Happy Holidays SDN Anesthesiologists #Case_05

[MirrorTodd]

Basic question. So let’s say we did the inhalation induction and patient is still spontaneously breathing but the mouth is still too rigid to open, so you decide to give roc. Is there a part that we are still rolling the dice that roc will work to open her mouth? Giving roc in a closed mouth can make her obstruct with tongue/ soft tissue rolling back after muscle relaxation to make her difficult to mask? I feel like this whole situation is predicated in that we have to be 100% sure that roc will relieve her jaw rigidity. Even with mask induction getting her deep enough she can obstruct too and then lead to difficult ventilation and intubation. Personally given all that I would have done awake foi nasal as my first attempt. If in a place without fiber optic, I would do inhalational and ketamine. If that didn’t work I’d do roc and hope it opens the mouth. And with all this having colleague ready for surgical airway. My main goal is airway so would not to burn bridges by maintaining spontaneous ventilation, secondary goal would be maintaining her CPP. Keeping a close eye on BP. Thoughts?

You could throw in a nasal trumpet if you needed to mask but she's obstructing with her tongue. Not foolproof, but could help in the situation of difficult mask, obviously just suction the NG tube and then pull it. It's not needed right now and you could just throw in an OG for the surgery. Granted equipment may not be 100% available in places outside the US like Iraq and even then there may be a lot of pressure on not using extra equipment just because one can.

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[DrAmir0078]

Basic question. So let’s say we did the inhalation induction and patient is still spontaneously breathing but the mouth is still too rigid to open, so you decide to give roc. Is there a part that we are still rolling the dice that roc will work to open her mouth? Giving roc in a closed mouth can make her obstruct with tongue/ soft tissue rolling back after muscle relaxation to make her difficult to mask? I feel like this whole situation is predicated in that we have to be 100% sure that roc will relieve her jaw rigidity.

That is absolutely the case, Sevoflurane alone would sleep the patient - with MAC intubation (if normal no jaw issue) would at least open any mouth except closing mouth like her; here I decided to give Propofol and it is in literature (I believe) have some relaxation effect - (correct me if I am wrong). I believe you could imagine the situation, and I am not defending Propofol magic effect, but it is truly worked for me and let her mouth opened and I could go with ease to see her larynx and the vocal cords and they were partially opened, and I could do intubation, but now I am realizing every time I am writing or aka explaining and finding my mistakes, like if I intubated her before muscle relaxation, that would make her (if she didn't sleep properly) cough on the tube and would increase her intra-abdominal pressure jeopardizing aspiration - right? But I gave the muscle relaxants and her tongue rolled back and then (Thanks I gave her good preoxygenation) I tried to manipulate the tongue by my fingers and then mac blade - imagine if I didn't act fast, it could've faced an obstructed airway (honestly, I didn't ventilated her by mask in this part - my aim is to relieve the obstruction "if any" of this tongue) !
But the question, why with propofol - the tongue was normally located and the mouth was opened with ease? and then Why with muscle relaxants the tongue rolled to the back like shrunk down!

Personally given all that I would have done awake foi nasal as my first attempt. If in a place without fiber optic, I would do inhalational and ketamine. If that didn’t work I’d do roc and hope it opens the mouth. And with all this having colleague ready for surgical airway. My main goal is airway so would not to burn bridges by maintaining spontaneous ventilation, secondary goal would be maintaining her CPP. Keeping a close eye on BP. Thoughts?

This is good plan, awake Fiberoptic first (by the way - an NG tube was in, I think doesn't matter right? you can use the other nostril) - then you said next if didn't work, a Ketamine + inhalational (I did Propofol - so my question - do you have problems with propofol induction?) and as of Ketamine - we are concerned of ICP (but digging literatures and articles said in low analgesic doses with all other induction agents, there is no significant increase in the ICP ...) and again "we" still fear using it, and I would love to overcome this fear and use it the Ketamine, as well as the brave muscle relaxants the sux (succinylcholine) !

Back to your last two lines - are you against intubating a patient who is spontaneously breathing on propofol / inhalation (fearing a spike in sympathetic responses or ICP) - so how about what basic knowledge we studied in the first year of what is called Mac intubation (isn't able to abolish the sympathetic response to intubation - prior to it Mac Bar 1.5 ?)
What do you think?

