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    You are going to provide a General Anesthetic on a 30 y.o. female. Case is an outpatient orthopedic procedure. Surgeon requested general rather than regional. Significant medical hx includes BMI ~46, smoker, husband states she snores. Mallampati, 2, FROM, good thryomental distance. You give 2 mg IVP midazolam and go back with the patient. Patient helps move herself onto the OR table and you place monitors and begin to preoxygenate the patient. You have decided to RSI the patient.

    200 mcg Fentanyl
    100 mg Lidocaine
    150 mg Propofol
    140 mg Sux

    Open the mouth, DVL with Mac 4 and grade 1 view. Place the tube, inflate the cuff, attach the circuit, squeeze the bag and nothing. No fog in the tube, no end tidal, nothing.

    What are you thinking? What is your next action?


    Students first (and for a while) please. I will try to stay up on it and continue with what happened next or a post discussing what did happen if we get too far along with the differential.
    This article was originally published in forum thread: Failed intubation? started by BuckeyeRN View original post
    Comments 58 Comments
    1. RAYMAN's Avatar
      RAYMAN -
      Step 1-auscultate the stomach
      Step 2-if no gurgling heard with bagging then take a quick peek with the blade. If you see the tube through the cords then it's either a bronchospasm or mechanical obstruction/mainstem.
    1. BuckeyeRN's Avatar
      BuckeyeRN -
      Ok, lots of great ideas and thoughts. Here is what happened with me.

      I bagged 2 more times while auscultating the lungs on the first bag and stomach on 2nd. Nothing, nada. I then checked all my connections on the circuit and everything was tight. Put the end of the sample line in my mouth and quickly exhaled and it showed up on the monitor as I was putting it back on the circuit. Patient began to desaturate. I checked the balloon and it was spongier than I would like so I added an extra cc or two of air. I then did another quick look with DVL and it was through the chords, one more bag and still nothing, checked the balloon again and to me it felt spongy still so I dropped the balloon and pulled the tube. Placed an oral airway and attempted to bag mask the patient. While I was masking the patient she felt very tight but not exceptionally so for someone of that body habitus. I was getting mist in my mask but still no end tidal and Sp02 still dropping, more rapidly at this time. DVL'd with grade 1 view and placed tube through cords. Inflated the balloon, bagged the patient and still nothing, increased pop-off valve and still nothing. Patient SpO2 is 60s and dropping. Heart rate stable, now what?


      To those who wanted to know what the bag squeeze felt like. It felt very firm, similar to when breaking a laryngospasm with positive pressure.
    1. gaspass3's Avatar
      gaspass3 -
      Is the switch turned to bag, and not on vent? It is usually the obvious things we overlook.

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. ethernaut's Avatar
      ethernaut -
      smoker --> RAD vs mucus plug

      was filter/piece, where ETCO2 tubing attaches to on circuit, blocked?

      "wooden chest" from fentanyl?
    1. Chad's Avatar
      Chad -
      Would want to rule out equipment problem versus patient problem. Quickest method is to remove circuit and manually ventilate with Ambu. Sounds like a stuck exhalation valve or obstructed circuit.
    1. J-Dubya's Avatar
      J-Dubya -
      So, able to mask with mist but zero Co2 - sat 60%. I'd be thinking bronchospasm at this point. Even if there is a technical reason the co2 monitoring is not working, you should be able to mask her sat up. I'd be reaching for some epi - she's young, it won't hurt her.
    1. PaSSiNG GaS's Avatar
      PaSSiNG GaS -
      Turn gas on high and start reaching for epi


      Sent from my iPhone using GasTalk
    1. etherscreen's Avatar
      etherscreen -
      In this situation:

      Rule out machine problem - ventilate with ambu

      Rule out obstructed ett - pass a suction catheter or fiberoptic scope through it.

      If both of these are ruled out, then a patient problem is ruled in.

      Bronchospasam is at the top of my list. Not sure how much volatile agent is going to help if the bronchospsam has created a complete airway obstruction. Is the gas getting where it needs to go? No harm in cranking it, however. I believe that Miller speaks to this point. I'd deepen the anesthetic with propofol. Then I'd be quick to think about epi and steroids. A round of albuterol isn't going to hurt, but then again is it getting where it needs to go?

