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Awake Intubation & LMA Fastrach™ |
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 My name is Cindy and I work as an independent contractor for a CRNA only group. I am working Friday and my call will begin Saturday morning at 0700 and end Sunday morning at 0700. During this shift I am responsible for covering a 48-bed hospital including the busy OB department. I have another CRNA available as my back-up. Friday evening: A patient is admitted for IV antibiotics to treat a flank/back abscess.
he general surgeon says he would like to I and D the abscess on Saturday morning. I have the opportunity to do a pre-op visit before I leave for the night. I walk into the patient’s room and find the nurse having difficulty restarting the infiltrated IV. Our hospital does not have an IV therapy team, so I introduce myself and lend a hand with the IV start. I use this time to develop a rapport with the patient and go over her history. The patient is a 50 year-old Hispanic woman, 63" tall and weighs 375lbs. She has hypertension, sleep apnea, and is an insulin dependent diabetic. I make a phone call to the Saturday back up CRNA to discuss the situation. We decide that an awake intubation would be the safest option and I discuss this with the patient. I tell her to get some sleep and I leave for the evening. I go home and check my email over a Lean Cuisine™. Saturday morning: My colleague and I arrive and go over our plan for the awake intubation. We agree on sedation with midazolam and small doses of propofol, minimal narcotics to avoid respiratory depression and perhaps some ketamine for analgesia. Recognizing that a trans-tracheal block would be extremely difficult due to neck girth, we decide to use a lidocaine nebulizer to provide topical anesthesia. The Fastrach-LMA™ is our first choice for the airway, a light wand is available but may be of limited value due to neck girth. We set up the room with the equipment and make sure an emergency tracheostomy tray is available. I have the classical station playing on Sirius to relax both me and the patient. With our room ready and the surgeon available, we go to the floor to pick up the patient. She is with her daughter. They are very close and both seem to have a unique understanding for the seriousness of the implications of the mother’s health. I go over the anesthetic plan again with both of them. The patient’s daughter holds her mom’s hand tight in her own. When I am done, they embrace. I roll the patient to the operating room. We arrive in the OR. I give the patient IV midazolam. We help the patient move over onto the OR table and position her onto a ramp of bath blankets to optimize her position for intubation, elevating her head and shoulders. She has considerable pain with movement, so we give a small dose of ketamine. She appears calm and cooperative while breathing through a lidocaine nebulizer. I preoxygenate for what seems like forever. I start to titrate in some sevoflurane, then insert a #4 Fastrach LMA™ with minimal resistance. She maintains spontaneous respirations with good end-tidal CO2. I give the patient more IV sedation, increase the sevo concentration, and place the ETT through the LMA. I continue to ventilate the patient and feel relieved that everything is going well. Since this will be a short case, I elect to keep both the Fastrach™ and ETT in place to avoid losing the airway during positioning and prevent problems on emergence. Next, the OR team positions the patient laterally and proceed with the surgery and wound vac placement. At the conclusion of the surgery I remove the ETT and leave the LMA in until the patient is responsive. I take her to the PACU and give report to the RN. Thirty-minutes later, the patient is ready to return to her room. I check on her one final time and then head home...nineteen hours left to go. In retrospect I was not happy with the anesthesia from the nebulized lidocaine. In the future I would consider a topical spray, viscous lidocaine gargle, and topical on the base of tongue. Although a “quick look” with a laryngoscope may have allowed a quicker intubation, the Fastrach™ allowed me to first obtain an airway with the LMA, making a gradual, controlled transition to intubation.
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Comment by masker on 2008-08-18 13:46:43
I have not done an awake intubation since we received our Glidescope. I was(am) very adept at fiberoptic intubation and often would do a "looksy" with topical spray and viscous lidocain. Since we have started using the glidescope, I have not had a need to employ the fiberoptic or rescue LMA. I think this is a significant new weapon in our tool shed and will save countless hours of anxiety. The technique used and the second set of hands was definately the way to go in absence if the glidescope. |
Comment by dennisgun on 2009-01-01 19:55:23
The problem I have with a Glidescope approach is that I must assume you are using muscle relaxants. Although I have heard much praise to the ease of the Glidescope, what if your relaxant results in a can't ventilate situation ? Seems to me with the Glidescope and a muscle relaxant you have "burned a bridge", whereas the awake LMA approach maintained the airway. |
Comment by GUEST on 2009-12-11 00:22:58
The glidescope is a wonderful tool in almost any situation but that is not to say that other adjuncts shouldn't be employed or at least practiced with. I have used all tools mentioned above but would take glidescope over pretty much anything else. The "looksy" can be done with the glidescope while the patient is lightly sedated and spontaneously breathing. A MADgic atomizer with 4% lido can be used to anesthetize the VC just prior to intubation with good results. |
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