Clinical Case 072: The Difficult Airway that Wasn’t

Today I have another Airway case for you from Dr James DuCanto, M.D. Aurora St. Luke’s Medical Center in Milwaukee, Wisconsin, USA

Here is the case as described by James:  Watch the video here:  JDucanto difficult airway

Middle aged male presents for urgent surgery with multiple medical co-morbidities (on renal transplant list), and multiple indicators of difficult direct laryngoscopy:

1. Obesity/sleep apnea/fat neck
2. Mallampatti 4
3. Thyromental distance 6 cm
4. Neck Range of motion limited to less than 90 degrees.
Plan (A) was thorough BiPAP pre oxygenation followed by DL/VL with moderate to deep sedation (no Succinylcholine of Non-depolarizing muscle relaxants, as mask ventilation predicted to be difficult to impossible based on above data and my clinical intuition).  Plan (B) was an SGA based technique, based on the needs for sedation and topical local anesthetic application.
Difficult pre-O2 period, as light sedation and poor mask fit with tight-fitting mask straps proved a bit problematic until I manually improved the mask fit and performed a light jaw thrust to allow the Oxylator to reach its pressure release setting of 20 cm H2O.  This despite light sedation (fentanyl 20 mcg, hydromorphone 0.2 mg, midazolam 1 mg).
Upon reaching the target pre oxygenation level per gas analyzer (End-tidal O2 88%), deep sedation induced with rapid injection propofol 50 mg in lidocaine.
Direct laryngoscopy grade 2A, Video laryngoscopy grade 1 with the McGrath Mac 3.  Brief pause of tracheal tube at laryngeal opening to allow for the relaxation of vocal cords to permit tracheal tube passage off of a GlideRite stylet.  Small amount of yellow secretions seen during laryngoscopy, but they did not soil airway or impair optics of the McGrath VL scope.
Here are the talking / teaching points James has identified.
1. The use of a combined DL/VL device permitted me to “grade” the DL experience for current and future airway endoscopists, and permitted me the flexibility and safety of an advanced airway tool in the event that the airway was unmanageable by DL.
2. The McGrath Mac laryngoscope is lightweight and allows gentle endoscopy which permits its use during sedated laryngoscopy procedures.  Following the base of tongue with the device into the proper position before force is briefly applied to document the DL grade allowed this procedure under deep sedation.
3. BiPAP preoxygenation contributed to the safety of this procedure.  Passive pre-oxygenation procedures (which are standard operating procedure in the current day and age) require substantial revision when dealing with airways in which difficulty with tracheal intubation are predicted.
Do you have any questions or comments for Dr James DuCanto – leave them on the comments below and get the conversation going.

Difficult intubation deliberation

Last week I posted on a tricky airway requiring AFOI (awake fibre-optic intubation) – see Awake Intubation Procrastination.

I got a bit of correspondence from the readers and a very special reader – Dr James DuCanto, M.D. from Milwaukee, Wisconsin, USA.  (yep, Happy days, the Fonz.. you know the place.)  You will recognize Jim D if you have seen the Emcrit or PHARM blogs – he pops up there with great airway demos on a regular basis.

Jim was keen to show me how he approaches the patient with a predicted “difficult tube” due to poor mouth opening – such as my patient in the above post.

Rather than just describe it – he has sent me (and you) a great demo video of his technique in action.  It is a nice trick – one that might come in handy if you are like me – a very amateur AFOI user, but often in “no-backout” situations. Click below for the multimedia, commentated video:

Recognised Difficult Airway (TMJ) Managed with Oxylator Air-Q and Optical Stylet

Now.  How cool was that – is that not the coolest thing out of Milwaukee since the Fonz?  A purist might say that AFOI is the gold standard, but this is “tiger terrritory” if you are not proficient with a scope and the topicalization involved.

Whilst we are discussing cool stuff (if you are on the nerdy side).  I have to mention my mate Dr Tim (KI Docs) has upgraded his site and gone to a new adress.  He is now at:  (see Blog roll) – add it to your reading list.  Tim is nothing if no interesting, fearless campaigner for rural GPs lot and a major tech, anaesthesia geek.

Tim has just posted on Apps for Airways etc – his own review of a bunch of Apple Apps that come in handy in his practice as a small town GP-anaesthetist.  Check out his reviews – I think I might add a few to my pocket brain.

Amongst the apps was the ANZCA app for all things Anaesthesia – including topicalization of the airway.  I think this might be a way of saving a memory in my brain for the occasional moments when I need o know how to do this.

Dr DuCanto will be answering any questions and giving his time to you all – so watch the video, imagine yourself in your theatre and ask him what you think will be the stumbling block for your practice.  He is a seriously smart, and super nice guy – so get on to the comments and take this opportunity to learn from a master.  Casey


Ultrasound for Epidurals… I ask an expert: Dr Mitch

I have had a few readers ask questions about the use of ultrasound for the difficult epidural – usually in the labour ward context, but we sometimes run into this in the OT for combined spinal-epidural blocks.  Now I  love all things ultrasound – but looking at the literature it is tough to get a read on the utility of US in the often troublesome area of epidurals.  All those bones – can we see anything useful?  So I have asked an expert, and gotten a few handy, practical pointers.