 

[DrAmir0078]

You could throw in a nasal trumpet if you needed to mask but she's obstructing with her tongue. Not foolproof, but could help in the situation of difficult mask, obviously just suction the NG tube and then pull it. It's not needed right now and you could just throw in an OG for the surgery. Granted equipment may not be 100% available in places outside the US like Iraq and even then there may be a lot of pressure on not using extra equipment just because one can.

A question for you Todd !
In case of a patient requires RSI - he is already having an NG tube !
What do you prefer? suction first and do RSI (keeping the NG in) or remove the NG and do RSI - both with BURP ?
Thanks

 

[deleted162650]

A question for you Todd !
In case of a patient requires RSI - he is already having an NG tube !
What do you prefer? suction first and do RSI (keeping the NG in) or remove the NG and do RSI - both with BURP ?
Thanks

Keep it in. Keep it to suction. Elevate head of bed. Cricoid pressure and BURP are not the same thing.

 

[deleted875186]

Seems like your main concern was securing the airway, but you didn’t clearly have a plan B if you couldn’t DL the patient. Plan B would be fiberoptic nasal, fiberoptic oral, video laryngoscope, etc. From your preoperatively assessment, I’m not sure why she had limited mouth opening, but otherwise no risk factors for difficult mask ventilation, so I would have done a traditional IV induction with prop and roc.

You thought roc would relax the jaw and help you (almost always true), but suggamadex is not available and no plan B for intubation was available. That is the concern, what happens if you can’t open the jaw to intubate after rocuronium. I would be fine giving rocuronium if you told me you took over breathing and she was easy to ventilate, or you were able to slip in an oral airway or a nasal airway and were confident you could ventilate, than go ahead and give the muscle relaxant, you’ve proved you can ventilate her.

 

[DrAmir0078]

Keep it in. Keep it to suction. Elevate head of bed. Cricoid pressure and BURP are not the same thing.

Yes, BURP (Backwards, Upwards, Rightwards Pressure), my mistake, it confuses me with cricoid pressure (20-40 newton) [2-4 kg] pressure like !
Alright, I always like reversed trendelenburg when I do RSI ! - But to keep it always in suction? interesting Salty !

 

[Katheudontas parateroumen]

That is absolutely the case, Sevoflurane alone would sleep the patient - with MAC intubation (if normal no jaw issue) would at least open any mouth except closing mouth like her; here I decided to give Propofol and it is in literature (I believe) have some relaxation effect - (correct me if I am wrong). I believe you could imagine the situation, and I am not defending Propofol magic effect, but it is truly worked for me and let her mouth opened and I could go with ease to see her larynx and the vocal cords and they were partially opened, and I could do intubation, but now I am realizing every time I am writing or aka explaining and finding my mistakes, like if I intubated her before muscle relaxation, that would make her (if she didn't sleep properly) cough on the tube and would increase her intra-abdominal pressure jeopardizing aspiration - right? But I gave the muscle relaxants and her tongue rolled back and then (Thanks I gave her good preoxygenation) I tried to manipulate the tongue by my fingers and then mac blade - imagine if I didn't act fast, it could've faced an obstructed airway (honestly, I didn't ventilated her by mask in this part - my aim is to relieve the obstruction "if any" of this tongue) !
But the question, why with propofol - the tongue was normally located and the mouth was opened with ease? and then Why with muscle relaxants the tongue rolled to the back like shrunk down!


This is good plan, awake Fiberoptic first (by the way - an NG tube was in, I think doesn't matter right? you can use the other nostril) - then you said next if didn't work, a Ketamine + inhalational (I did Propofol - so my question - do you have problems with propofol induction?) and as of Ketamine - we are concerned of ICP (but digging literatures and articles said in low analgesic doses with all other induction agents, there is no significant increase in the ICP ...) and again "we" still fear using it, and I would love to overcome this fear and use it the Ketamine, as well as the brave muscle relaxants the sux (succinylcholine) !

