an awake FOI. i said that i will only give it after trying to go without first, and if i do give it, it will be only versed - no fentanyl and definitely not ketamine.

if i am certain i can mask the patient but expect difficult intubation - proceed with ASLEEP FOI.

if i am uncertain as to whether we will be able to mask the patient and expect difficult intubation - proceed with AWAKE FOI.

there is no grey area in between. I DON'T DO KINDA SLEEPY FOI's. as hoyden said, things change quickly. why burn bridges unless you have to? you can't suck the sedation out once you've given it.

i have thought about "if it was me". if it was me, i would want the safest most comfortable airway. i like my neurons, and my neurons like oxygen. topicalization done correctly ie in advance, patiently, and with verbal reassurance and confidence displayed, has in my limited experience been sufficient for safe comfortable awake FOI for most patients.

lidocaine and cocaine make things numb; numb means you can't feel... if they feel it, they're not numb enough... if limbic excitation is the problem, they get smidges of versed until they feel ok, then tube, ETCO2, propofol.

lastly, i don't ram a big endotracheal tube into patients' nares. i topicalize, vasoconstrict, dilate with smallest to largest nasal trumpets and lubrication, and place the smallest possible nasal rae with enough length to safely clear the nostril. i do this before scoping to pre-empt the necessity for ramming. perhaps the ramming technique is your problem 🙂

Fair enough. Someday you will have somebody come back to you and say they had an awake FOI and it was the worst experience of their life. It sounds like this guy is maskable. The "easily palpable neck anatomy" comment in the orginal post and the fact that he did not desat through 4 attempts are good indicators of this. With this information are you going to go to sleep with this guy or do it awake? I agree with the asleep option, but the no sedation, he will be fine with just topicalization and kind soothing words option I don't agree with. Also, the "I give a set amount of sedation to anybody that I stick a scope into" answer is one I don't agree with either. That is what I was commenting on earlier. I know that you didn't like the fact that I would give ketamine and fentanyl but in small doses I have found this to work for me in appropriate patients much better than just giving versed.

 

[Noyac]

I know that you didn't like the fact that I would give ketamine and fentanyl but in small doses I have found this to work for me in appropriate patients much better than just giving versed.

I liked it.

Those that think ketamine will cause the pt to salivate too much are using too much ketamine or they haven't used it at all and are relying on what they read.

I'd use anything I wanted to sedate this guy. Even propofol if I needed to. I wouldn't do an awake FOI without sedation unless the pt was super mellow. Sure you could get by without it but why? Even with great topicalization, a little sedation is a good thing. How many times have you given a little sedation and the pt stopped breathing. I can't remember the last time that happened to me.

So obviously everyone here has their own approach.

 

[hoyden]

"Everyone under 80 Y/O gets some sort of sedation"
Seems that this is my "cultural" problem - back home THEY DIDN'T get it....
Except children and people with heart problems - and you know why.
On the other way here - when the stipend depends on patient "satisfaction" I am the "make them happy" guy...
BTW - the awake intubation is called like that because the other way it is -
"not awake intubation"
2win

Really?!? Back at home ( my home) everyone, including the infants were getting IM premedication 40-60 minutes before roll-in into the OR - atropine, meperidine ( yeah, the only one available, fentanyl was only for OR, meperidine not given to kids younger than 2), benadryl, droperidol -and all adults were scheduled to have PO premedication meds a night before the bigger operation ( yes, they were admitted a night before)))))

 

[nap$ter]

Fair enough. Someday you will have somebody come back to you and say they had an awake FOI and it was the worst experience of their life. It sounds like this guy is maskable. The "easily palpable neck anatomy" comment in the orginal post and the fact that he did not desat through 4 attempts are good indicators of this. With this information are you going to go to sleep with this guy or do it awake? I agree with the asleep option, but the no sedation, he will be fine with just topicalization and kind soothing words option I don't agree with. Also, the "I give a set amount of sedation to anybody that I stick a scope into" answer is one I don't agree with either. That is what I was commenting on earlier. I know that you didn't like the fact that I would give ketamine and fentanyl but in small doses I have found this to work for me in appropriate patients much better than just giving versed.

i will never be sued for explaining to a patient the safest procedure, and then doing just that, when i have the patients' best interest in mind. you can, however, be held liable for doing exactly what the patient requests, and killing or maiming the patient. we know better. even if it is the worst experience in a patient's life (which i seriously doubt), it would have been necessary and every reasonable measure to ensure patient comfort would have been undertaken.

i also don't agree with the quote in red - i certainly never said that.

 

[2win]

I liked it.

Those that think ketamine will cause the pt to salivate too much are using too much ketamine or they haven't used it at all and are relying on what they read.

I'd use anything I wanted to sedate this guy. Even propofol if I needed to. I wouldn't do an awake FOI without sedation unless the pt was super mellow. Sure you could get by without it but why? Even with great topicalization, a little sedation is a good thing. How many times have you given a little sedation and the pt stopped breathing. I can't remember the last time that happened to me.

So obviously everyone here has their own approach.

Ketamine is a great choice.
Propofol is great too.
As a risk/reward drug I will chose something that can be reversed. Benzo's are great for that. I still remember my days when I was doing bronchs.
It is working. That's the beauty - in skilled hands you can make it work.

 

[2win]

Really?!? Back at home ( my home) everyone, including the infants were getting IM premedication 40-60 minutes before roll-in into the OR - atropine, meperidine ( yeah, the only one available, fentanyl was only for OR, meperidine not given to kids younger than 2), benadryl, droperidol -and all adults were scheduled to have PO premedication meds a night before the bigger operation ( yes, they were admitted a night before)))))

Yep - tough people there....

 

[lushmd]

Precedex also works nicely in this setting

 

[Planktonmd]

Awake fiberoptic intubation in experienced hands is not a traumatic experience!
The key here is good airway anesthesia, if you know how to do that and you know how to drive a fiberoptic scope, the patient will not have a traumatic experience.

 

[hoyden]

Precedex also works nicely in this setting

yep... except I have never used it and it doen't look like will use soon 🙁

 

[Planktonmd]

Precedex is a nice drug that is looking for an indication!
It's similar to lumbar plexus blocks: nice technique that is looking for an indication.