Dr Chris Mitchell is a Consultant Anaesthestist at King Edward  Memorial Hospital for Women in Perth, Western Australia. But Mitch is more than an Anaesthetist – before he went into specialist training Chris was a rural GP-Anaesthetist in NW WA.  In fact my first job after my training in Anaesthesia I actually replaced Chris!

Now onto the meat of the post – here are Chris’s tips in beautifully illustrated form – click here [US for Epidurals]

I think it should be said – epidurals in the labour ward are an elective procedure.  There is a risk : benefit pay off.  If you are increasing the risk side of the equation as a result of a difficult insertion, then you need to discuss that with the patient – so before calling for he US machine I think it is worth a pause to consider if this is worth a try – I am sure that for the occasional operator this technique wil help, but is no magic bullet!

We usually try and avoid the patients with really tough anatomy – if the BMI is over 35 we usually start to strongly consider referral to a larger institution for a whole raft of safety reasons.

Huge thanks to Dr Mitch for his pearls on epidurals and US.  I would love to hear your experiences and if you have any questions for Chris I will pass them along.  Comments please



Clinical Case 048: We Ask an Epidural Expert

This case is an opportunity for us to learn from an expert.  Epidural analgesia in labour can be rewarding and infuriating.  So I have enlisted the help of Dr Roger Browning – Consultant Anaesthetist at Fremantle and King Edward Memorial Hospitals {tertiary maternity centre in WA}.  I put a few questions to Roger based around a real case to see how the expert goes about troubleshooting common epidural problems. Here we go:

26 yo primigravida, induced for postdatism @ 41 weeks.  She is now ~ 6cm dilated with slowish progress.  You have been called to put in an epidural after she has tried nitrous and a dose of IM morphine.  As you arrive she is clearly very distressed with each contraction.  They are coming every 4 minutes on an Oxytocin infusion.  She is otherwise fit and well, normotensive.
Practitioners should use the technique they have learnt and are most familiar with. I would place a lumbar epidural using a 16G tuohy kit and loss of resistance to saline, and thread the catheter in leaving 4-4.5 cm in the space and secure it to her back using a “lockit”, medium tegarderm and surrrounding fixomull dressing for reinforcement. I would aspirate the catheter to check for blood or CSF and then test the catheter with a 7-8 ml injection of bupivacaine 0.125% + fentanyl 5mcg/ml. If there is no major motor block within 5min (ie indicating subdural or intrathecal catheter) I would then give another 5-8ml of solution ie 15ml in total to get initial analgesia.
At KEMH we use bupivacaine 0.0625% + fentanyl 2.5mcg/ml background infusion of 5ml/hr and PCEA 10ml with 20min lockout, via a CADD pump. In a rural hospital (and other metro hospitals like osborne park) I would prescribe intermittent topups: bupivacaine 0.125% + fentanyl 5mcg/ml 10-15ml hourly PRN, for breakthrough bupivacaine 0.25% 5ml hourly prn, rectal pressure pethidine 50mg/5ml hourly prn, and instrumental delivery / suturing ligonocaine 2% + adrenaline 1:20000 4ml + 4ml one dose only.
3 hours later….
You are called by the midwife for help.  She states that the epidural you put in worked great initially, but… now it is not so good.  She hasn’t made much progress up to 8 cm now.  We are still expecting a few hours of pain at best….
You need to assess whether or not you think the epidural cathetter is still in the epidural space. Check the patient’s back & dressing, if the catheter is now less than 3cm in the space, or there is a lot of fluid under the dressing don’t waste time trying more drugs etc, it has come out, take it out and place another epidural. If everything looks ok then carefully titrate in more bupivacaine 0.125% + fentanyl5mcg/ml solution, larger volumes will often “spread further” and tend to be better than small volumes of more concentrated LA. I will give up to another 20-25ml in increments over 10-20min. If this doesn’t work you should probably take it out and place a new epidural catheter.
Our 26 yo primi has made it to fully, but not really descending well.  The CTG trace has been getting ugly…  some decelerations at first, but now it has become flat / unreactive.  The Obs team call you for a Csection.  It is not Cat 1 urgent, but you want to get her ready ASAP.
Before starting an epidural topup for a CS once again you want to be sure the catheter is in the epidural space and it is working. Look at her back is the catheter < 3cm in the space? is there a lot of fluid under the dressing? has it been working well down in labour ward? If the answer is no to any of these you are probably better off taking it out and doing a spinal.  At KEMH to topup a epidural we use lignocaine 2% + adrenaline 1:200000 (which comes in a 20ml ampoule) and fentanyl 50-75mcg. You should aspirate the catheter to check for csf / blood and then give 5ml as a test dose, check for early profound block (?intrathecal) or tachycardia, perioral tingling (?iv). You should titrate in the lignocaine in 5ml increments every 5min, to max of 7mg/kg (in the average female this is around 25ml) checking the block height regularly, aiming for loss of cold sensation to T4 (nipples) and signs of sacral spread also (difficulty lifting legs off the bed). If after the maximal dose you have an inadequate block you should consider doing a CSE or spinal (using a smaller dose than usual as there is a risk of a high spinal) rather than causing local anaesthetic toxicity with even more lignocaine. I often also give pethidine 50mg (personal practice not dept) as it decreases the severity / incidence of shivering.
You give your top-up, get her ready and the Obs team start cutting.  As soon as they hit the peritonela layer she winces and says she feels sick.  A minute later and she is crying in pain – her husband is looking very scared.
And how do you go about making this decision?]  This description suggests she has an inadequate block and you should stop the surgeons before they proceed to making a uterine incision. The critical issue here is that once the surgeons incise the uterus they are commited to continuing, placental perfusion and foetal oxygenation is impaired and maternal haemorrhage starts, the surgeons cannot / should not be asked to stop for 15min whilst you try to “fiddle with your block”! You need to make a decision prior to this point. Clarify with the patient are they feeling pain or merely touch, believe them if they say it is pain. Check the dermatomes with ice and get the surgeons to “check with forceps etc in the surgical field. If the patient has significant pain at the point of peritoneal incision as in this scenario, and the block appears to be obviously inadequate I would err on the side of converting to a GA before then letting the surgery proceed. If you have already “topped up” with a decent volume of lignocaine 2% + adr (ie 15-25ml) and given this time to work (15-30min) it is unlikely that stopping for another 10min and giving another 5-10ml will make it into a working block. Having said that if they have a difficult airway or look high risk for a GA and you think some more time and more drugs will make a difference then it might be worthwhile to persist, this is an individual risk/benefit decision and you need to talk to the patient /surgeon and explain all of these issues. The most common scenario for pain during a caesarean occurs post delivery, is usually only mild, and related to temporary surgical stimulation whilst swabbing high in the abdomen or fiddling with the ovaries etc. Often you can get a patient through this with iv opioids, inhaled N20, some surgical infiltration of LA (beware max dose if you used alot in the epidural) and distraction with the baby! Sometimes you still need to do a GA to allow the surgery to finish though…
OK – that is epidurals through the eyes of an expert.   Big thanks to Dr Browning for taking the time to answer my questions. This is certainly a part of medicine with plenty of art, less science and a lot of inter-individual variation.  I am keen to hear your tricks and techniques.  Let us know on the comments.

