Approach to difficult airway scenarios. PACCM fellows core conference Phil Lamberty & Stephanie Maximous 9/9/2016
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1 Approach to difficult airway scenarios PACCM fellows core conference Phil Lamberty & Stephanie Maximous 9/9/2016
2 Case 65yo man with alcoholic cirrhosis p/w faggue. One episode of vomigng at home. Saw some blood. VS: Afebrile, HR 110, BP 90/50, RR 22, SpO2 95 Hgb 6.5 He has a couple more episodes of vomigng with blood streaking in the ED
3 Airway in pagent w hematemesis or other vomigng or hemoptysis What things do you want to consider? What are our prioriges? AspiraGon was the single most common cause of death in peri- intubagon in the NAP4 cohort 4th NaGonal Audit Project of the Royal College of AnaestheGsts.
4 Minimize stomach contents
5 Minimize stomach contents
6 Minimize stomach contents
7 Minimize stomach contents Ultrasound stomach NG decompression Goal is to limit aspiragon risk a_er giving drugs, laying flat SGll preoxygenate and posigon prior to giving drugs Need good bag- mask venglagon technique to limit insufflagng the stomach Koenig et al. Intensive Care Med 2011.
8 What is RSI?
9 To bag or not to bag Gentle bag mask venglagon appears to be OK Weigh the risk of hypoxia vs risk of aspiragon Always use it for rescue El- Orbany and Connolly. Anesth Analg 2010.
10 Cricoid pressure debate Sellick, 1961: no regurgitagon into pharynx by 26 high aspiragon risk pagents Effect not consistently reported in the literature, not validated Nonstandard/ inappropriate applicagon when to apply, how much pressure, untrained, might obstruct view or tube delivery Sellick. Lancet, 1961.
11 Drugs Rapid sequence intubagon: InducGon agent Etomidate 0.3mg/kg TBW Ketamine 1.5mg/kg IBW (dissociagve dosing) Propofol 1.5mg/kg TBW + NMB Succinylcholine 1.5mg/kg TBW Rocuronium 1.2mg/kg IBW Vecuronium 0.15mg/kg IBW Goal is also to limit aspiragon and more vomigng Note that there is no data great data for RSI Neilipovitz and Crosby. Canadian Journal of Anesthesia, 2007.
12 Succ vs Roc Cochrane meta- analysis Succ: Onset 45-60s; DuraGon 6-10min ContraindicaGons: malignant hyperthermia, muscular dystrophy, neuromuscular disease with denervagon, old CVA, rhabdo, old burn, hyperkalemia Benefit: Faster, ok in MG Roc 60-75s; DuraGon 45min Tran et al. Cochrane Database Syst Rev 2015.
13 Method SomeGmes video laryngoscopy/glidescope/ bronchoscope does not work Direct laryngoscopy Always have SUCTION available and working Use biggest tube you can fit in May need to do more procedures (possible endobronchial blocker or bronchoscopic sucgoning any aspirated material)
14 When to secure the airway in vomigng/ hemoptysis? Early vs when they desaturate? It is too late when they are desaturagng, needing to dial up O2 b/c coagulated blood is now obstrucgng the airway
15 AddiGonal techniques for hemoptysis RMSB intubagon if bleeding on the le_ Endobronchial blocker placement AcGvate IR
16 Case 54yo woman with scleroderma and severe PH, listed for lung transplant StarGng to have longer periods of desaturagon on 80L 100% VS: Afeb, HR 99, BP 90/50, RR 35, SpO % on high flow What are you thinking about, concerned about
17 Airway in pagent w hemodynamic risk What things do you want to consider? What are our prioriges?
18 How to not kill the shock pagent by intubagng him/her PLAN AHEAD Consider AWAKE FIBEROPTIC: maintain adrenergic tone ALL sedagves affect pagents in shock NegaGve to posigve pressure effects
19 Pre- intubagon Make the BP HIGH PUSH dose pressors Start drip pressor beforehand Get fluids with pressure bag Have good ACCESS Don t forget IO opgon It s worth it to get the arterial line
20 Push dose pressors
21 Push dose pressors
22 Drugs What s the deal w etomidate? AlternaGves? ALL sedagves will drop the BP if already hemodynamically unstableà adjust your dose Err on the side of LOWER DOSES of sedagve: Ketamine 0.5mg/kg actually augments BP Etomidate dose probably the same And HIGHER DOSES of paralygc: (takes longer, need more) Roc 1.6mg/kg Succ 2mg/kg
23
24 PH/Right heart failure Prepare, prepare, prepare Access and A- line Prepare the push dose pressors Maximize preoxygenagon Assess for any anatomic issues and choose your method carefully (Small mouth? Obese?) Anything else? Prepare inhaled pulmonary vasodilators Epoprostenol vs NO
25 PH physiology in MV
26 ObstrucGve lung disease Beware air trapping, aggressive bagging
27 References El- Orbany M, Connolly LA. Rapid sequence inducgon and intubagon: current controversy. Anesth Analg 2010;110(5): Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of posgntubagon hypotension during emergency airway management. J Crit Care 2012;27(4):417.e9 13. Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubagon in acutely ill pagents: a mulgcentre randomised controlled trial. The Lancet 2009;374(9686): Jung B, Clavieras N, Nougaret S, et al. Effects of etomidate on complicagons related to intubagon and on mortality in sepgc shock pagents treated with hydrocorgsone: a propensity score analysis. Crit Care 2012;16(6):R224. Koenig SJ, LakGcova V, Mayo PH. UGlity of ultrasonography for detecgon of gastric fluid during urgent endotracheal intubagon. Intensive Care Med 2011;37(4): Koerber JP, Roberts GE, Whitaker R, Thorpe CM. VariaGon in rapid sequence inducgon techniques: current pracgce in Wales. Anaesthesia 2009;64(1):54 9. Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically compromised emergency pagents: does ketamine represent the best choice of inducgon agent? Anaesthesia 2009;64(5): Price B, Arthur AO, Brunko M, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubagon in the air medical seung. Am J Emerg Med 2013;31(7): Sellick BA. Cricoid pressure to control regurgitagon of stomach contents during inducgon of anæsthesia. The Lancet 1961;278(7199): Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence inducgon intubagon. Cochrane Database Syst Rev 2015;(10):CD Zed PJ, Abu- Laban RB, Harrison DW. IntubaGng condigons and hemodynamic effects of etomidate for rapid sequence intubagon in the emergency department: an observagonal cohort study. Acad Emerg Med 2006;13(4):
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