Back to your last two lines - are you against intubating a patient who is spontaneously breathing on propofol / inhalation (fearing a spike in sympathetic responses or ICP) - so how about what basic knowledge we studied in the first year of what is called Mac intubation (isn't able to abolish the sympathetic response to intubation - prior to it Mac Bar 1.5 ?)
What do you think?

Good questions. In my option, airway is more important than the CPP/ICP concerns for this patient. Therefore, I’d keep ventilation as my main goal. Ketamine has less respiratory effects than propofol and could achieve some relaxation as well. Worth the try if I was in that situation. I might be criticized for saying this by reading the above, but propofol well titrated to see if the jaw opens is ok, but you have less margin of error and less of a backup plan IMO. As far as MAC BAR you actually have to give enough time to reach BAR several minutes at 1.5 MAC to have the effect. Also MAC is to surgical stimulus by definition if I remember. Laryngeal manipulation may actually require more MAC.

 

[DrAmir0078]

Good questions. In my option, airway is more important than the CPP/ICP concerns for this patient. Therefore, I’d keep ventilation as my main goal. Ketamine has less respiratory effects than propofol and could achieve some relaxation as well. Worth the try if I was in that situation. I might be criticized for saying this by reading the above, but propofol well titrated to see if the jaw opens is ok, but you have less margin of error and less of a backup plan IMO. As far as MAC BAR you actually have to give enough time to reach BAR several minutes at 1.5 MAC to have the effect. Also MAC is to surgical stimulus by definition if I remember. Laryngeal manipulation may actually require more MAC.

Yup, MAC intubation is double MAC !
Thanks for the explanation and I liked the "less margin" !
Okay, will try Ketamine, as now, I am sure it won't elevate the ICP !

 

[MirrorTodd]

A question for you Todd !
In case of a patient requires RSI - he is already having an NG tube !
What do you prefer? suction first and do RSI (keeping the NG in) or remove the NG and do RSI - both with BURP ?
Thanks

I would say it depends. It's probably better to keep things simple. If there's a tube someplace in the pt, leave it alone unless it is really messing you up. If you can get a good mask seal and preoxygenate with it still in, then by all means keep it to suction and leave it in. It'll at least tell you where not to put the tube.
Also depends on the reason for it. Did she eat 2 hours ago and now they're trying to suction all that out? Or has it been in for a coupla days and the pt has been npo since then? If I couldn't get a good mask seal, I'd probably pull it and suction on the way out. And then preoxygenate appropriately.

How concerned were you about her her aspiration risk? Was the rsi purely for aspiration prevention or because this was an emergency surgery?

 

[coffeebythelake]

In my option, airway is more important than the CPP/ICP concerns for this patient.

What good is getting the tube in if the patient ICP spikes majorly in thr process and they herniated? You would have successfully intubated a dead patient.

I know some people here suggested AFOI but i think that is a BAD idea. If elevated ICP was a major concern this patient should NOT get an awake technique period. INDUCE them, ideally with muscle relaxant by RSI, have your difficult airway tools around, and if very worried about thr airway have a surgeon with a scalpel ready to cut the neck.

 

[deleted162650]

But to keep it always in suction?

Yes, why would you not keep it to suction?

There are 2 things you are trying to avoid when you do an RSI. One is active vomiting, and the other is passive regurgitation.

Preventing active vomiting is easy - give muscle relaxant. The patient can't vomit if they are paralyzed. That's why you give either sux or high-dose roc - AND GIVE IT TIME TO WORK. The best way to end up with a face full of gastric contents is to stick a blade and tube into the posterior pharynx before the patient is adequately paralyzed.

Preventing passive regurgitation requires keeping the pressure in the stomach less that the pressure in the esophagus and pharynx. One way is to elevate the head of the bed - let gravity be your friend. The other way is to maintain suction in the stomach. Keep that negative pressure gradient in place as best you can.

 

[DrAmir0078]

I would say it depends. It's probably better to keep things simple. If there's a tube someplace in the pt, leave it alone unless it is really messing you up. If you can get a good mask seal and preoxygenate with it still in, then by all means keep it to suction and leave it in. It'll at least tell you where not to put the tube.
Also depends on the reason for it. Did she eat 2 hours ago and now they're trying to suction all that out? Or has it been in for a coupla days and the pt has been npo since then? If I couldn't get a good mask seal, I'd probably pull it and suction on the way out. And then preoxygenate appropriately.

