Can someone explain this to me: Changing out various airway tubes.

  1. This morbidly obese lady (approx 550 lbs) self-extubated, and anesthesiology was called. Took them a while to re-intubate because when they went in to visualize, all they saw was soft tissue. They wound up having to reintubate with a combi-tube (sp?). The husband was adamant about not going through extreme measures to save his wife's life, and he distinctly said he did not want her trached. At that time, her k-level was around 4, but her INR was around 3.2. So yesterday (about 24 hrs posts reintubation with the combi-tube), the attending MICU doctor and the chief of anesthesiology at my hospital got together and made plans to attempt to reintubate with an ETT. I was the primary nurse for the patient, btw, and spent about 4 hours preparing the patient, getting lab values (k level was around 4.5, INR was around 1.7), ensuring the patient was completely sedated (I placed the pt on 300 mcg/hr of propofol and 8 mg/hr of lorazepam, v/s were wnl, and they even bolused her with about 5 cc's of propofol right before the procedure), and all the doctors were discussing how they would change out the tubes and getting their own equipment together. Then the big wigs of the entire medical center came in. Chief of Anesthesiology of the entire medical center, chief of anesthesiology of the medical school, chief of anesthesiology of the hospital, chief of anesthesiology of ob/gyn, Attending and Professor of MICU. Not sure if I got all the titles correct, but I know this case is about as serious as it gets as far as important people. Then they started the procedure, and it didn't even last maybe 10 minutes! When it was over, I was more baffled about it all. Can someone please explain what happened? I don't understand why they got all these chiefs in here for what looked like a really minor procedure. Sorry for my ignorance.
    Last edit by Diprivan/Vented on Jul 3, '04
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  2. 22 Comments

  3. by   Diprivan/Vented
    Also, why didn't they try to do go in and nasally intubate her, blind. I've seen some anesthesiologists do that, especially with really obese pts. Was it because her INR was so high they didn't want her to bleed? But I would think that you could fix that with blood products pretty quickly and then go in blind because what I heard when they initially tried to reintubate was that they were afraid to cause trauma so they used the combi-tube instead.
  4. by   Lorus
    Quote from Diprivan/Vented
    Was it because her INR was so high they didn't want her to bleed?
    I thought the normal range for an INR was 2.0-3.0 (2.5-3.5 for mechanical heart/valve replacement). So wasn't it a little low during the reintubation (1.7)? Seems like they were more concerned with managing a difficult airway than with the possibility of bleeding.

    Edited to add:

    It seems like the main reason they initially used the combitube in this situation was due to the difficulty in visualizing this patient's airway. The combitube can be placed blindly (and as i understand it, usually ends up in the esophagus) and its true placement can be determined with ventilation attempts, co2 detectors, chest rise, auscultation, sats, etc..
    Last edit by Lorus on Jul 3, '04
  5. by   rjflyn
    To the original poster- did they not try intubation with a fiber optic scope, ie bronchosope. You didnt mention this in your inital post. Reason I mention this is when we call anesthesia they bring one with them because if our docs in our level 1 ED can get it they probably would not without it.

    Rj
  6. by   purplemania
    the MDs might have been there to assure the husband's directions were followed or to support you all in case she was not able to be intubated. Might have been serving as legal witnesses, or on request of the ethics committee. Hope your pt. is ok now.
  7. by   pasgasser
    The reason for such a large ordeal is that if it the original intubation resulted in the pt being intubated with a combitube it can be assumed all other avenues were tried unsuccessfully. Combitubes are a last resort measure.

    The normal INR is 1 in nonanticoagulated pt's. An INR of 1.7 correlates to an INR in the 7th standard deviation from normal and a blind nasal technique would have had a high risk of bleeding. Also with this pt's sedation doses I assume she was not spontaneously ventilating which makes a blind technique very difficult.
  8. by   stevierae
    Kind of surprised they did not try an LMA or Fas-Trach before resorting to the combi-tube. Well, maybe they did--it just does not say. I agree with the supposition that these people were probably members of the hospital ethics committee, or requested to be there by the hospital ethics committee. Or--they could have been there as a learning/teaching experience, or to be able to present the case at grand rounds or write a joint article about it.

    I always wonder why morbidly obese people don't remain intubated overnight post-op, not just after bariatric surgery but for ANY surgical procedure. It seems like they all have sleep apnea and /or hiatal hernias and often run into problems upon extubation in the oR, or they end up needing to be reintubated in the PACU.

    I've seen more than one death on simple post-op tonsillectomies on morbidly obese adults, and wondered if they could have survived if they'd been left intubated overninght, admitted to the ICU, and then extubated under controlled conditions in the ICU, with both anesthesia and RT present, 24 hours post-op.

    Maybe following a similar protocol that they do with severe asthmatics who are intubated and admitted to ICU from the ER after an acute attack, and put on high dose steroids, then weaned off gradually? I am an operating room nurse, not an anesthesia provider, so am interested in the thoughts of those of you who ARE anesthesia providers as to why this wouldn't be prudent.

    Also, question: What is the difference, exactly, (if any) between an LMA and a Fas-Trach?
    Last edit by stevierae on Jul 3, '04
  9. by   Lorus
    Quote from pasgasser
    The reason for such a large ordeal is that if it the original intubation resulted in the pt being intubated with a combitube it can be assumed all other avenues were tried unsuccessfully. Combitubes are a last resort measure.