Consultation Skills: Intro

Consultation Skills – not the most exciting topic in medicine, but these are essential skills we use every day.  I think most doctors learned the basics in Med School, then went into real-world practice, found some approaches that worked and some that didn’t and ‘evolved’ a style.  My guess is that we opt for what works without thinking about it too hard.  Most of us get by, on average we are nice people and like to help where we can.  Basic communication skills are not too hard to master.  But can we do better?

If done well – good consultation can save you time, make your outcomes and compliance better and you might avoid complaints and even getting sued.  Mostly though – they make the job more fun!

GP training actually spends quite a bit of time and effort in improving one’s consultation skills – though I am not sure how much the other specialties do this?  I have spent a lot of time watching specialists from specialties massacre consults.  To be fair though, there are a lot of great ‘consulters’ out there – some are surgeons.

There is a lot of material out there.  It seems every state has a guru who has written a book on the topic, and some are better than others – though a lot of pop-psychology and idealised rhetoric must be waded through!  So I thought I would enter the fray with a few posts on one of my favourite topics – communication, the doctor-patient relationship and some evidence around this – yes, there is actually evidence!

For me there are two basic types of “consultations” [I use the term to describe any interaction between a doctor and a patient / family].  In true Broome Docs style I have gone for massive simplification as that is how my brain functions.

This is a bit analagous to ventilator strategies for the Crit Care folk out there –

  •  there is the one that is pretty good for most patients, normal people who understand the context and dynamics of the interaction
  • and then there is the strategy I use when I am dealing with abnormal  psycho-dynamics: where the relationship is strained, there is a heavy emotional component, the patient is not playing by normal social rules (read: personality disordered, or just having a really bad day), or sometimes where we just have different agendas / outcomes we are trying to achieve.

So why not just use the first strategy and see how it rolls, then switch if necessary ??  Well, the problem is that if you go with the “normal” strategy you just might get taken for a big ride, find yourself agreeing to all sorts of odd things and getting very frustrated / angry at the patient.  If you recognise you are not in “normal consult” territory – then you can use the other strategy up front and “Own the Consult” – ensure the conversation goes where you need it to, and save your cortisol / hair dye!

Why have I decided to do this?  Well I have been reading a few great books lately and they have inspired me, crystallized my usually random, free-floating ideas into a more coherent order.  Oh, and I have to start teaching a new crop of students in a few weeks and want to start with something that they can use for the next 30 years hopefully!

So here are the proposed titles of a series of posts on Consultation Skills:

  1. The “normal” people strategy – Understand the patient’s point-of-view and prosper
  2. When Agendas Collide – dealing with the difficult patient
  3. The emotional consult – Being Good at Bad News
  4. Dealing with Poor Outcomes: how to run the ‘sorry consult’

I am not an expert and hope to get a conversation going around this topic so we can all learn.  Let me know what you think and comment below.   Casey