How concerned were you about her her aspiration risk? Was the rsi purely for aspiration prevention or because this was an emergency surgery?

Good explanation too.
I was concerned of course about her aspiration risk, I mentioned that I did suction of the tube prior to my mask ventilation to see what's going on and I saw as I mentioned that dark yellow greenish pure color fluid with frothy like secretion, and I couldn't complete the suction - it stays in the tube and I asked the neuro resident and he said they were preparing her for this operation - that means I can guarantee the fasting !
But as you remember from my thread, I wasn't doing RSI for her, because I started with Sevo then Propofol then rocuronium (I did suction at the beginning), and I said I had some leaks while fitting the mask - I used QuadraLite mask and it helps me a lot, better than other masks around me. However, my concern was more about airways, since she got NG in place and I did suction !
Thanks

 

[DrAmir0078]

Yes, why would you not keep it to suction?

There are 2 things you are trying to avoid when you do an RSI. One is active vomiting, and the other is passive regurgitation.

Preventing active vomiting is easy - give muscle relaxant. The patient can't vomit if they are paralyzed. That's why you give either sux or high-dose roc - AND GIVE IT TIME TO WORK. The best way to end up with a face full of gastric contents is to stick a blade and tube into the posterior pharynx before the patient is adequately paralyzed.

Preventing passive regurgitation requires keeping the pressure in the stomach less that the pressure in the esophagus and pharynx. One way is to elevate the head of the bed - let gravity be your friend. The other way is to maintain suction in the stomach. Keep that negative pressure gradient in place as best you can.

What Pearls Dr SaltyDog !
I got it right about active vs passive and with the position and gravity friend - this comment is a sticky note in my brain now !
I had read about the pressure of the sphincter won't exceed 25 cmH2O because it will open the cardiac esophageal sphincter and infilate the stomach and by this way might aid dangerously into aspiration ! (So, I always monitor my peak airway pressure on monitor while doing mask bag ventilation - am I right? or have been again confused Dr SaltyDog?)
Regarding the continuing suction - our suction machines are really (I hope no one can hear us) bad functioning and I can't trust it (over and over use - but always new set and mouth piece but as a machine is very bad), and I fear it sucks more that can harm the stomach mucosa (I feel it is silly, but I do not trust our suction machines) !

 

[deleted162650]

I had read about the pressure of the sphincter won't exceed 25 cmH2O because it will open the cardiac esophageal sphincter and infilate the stomach and by this way might aid dangerously into aspiration ! (So, I always monitor my peak airway pressure on monitor while doing mask bag ventilation

Yes, this is the classic teaching, and is the reason you DO NOT ventilate at all for a true RSI.

For a routine induction, just set the pop-off (APL) valve at 20 so you can’t generate enough pressure to inflate the stomach.

 

[deleted162650]

What Pearls Dr SaltyDog !

They call me “The Oyster.”

 

[DrAmir0078]

They call me “The Oyster.”

The Pearl's Keeper !

 

[pgg]

Welcome back Amir.

Just one thing to add, may have been mentioned already. Be careful with these inhalation / spontaneous ventilation inductions in patients with ICP issues. A little hypoventilation and obstruction can go a long way toward CO2 retention and ICP increases.


Others - please no sniping at each other in this thread. Let's stay on topic with discussing his case. There's a place for frank feedback and tough love but not for rehashing previous personal disagreements.

 

[gh72]

She had surgery 2 weeks ago. What was her airway like then?

 

[DrAmir0078]

Welcome back Amir.

Just one thing to add, may have been mentioned already. Be careful with these inhalation / spontaneous ventilation inductions in patients with ICP issues. A little hypoventilation and obstruction can go a long way toward CO2 retention and ICP increases.