    The normal INR is 1 in nonanticoagulated pt's. An INR of 1.7 correlates to an INR in the 7th standard deviation from normal and a blind nasal technique would have had a high risk of bleeding. Also with this pt's sedation doses I assume she was not spontaneously ventilating which makes a blind technique very difficult.
    Thank you for this clarification gaspasser. I was thinking that these levels would be low for a patient was receiving anticoagulant therapy. So either way this pt. would be a bleeding risk especially with any inflammation resulting from a recent self-extubation, correct? Why is a blind technique more difficult with a patient who is not spontaneously ventilating? Is it due to the relaxation of the airway? I would imagine the effects of this would be much worse in a 500lb patient.
  10. by   Brenna's Dad
    Pt's need to be spontaneously breathing for blind nasal placement because it is the auscultation of breath sounds through the endotracheal tube that guides your placement.

    Just curious since I didn't read it in your post, but how did they accomplish the reintubation? A combitube takes up a whole lot of room in airway and because of their design, you cannot pass a catheter. This means you have to remove the Combitube before attempting any other airway device. BTW, this is why the procedure was not minor. Morbidly obese, unable to intubate, potential unable to ventilate= BIG BEAL.

    To all the anesthesia people, what would your plan be for reintubating this lady? Without knowing the full extent of her medical history, I'm thinking a fasttrack would be the way to go. Secure the airway to provide some oxygenation while the ETT is secured. If she was able to maintain oxygenation while spontaneously breathing, then I'd go for the fiberscope through a tight mask.
  11. by   athomas91
    if they knew where the combitube was (ie - which port they were ventilating through) - well if it was placed correctly - they could have just used a tube changer...
    as for the post on LMA's - on such a morbidly obese patient - that is a relative contraindication to use - combitube was a better option for protection of the airway.
  12. by   jwk
    Quote from stevierae

    Also, question: What is the difference, exactly, (if any) between an LMA and an LMA Fas-Trach?
    An LMA is what you routinely use in the OR. A Fas-Trach LMA has a permanent bend in it with a metal handle. It's designed for difficult airways, and comes with a special ET tube and "pusher" that fits through the channel in the LMA. You place the LMA, then when everyone's heart rate has come back down and the patients SAO2 has come up, you pass the ET tube through the LMA, confirm proper placement, then use the pusher tube to hold/push the tube in place as the LMA is withdrawn. Attach the ET connector to the tube and you're ready to go. Remember when you're done to keep the ET tube and pusher and re-sterilize them. They are NOT disposable and they are expensive to replace.
  13. by   todabnrn
    If they already have a combitube in place, why did they not use a cook airway exchanger and slide a new tube in over that?????. By utilizing the CAE you WONT lose your airway. Works like a charm....
  14. by   Dixiedi
    Quote from Diprivan/Vented
    This morbidly obese lady (approx 550 lbs) self-extubated, and anesthesiology was called. Took them a while to re-intubate because when they went in to visualize, all they saw was soft tissue. They wound up having to reintubate with a combi-tube (sp?). The husband was adamant about not going through extreme measures to save his wife's life, and he distinctly said he did not want her trached. At that time, her k-level was around 4, but her INR was around 3.2. So yesterday (about 24 hrs posts reintubation with the combi-tube), the attending MICU doctor and the chief of anesthesiology at my hospital got together and made plans to attempt to reintubate with an ETT. I was the primary nurse for the patient, btw, and spent about 4 hours preparing the patient, getting lab values (k level was around 4.5, INR was around 1.7), ensuring the patient was completely sedated (I placed the pt on 300 mcg/hr of propofol and 8 mg/hr of lorazepam, v/s were wnl, and they even bolused her with about 5 cc's of propofol right before the procedure), and all the doctors were discussing how they would change out the tubes and getting their own equipment together. Then the big wigs of the entire medical center came in. Chief of Anesthesiology of the entire medical center, chief of anesthesiology of the medical school, chief of anesthesiology of the hospital, chief of anesthesiology of ob/gyn, Attending and Professor of MICU. Not sure if I got all the titles correct, but I know this case is about as serious as it gets as far as important people. Then they started the procedure, and it didn't even last maybe 10 minutes! When it was over, I was more baffled about it all. Can someone please explain what happened? I don't understand why they got all these chiefs in here for what looked like a really minor procedure. Sorry for my ignorance.
    Ya know, when my 1st husband was in the hospital, dieing. He extubated himself (ETT). He was a DNR at the time, discussed at length with his attending because of our age.
    When a redisdent, in the attendings absense decided to trach him when he extubated himself, I just happened to walk in. 6 months pregnate and not in the soundest of states.
    I whacked that resident with the trach tray, in the nose. My first husband died 22 years ago in the 2nd. I wonder how that womans' husband is feeling now, his orders were not followed. How did she fair with the Tx?
    I haven't worked a unit sisnce shortly after my 1st husband died, found it just too much for too long and LPNs are not generally welcome there anymore so I can not answer the questions about the tube choices, I am interested thought. I do follow (at least I try to) what's going on with updates.
    My comment is more asking a question about the husband. Generally speaking, self extubation on a DNR = do no reintubate as intubation is an extrodinary measure in a non-emergency setting (emergency setting being the ER, OR before a DNR is signed). At least the courts agreed with me on that.

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