      Hemodynamics are stable? This makes some sort of mediastinal mass unlikely.
    1. ethernaut's Avatar
      ethernaut -
      I'm sure I'm pointing out the obvious, but steroids won't help in the acute, deteriorating situation. if true bronchospasm, as said, consider epi +/- short-acting beta2 agonist.
    1. notnecessarilyanesthesia's Avatar
      what type of machine was it? on drager fabius machine even if the pop-off is turned to 70cmh20, if you pull straight up on it, it will release and open pop-off. when pop-off is completely turned open, you'll notice that it raises up to this position with a sight gap btw the base of knob and the machine. that being said, i once couldn't ventilate and eventually noticed that the o2 sat cable was stuck in the "gap", which meant popoff was completely open, despite being turned to 70.
    1. notnecessarilyanesthesia's Avatar
      i see now that the bag felt "tight". prob not what was happening

      Quote Originally Posted by notnecessarilyanesthesia View Post
      what type of machine was it? on drager fabius machine even if the pop-off is turned to 70cmh20, if you pull straight up on it, it will release and open pop-off. when pop-off is completely turned open, you'll notice that it raises up to this position with a sight gap btw the base of knob and the machine. that being said, i once couldn't ventilate and eventually noticed that the o2 sat cable was stuck in the "gap", which meant popoff was completely open, despite being turned to 70.
    1. notnecessarilyanesthesia's Avatar
      dysfunctional hme filter?
    1. etherscreen's Avatar
      etherscreen -
      Forgot to add for severe/refractory bronchospasm - IV lido and inhaled ipatroprium.
    1. etherscreen's Avatar
      etherscreen -
      Quote Originally Posted by ethernaut View Post
      I'm sure I'm pointing out the obvious, but steroids won't help in the acute, deteriorating situation. if true bronchospasm, as said, consider epi +/- short-acting beta2 agonist.
      Steroids are a component of many algorithms for severe and/or refractory bronchospasm. Sure they won't work as quickly as epinephrine, but this does not discount their value.
    1. BuckeyeRN's Avatar
      BuckeyeRN -
      Great thoughts so far. Around this point Spo2 continued to drop and I heard beep tones that no one should hear. I had already called for the crash cart in case it was something outside of what I was thinking. I asked for some epi and they couldn't get the crash cart open. I reached for one of the vials in my anesthesia cart and gave the entire thing, as I was pushing it her HR began to drop. Made sure the IV line was wide open. Still no ETCO2, finally after what seemed like eternity as her HR got below 50, it suddenly reversed direction and the HR started climbing, at this point I first noticed an ETCO2 tracing. It was one of the most shark fin looking tracings I have ever seen.

      I cranked the Sevo at this point and did my best to ventilate by hand.

      You now have a patient with Spo2 in the 60s and you are barely able to ventilate. Now what? She's coming back from the Sux and starting to fight you. Next course of action?
    1. Anesthesinator's Avatar
      Anesthesinator -
      It is time to hit the reset button! If the patient is able to breathe on her own, protect her airway, and her vitals are improving then my instinct would be to support her return to her normal baseline where she isn't so close to death. It seems she does better unrelaxed. Extubate if she meets acceptable criteria. Cancel the case (I think it's an elective ortho case) and figure out what the hell happened! My big concern is the shark fin. I think that's bronchoconstriction maybe the sux caused it with the histamine release. I would hold extubation until the waveform normalized. I would not give any histamine releasing drugs such as sux, atracurium, morphine, and administer bronchodilators. If I have to relax then l would chose a safe NMBA like vec or cis. My goal will be to stabilize her bronchoconstriction and get her to the ICU.


      Sent from my iPhone using Tapatalk
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by etherscreen View Post
      Steroids are a component of many algorithms for severe and/or refractory bronchospasm. Sure they won't work as quickly as epinephrine, but this does not discount their value.
      agreed
    1. J-Dubya's Avatar
      J-Dubya -
      You gave the whole amp of Epi IV? I guess if the HR was dropping, why not, but I would have just given either a little bit (like .3) IV or just given it subq. It works really fast subq IME.
    1. deemo21's Avatar
      deemo21 -
      Salbutamol IV? 10mcg/kg to a Max of 500mcg? Otherwise I'm not sure...I'll have to do some more thinking.

      Perhaps Aminophylline? 6 mg/kg then 0.7 mg/kg/hr
    1. JoshCRNA's Avatar
      JoshCRNA -
      Quote Originally Posted by deemo21 View Post
      Salbutamol IV? 10mcg/kg to a Max of 500mcg? Otherwise I'm not sure...I'll have to do some more thinking.

      Perhaps Aminophylline? 6 mg/kg then 0.7 mg/kg/hr
      I don't know about you but where I've done clinicals, these drugs aren't exactly on hand or quickly available...or maybe they are but I'm just not aware.

      In addition to the epi and cranking up sevo, I would give ketamine.