• Featured News

  • Cant Bag Uh oh.



    Ok

    You have what appears to be an easy to ventilate patient.

    You take the plastic wrap off the mask thats on your circuit and pre ox, monitors on all is ready.

    You give standard induction drugs. Patient goes apnic as expected.

    Since this time you decided to use rocc and not sux to intubate you decide to ventilate while the roc is setting up.

    But you cannot ventilate! Cant move ANY air at all.

    Now what?
    Comments 27 Comments
    1. JoshCRNA's Avatar
      JoshCRNA -
      Oral airway and two person mask vent first -> still no vent? -> Intubate -> can't? -> call for more help and depending on view and in-the-moment impression of first try either use a different blade or place LMA, while calling for video laryngoscopy and airway cart STAT! -> Can't intubate? -> LMA -> LMA not ventilating? -> possibly different LMA size depending on current O2 sat and impression of first try -> no dice?... for me, last resort to save pt's life is needle cric: 14g angio thru cricothyroid membrane, needle out, 3cc syringe with plunger popped out, 7.0 ETT adapter, jet vent with O2 flush...
    1. dkshrugged's Avatar
      dkshrugged -
      JoshCRNA's answer... then retrograde intubation?
    1. FORANE's Avatar
      FORANE -
      I have been in this situation twice in my 18 years doing this work.

      The first time was for a tumor debulking located just superior to the cords. The patient had a prior history of emergency trach after induction of anesthesia for debulking of the same tumor. I was working in an ACT practice at the time. We planned awake sedated laryngoscopy. I do not remember whet we used for sedation but upon laryngoscopy the patient bucked somewhat. The MDA then gave a few more cc's fentanyl which was soon followed by apnea and desaturation. The tumor acted as a ball valve to prevent air movement during positive pressure ventilation. This was before the glidescope was available. What saved us was intubating with a small ett. I was unable to pass a standard size tube but something like a 5.0 passed.

      The second time is discussed here: http://www.nurse-anesthesia.org/show...nable+intubate

      I like the approach illustrated by Josh. The glidescope, LMA and extra trained hands are your friends which should be called at the first sign of difficulty (which will be prior to induction in most cases where thorough assessment was done). Don't underestimate the significance of an OSA history. Do not use agents with high likelihood of inducing apnea when difficult airway is suspected. Maintaining spontaneous respiration in the known difficult cases is possibly the single best advice I can offer from my experience. Understand that anytime you are outside the OR you are away from the equipment and extra help found in the OR; as such it may be beneficial to consider all cases outside the OR as known difficult cases where maintaining spontaneous respiration is advisable.
    1. ISOSLEEPY's Avatar
      ISOSLEEPY -
      Remove the residual plastic from the mask wrapper that is occluding the the circuit/connector?

      I have had this situation happen once or twice and I decided to intubate and had no problem ventilating, only to find there was a piece of plastic wrapper that had been occulting the circuit.
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by ISOSLEEPY View Post
      Remove the residual plastic from the mask wrapper that is occluding the the circuit/connector?

      I have had this situation happen once or twice and I decided to intubate and had no problem ventilating, only to find there was a piece of plastic wrapper that had been occulting the circuit.
      The circuit was satanic?

      Sent from my SAMSUNG-SM-N900A using Tapatalk
    1. JoshCRNA's Avatar
      JoshCRNA -
      When I was in school, there had recently been a situation at the big trauma hospital there when a provider ran into a legit can't ventilate scenario even after getting the patient intubated. Unfortunately, it led to a bad patient outcome. (I really don't know any more details than that)

      Subsequent investigation found out that they had been shipped faulty Y-piece connectors which did not have the inner lumen plastic punched out. The Y-piece connectors were solid plastic on the inside making it impossible to ventilate through the circuit.

      Moral of the story...do a thorough machine and equipment check to prevent your machine from becoming part of the problem. Of course with a solid Y-piece you're going to pass a high pressure leak test, but testing the ventilator to ensure you can ventilate would have demonstrated a serious problem (although probably hard to figure out without a lot of head scratching...).

      Grabbing an ambu bag and ventilating through a well-placed ETT would have saved the patient's life as well.
    1. My_brain_hurts's Avatar
      My_brain_hurts -
      Never underestimate the value of the "alternate ventilation system" (AMBU BAG).

      As a student, on call, had one of those urgent something or others at 3am. I was always told to check my own circuit, however, I as I was getting drugs, the senior resident/board runner said "I'll get your machine ready" and I said OK. Big lady on the table, no residual lung capacity, I have a good view and intubate quickly but her sats are already in the 80s. I had good view and a could swear on a stack of bibles I saw that tube go through the cords. . . and when I squeeze the bag, *pfffft* no resistence at all, tighten APL all the way, fill the bag, squeeze. *pfffft*, no resistance. My attending asks "is there any chance you aren't in?" and I say "No, I watched it go in. Hand me the Ambu" Aaaaand voila! ventilating like a charm.