Thanks Dr pgg, it has been a year already !
That is a very valuable explanation that I missed it, and it is a truly hidden gem, yes Hypoventilation / CO2 retention (especially in my case where I don't have a capnography handy), will make the ICP worsening if my priority was ICP !
So, no matter her O2 sat was kept 100%, but still I do not have a tool to monitor CO2 end tidal, so RSI is mandatory here with Ketamine (I can see why you prefer it now over propofol, because the latter induces apnea and hypopnea - CO2 retention!) - beside using Ketamine won't elevate ICP (in analgesic doses), so RSI (Ketamine + High dose roc (if I have sugammadex) but can use Sux (which is Okay I believe from my understanding, it can elevate the ICP briefly and still better choice if there is no contraindication!) am I right Dr pgg ?
I asked my colleagues, and they also said "we are still concerned that Ketamine or Sux increase ICP" - and I provided them with a summary of this discussion and also this article Rapid Sequence Intubation in Traumatic Brain-injured Adults (I hope it has valuable info too)
I truly want to stand on a solid ground regarding Ketamine and Sux (we have limited drugs you know Dr pgg)
Many thanks !

 

[DrAmir0078]

She had surgery 2 weeks ago. What was her airway like then?

Yes, she had !
I didn't see any special notes from Anesthesia Team regarding the airways, and if there is one, I would read it in the patient chart!
But her status was worsening because of this blocked shunt over the time !

 

[vector2]

Yes, she had !
I didn't see any special notes from Anesthesia Team regarding the airways, and if there is one, I would read it in the patient chart!
But her status was worsening because of this blocked shunt over the time !

The anesthetic record, regardless of whether it is paper or electronic, should always include

1. the details of the pre-anesthetic airway evaluation (mallampati, dental, neck range of motion, thyromental distance etc)

2.. Whether bag-mask ventilation was easy if it was attempted, and if an oral or nasal airway was required

3. The blade used for intubation, ett size, cormack lehane grade, number of attempts, whether it was successful, any accessories used (bougie), and how ETT position was confirmed

 

[DrAmir0078]

The anesthetic record, regardless of whether it is paper or electronic, should always include

1. the details of the pre-anesthetic airway evaluation (mallampati, dental, neck range of motion, thyromental distance etc)

2.. Whether bag-mask ventilation was easy if it was attempted, and if an oral or nasal airway was required

3. The blade used for intubation, ett size, cormack lehane grade, number of attempts, whether it was successful, any accessories used (bougie), and how ETT position was confirmed

Hello Vector2
Yes, we encourage to write the info on patient chart and we have this chart and it was made by a special committee of Anesthesiologists at the Ministry of Health, when I started my residency I scanned it and kept it!
It is mandatory, but sometimes we use extra paper to write notes by hand without going to the detailed Anesthesia chart !
Yes, I am in Iraq, a developing Country, and we had lots of obstacles - we are surviving and keep moving !

 

[deleted162650]

RSI is mandatory here with Ketamine (I can see why you prefer it now over propofol, because the latter induces apnea and hypopnea - CO2 retention!) - beside using Ketamine won't elevate ICP (in analgesic doses), so RSI (Ketamine + High dose roc (if I have sugammadex) but can use Sux (which is Okay I believe from my understanding, it can elevate the ICP briefly and still better choice if there is no contraindication!)

Using ketamine for RSI in this situation really doesn’t make any sense. Why are you concerned if your induction agent will cause apnea when you are giving a paralytic immediately afterwards??

I think you are getting a little too caught up in the details. Instead focus on what your goals and priorities are for the given situation - then work backwards to figure out what techniques and drugs will best allow you to achieve those goals and priorities.

Keep in mind that sometimes you may be dealing with multiple priorities that are at odds with one another - in that case, you have to pick which one is the bigger priority.

Also keep in mind that not everyone will use the same tools/techniques to achieve the same goal. In anesthesia there is almost always more than one right way. But, there is also most certainly a wrong way.

 

[DrAmir0078]

Using ketamine for RSI in this situation really doesn’t make any sense. Why are you concerned if your induction agent will cause apnea when you are giving a paralytic immediately afterwards??

I think you are getting a little too caught up in the details. Instead focus on what your goals and priorities are for the given situation - then work backwards to figure out what techniques and drugs will best allow you to achieve those goals and priorities.

