intubation of morbidly obese patients--have tips?

  1. I'm encountering a huge number of obese patients for gastric bypass--Would love any tips, tricks or hints on what you do to increase your success with intubations of these patients.
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  2. 17 Comments

  3. by   athomas91
    position, position, position......
    and of course by your exam - you will (hopefully) have some idea how hard they will be...
    however - position is key - (for me - in my limited experience)
  4. by   deepz
    Quote from gugal
    I'm encountering a huge number of obese patients .....
    That's a (non-PC) joke ... right? Huge number?

    For starters, I'd advise using the short-handled laryngoscope. Less prone to hang up on obese breasts, chest, etc. Position them semi-sitting if you can.

    What else?..........
  5. by   NCgirl
    I was gonna say the same as deepz, try using the short handle commonly used in OB. This is an issue I'm also trying to figure out!
  6. by   gaspassah
    try some reverse trendelenburg with the head of the table lowered a litte. also ramp and sniff.
    d
  7. by   yoga crna
    I do not have the name of the device, but I read somewhere that there is a wedge that is placed under the patient's head and upper chest. Apparently, it hyperextends the head and keeps the chest out of the intubating field. Maybe someone has more information. Maybe a firm knee wedge could be used.

    In my days of doing these cases, I did blind nasal intubations. It is tricky. but a great technique to learn.
  8. by   suzanne4
    In many of these cases where I have been the circulator, the patient was an awake intubation, many times nasally, and in a semi-sitting position. Found this done at several different facilities this way and with usually good results.
  9. by   J.L.Seagal
    Suzanne and Yoga...I was wondering if you could elaborate more on blindly nasally intubating someone who is awake. Instinctively, this sounds like a very uncomfortable procedure to me. Would you give some kind of sedation before performing this procedure? What drug would be optimal for a procedure that requires the pt's cooperation?

    How do you talk a pt. through a procedure like this? Just HOW do you talk a pt. into "inhaling" an ET tube????? Wouldn't this at least trigger a gag reflex? I'm not sure what the incidence of getting the tube into the esophagus vs. the trachea is, but how in the heck do you talk the patient into giving the procedure another shot when the tube just went down the wrong way?
    Although I have shadowed CRNAs before applying to school (and I realize I have A LOT to learn), I have never seen this procedure performed nor did the subject come up.

    I am intrigued by this and would love to hear your explanations and opinions on this procedure. Thanks!
  10. by   Brenna's Dad
    Local anesthetic allows all awake procedures to be done.
  11. by   suzanne4
    Quote from J.L.Seagal
    Suzanne and Yoga...I was wondering if you could elaborate more on blindly nasally intubating someone who is awake. Instinctively, this sounds like a very uncomfortable procedure to me. Would you give some kind of sedation before performing this procedure? What drug would be optimal for a procedure that requires the pt's cooperation?

    How do you talk a pt. through a procedure like this? Just HOW do you talk a pt. into "inhaling" an ET tube????? Wouldn't this at least trigger a gag reflex? I'm not sure what the incidence of getting the tube into the esophagus vs. the trachea is, but how in the heck do you talk the patient into giving the procedure another shot when the tube just went down the wrong way?
    Although I have shadowed CRNAs before applying to school (and I realize I have A LOT to learn), I have never seen this procedure performed nor did the subject come up.

    I am intrigued by this and would love to hear your explanations and opinions on this procedure. Thanks!
    Cetacaine spray or something similar. It really isn't any different than trying to put a large Ewald tube in a patient in the ER, or a gastroscopy tube for an EGD in endoscopy. Also, a quiet relaxing voice helps quite a bit. Think of inserting an NGT into an awake patient, you have them tuck their chin to their chest to get into the esophagus, with this tube it isn't much larger than a #18 Salem sump.
    Hope that this helps............................
  12. by   Tenesma
    it is a bit different from NGT/OGT as endotracheal is far more stimulating - especially as far as the sympathetic outflow goes --- some obese ischemic patient can be very high risk

    things i do: balanced techniques that include the use of ketamine - minimal sedation, awake intubations with trans/para-tracheal local anesthetic injection (with added glossopharyngeal coverage).

    the risk with obese patients is huge especially the super-obese for bariatric surgery --- if you look at the most recent deaths for gastric-bypass surgeries, they are either due to anastomotic leak (not our fault) or due to failed inubation or botched extubation with inability to reintubate...
    which brings up the next point - while the intubation should be done very carefully, you have to have a very well planned extubation with full capability to reintubate... i purposefully underdose narcotics... i'd rather have a breathing patient protecting their airway with pain, then the other way around...
  13. by   WntrMute2
    Quote from Tenesma
    it is a bit different from NGT/OGT as endotracheal is far more stimulating - especially as far as the sympathetic outflow goes --- some obese ischemic patient can be very high risk

    things i do: balanced techniques that include the use of ketamine - minimal sedation, awake intubations with trans/para-tracheal local anesthetic injection (with added glossopharyngeal coverage).

    the risk with obese patients is huge especially the super-obese for bariatric surgery --- if you look at the most recent deaths for gastric-bypass surgeries, they are either due to anastomotic leak (not our fault) or due to failed inubation or botched extubation with inability to reintubate...
    which brings up the next point - while the intubation should be done very carefully, you have to have a very well planned extubation with full capability to reintubate... i purposefully underdose narcotics... i'd rather have a breathing patient protecting their airway with pain, then the other way around...
    At one of the hospitals I trained at, all the bariatic cases got epidurals for intraop as well as post-op pain management to avoid most of the systemic narcotic problems. Also, I found that telling them that their pain at the conclusion of surgery might be greater than expected but once they were stable you would increase their analgesia was helpful and they knew what to expect. There was a recent study that showed that neck circumference as well as malimpatti score were the determining factors in predicting difficult intubations. Other factors such as weight were not predictive, the authors also found that in general, the bariatric patient had a similar incidence as the general population in being difficult to intubate.
  14. by   Tenesma
    wintermute: i think epidurals are a wonderful thing for bariatric patients... but unfortunately for some of the 700 pounders we just don't have long enough needles!!!!

    as far as predicting difficulty of intubation, i firmly believe that most of the literature still hasn't figured it out... primarily because when we expect a difficult intubation we modify our technique/positioning so as to increase our odds, and in a study it is difficult to make up for that bias...

    and i am sure others can agree... there are two types of difficult intubations: 1) planned and 2) unplanned.... and #2 sucks big time

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