      So then I look at the senior resident and said "The one time I don't pressure test my own machine. . . were you guys testing me or something?" and he goes "No! I did test it, it passed, I don't know what happend". Took us a few minutes, but this particular machine had a lovely little tube (can't remember where it was located now. . . too long ago), anyways, it had come loose between the time it had been pressure tested and we got back to room with pt. It had gotten knocked out with equipment movent and stuff. Anyways, we were always taught make sure you have an Ambu in the room as students, but let me tell you that single experience really drove it home. It is the first thing I look for when I go into a room, and I put it where I can get to it. If we hadn't had that Ambu I'd have had to blow into that lady's ETT. . . and I'm not much for mouth to tube ventilation

      My attending later told me I "did good back there, calling for the Ambu bag". Ah, the rare complement in anesthesia school. I'm still not convinced my attending didn't do it on purpose to see what I'd do.

      Never under estimate the importance of the humble Ambu bag, always in the background, there when you need him.
    1. MmacFN's Avatar
      MmacFN -
      Iso

      You are possibly the smartest CRNA i know.

      That is EXACTLY what happened.

      The plastic wrapper was removed but unbeknownst to the CRNA in the room when the anesthesia tech put the mask on the circuit there was a piece of plastic between the hole of the circuit and the actual mask. So no air could get through.

      Unreal!


      Quote Originally Posted by ISOSLEEPY View Post
      Remove the residual plastic from the mask wrapper that is occluding the the circuit/connector?

      I have had this situation happen once or twice and I decided to intubate and had no problem ventilating, only to find there was a piece of plastic wrapper that had been occulting the circuit.
    1. JoshCRNA's Avatar
      JoshCRNA -
      Quote Originally Posted by MmacFN View Post
      Iso

      You are possibly the smartest CRNA i know.

      That is EXACTLY what happened.

      The plastic wrapper was removed but unbeknownst to the CRNA in the room when the anesthesia tech put the mask on the circuit there was a piece of plastic between the hole of the circuit and the actual mask. So no air could get through.

      Unreal!
      HAHA, that's so crazy...
    1. Khaos05's Avatar
      Khaos05 -
      We were given that exact scenario during sim lab...you'll never forget to check that again
    1. FORANE's Avatar
      FORANE -
      Quote Originally Posted by My_brain_hurts View Post
      Never underestimate the value of the "alternate ventilation system" (AMBU BAG).

      I had good view and a could swear on a stack of bibles I saw that tube go through the cords. . . and when I squeeze the bag, *pfffft* no resistence at all, tighten APL all the way, fill the bag, squeeze. *pfffft*, no resistance. Hand me the Ambu" Aaaaand voila! ventilating like a charm.

      So then I look at the senior resident and said "The one time I don't pressure test my own machine. . . were you guys testing me or something?" and he goes "No! I did test it, it passed, I don't know what happend". Took us a few minutes, but this particular machine had a lovely little tube (can't remember where it was located now. . . too long ago), anyways, it had come loose between the time it had been pressure tested and we got back to room with pt. It had gotten knocked out with equipment movent and stuff. Anyways, we were always taught make sure you have an Ambu in the room as students, but let me tell you that single experience really drove it home. It is the first thing I look for when I go into a room, and I put it where I can get to it. If we hadn't had that Ambu I'd have had to blow into that lady's ETT. . . and I'm not much for mouth to tube ventilation


      Never under estimate the importance of the humble Ambu bag, always in the background, there when you need him.
      I had this same thing happen. Only differences were I checked my own machine. After I checked the machine and before I brought the patient to the room, the anesthesia tech changed my soda lime. After I intubated (RSI), bag went flat with no resistance. I stated "I need an ambu bag" MDA said oh no we can figure this out. I flipped the bag/vent lever to vent. The vent bellows went flat. I said again "I need an ambu bag." Sats started dropping. I jumped behind the machine, grabbed an ambu bag, and when I came back to the head the MDA was starting to lean over to give mouth to ett ventilation.
    1. volatilegases's Avatar
      volatilegases -
      Quote Originally Posted by MmacFN View Post
      Iso

      You are possibly the smartest CRNA i know.

      That is EXACTLY what happened.

      The plastic wrapper was removed but unbeknownst to the CRNA in the room when the anesthesia tech put the mask on the circuit there was a piece of plastic between the hole of the circuit and the actual mask. So no air could get through.

      Unreal!
      Ummmmm.... Ouch.
    1. BuckeyeRN's Avatar
      BuckeyeRN -
      Quote Originally Posted by MmacFN View Post
      Iso

      You are possibly the smartest CRNA i know.