Keep in mind that sometimes you may be dealing with multiple priorities that are at odds with one another - in that case, you have to pick which one is the bigger priority.

Also keep in mind that not everyone will use the same tools/techniques to achieve the same goal. In anesthesia there is almost always more than one right way. But, there is also most certainly a wrong way.

Yes, it sounds that I was drowning in details, and I was just talking to my colleague too and we are saying the procedure of giving the induction agent + paralytics won't cost more than 2 minutes and then rapid intubation then ventilator (hoping no difficult intubation scenario), especially if I don't have Capnography, but it seems also reasonable without it makes it difficult to judge ! (lots of details indeed)

 

[Hork Bajir]

For the trainees reading this thread: keeping someone breathing spontaneously while still getting them deep enough during our induction is not as easy as you might think. Volatile, ketamine, etc can all make a patient apneic. Sure, those things are better than propofol or opioids, but if you don’t believe me, for your next elective case where the patient is appropriately fasted, do an inhalational induction with 8% sevo. At some point you almost always need to do a jaw thrust, place an oral airway, or assist with positive pressure ventilation. In order to actually keep someone fully spontaneous while still inducing a deep enough plane of general anesthesia to tolerate airway manipulation, it requires a not insignificant amount of skill and PATIENCE.

For inhalational inductions (or the use of volatile in general), you ought to familiar with the concept of time constants. If you’re not, look it up (I think Open Anesthesia has a thing about it) and consider what it means with respect to what the patient’s brain is “seeing” even though your expired sevo says 4%.

 

[DrAmir0078]

For the trainees reading this thread: keeping someone breathing spontaneously while still getting them deep enough during our induction is not as easy as you might think. Volatile, ketamine, etc can all make a patient apneic. Sure, those things are better than propofol or opioids, but if you don’t believe me, for your next elective case where the patient is appropriately fasted, do an inhalational induction with 8% sevo. At some point you almost always need to do a jaw thrust, place an oral airway, or assist with positive pressure ventilation. In order to actually keep someone fully spontaneous while still inducing a deep enough plane of general anesthesia to tolerate airway manipulation, it requires a not insignificant amount of skill and PATIENCE.

For inhalational inductions (or the use of volatile in general), you ought to familiar with the concept of time constants. If you’re not, look it up (I think Open Anesthesia has a thing about it) and consider what it means with respect to what the patient’s brain is “seeing” even though your expired sevo says 4%.

Thanks a lot for the clarification, I had enjoyed every single word in it from all of you - honesly I went to openAnethesia and I found it Overview of Anesthestic Techniques (Anesthesia Text) it is amazingly described and that means what I did with 4% wasn't enough too (although, I was thinking it is double the Mac dialer 4%/Mac Sevo 1.8 = 2.2 Mac delivered, I learned it here from the comment posts in my previous post "Ain't silly question"), so that now you are answering exactly what happened, it didn't work to bring her jaw down, and I used Propofol and within less than a minute, I had the jaw down, looked it at the vocal cord and then gave MR and then with some difficulties I could intubate !
I am really thankful and I am not always justifying that I am from Iraq (having limited resources), but I am so sure that such threads is of interest even to many residents in anesthesia around the globe, and I hope it will make them discussing and enlightening their horizons of thinking from the pearls you are providing us !
For me, and to be honest, I feel this forum as my second Home to write in free style and I accept all the comments, and very tolerant.
I am so thankful to all of you and wherever you are now !

 

[gh72]

My point was that if she was an easy intubation 2 weeks ago, unless something has drastically changed with her airway, she is probably still an easy intubation, no matter what her neurological status changes were. Your anesthetic records look fine, but if your colleague didn't fill it out, or you didn't read it, that's a problem.

 

[DrAmir0078]

"If it was easy to intubate, it is easy to intubate until proven otherwise" - gotcha !

My point was that if she was an easy intubation 2 weeks ago, unless something has drastically changed with her airway, she is probably still an easy intubation, no matter what her neurological status changes were. Your anesthetic records look fine, but if your colleague didn't fill it out, or you didn't read it, that's a problem.