      That is EXACTLY what happened.

      The plastic wrapper was removed but unbeknownst to the CRNA in the room when the anesthesia tech put the mask on the circuit there was a piece of plastic between the hole of the circuit and the actual mask. So no air could get through.

      Unreal!

      I have had that happen to me but I noticed it during preoxygenation. If you strive for a good seal and actually noticing your bag inflating/deflating with breaths and seeing end tidal Co2 on your monitor as your preoxygenate/dinitrogenate how would this not be noticed then?
    1. MmacFN's Avatar
      MmacFN -
      If you cannot ventilate a patient the bag stays taught, if the plastic is covering that circuit mask area the result is the same. same with ETCO2. It would totally mimic inability to ventilate as if you had a great seal



      Quote Originally Posted by BuckeyeRN View Post
      I have had that happen to me but I noticed it during preoxygenation. If you strive for a good seal and actually noticing your bag inflating/deflating with breaths and seeing end tidal Co2 on your monitor as your preoxygenate/dinitrogenate how would this not be noticed then?
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by BuckeyeRN View Post
      I have had that happen to me but I noticed it during preoxygenation. If you strive for a good seal and actually noticing your bag inflating/deflating with breaths and seeing end tidal Co2 on your monitor as your preoxygenate/dinitrogenate how would this not be noticed then?
      Exactly. If you did your due diligence before the case, including assuring end tidal before induction, this CANNOT happen.

      Sent from my SAMSUNG-SM-N900A using Tapatalk
    1. MmacFN's Avatar
      MmacFN -
      Oh i see what you are telling me

      So you are saying when you are pre-oxing the pt you hold the seal on (while they have no drugs and are awake) enough to always get ETCO2.

      Good for you, I dont. I sit the mask on their face held in place by the tube tree. Im sure MANY do something similar.

      This was not actually my pt it had happened to a partner of mine before he came to our practice and told us all the story.

      Quote Originally Posted by gaspass3 View Post
      Exactly. If you did your due diligence before the case, including assuring end tidal before induction, this CANNOT happen.

      Sent from my SAMSUNG-SM-N900A using Tapatalk
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by MmacFN View Post
      Oh i see what you are telling me

      So you are saying when you are pre-oxing the pt you hold the seal on (while they have no drugs and are awake) enough to always get ETCO2.

      Good for you, I dont. I sit the mask on their face held in place by the tube tree. Im sure MANY do something similar.

      This was not actually my pt it had happened to a partner of mine before he came to our practice and told us all the story.
      If it was not your case, why would you possibly care if there was criticism of less than ideal technique?

      And if the mask seal is so loose that you cannot even get a Co2 tracing, even a blip or two, your not preoxygenation anything. And your surely aren't denitrogenating anything either. Might as well just induce with cannula and call it a day. And while we are at it, your patients get induced without any pre - med of any kind? Really? Seems draconian to me. Mine have Versed and Narcotic on board and most don't seem to mind the mask at all. You should try it.

      Sent from my SAMSUNG-SM-N900A using Tapatalk
    1. MmacFN's Avatar
      MmacFN -
      Are you implying something?

      No it was not my case, but the individual is my friend and an excellent CRNA.

      Suggesting that not getting an ETCO2 tracing because of a loose mask means they are not getting pre ox'd ignores physics. Is there entrained room air? Sure, is it clinically relevant on the vast majority of patients, absolutely not. I can even calculate it out for you of you like.

      Premedication such as versed isnt induction. I have no idea what you are referring to exactly. However you know as well as i do that many patients are not appropriate for pre medication. I dont give versed to 80 y/o patients not on benzos.

      This was intended as a learning case so people know to be aware this can happen. For some reason you are turning it into some sortof weird attack. Why i have no idea.

      Quote Originally Posted by gaspass3 View Post
      If it was not your case, why would you possibly care if there was criticism of less than ideal technique?

      And if the mask seal is so loose that you cannot even get a Co2 tracing, even a blip or two, your not preoxygenation anything. And your surely aren't denitrogenating anything either. Might as well just induce with cannula and call it a day. And while we are at it, your patients get induced without any pre - med of any kind? Really? Seems draconian to me. Mine have Versed and Narcotic on board and most don't seem to mind the mask at all. You should try it.

      Sent from my SAMSUNG-SM-N900A using Tapatalk
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by MmacFN View Post

      Good for you, I dont. I sit the mask on their face held in place by the tube tree. Im sure MANY do something similar.

      .
      Yup....unless conditions dictate otherwise...
    1. ISOSLEEPY's Avatar
      ISOSLEEPY -
      Quote Originally Posted by RAYMAN View Post
      Yup....unless conditions dictate otherwise...
      +1