Awake Fiberoptic with Ketamine? Any other tricks?

versatile_kat · Jul 3, 2006

For my awake FOI's (not like I'm an expert - only have 9 under my belt), I anesthetise the airway with 5cc 4% Lido in a nebulizer (about 5-10min before heading back to the OR) +/- Cetacaine spray to the posterior oropharynx, depending on the patient. For awake nasal I use viscous lido in an atomizer + afrin to bilat nares with the above.

As far as Ketamine goes, I make a mixture of Ketamine & Propofol (1:10) in a 20cc syringe, give the patient whatever he/she needs to remain comfortable and start the intubation. It goes without saying, they receive around 4-5mg of Versed in preop. This technique has served me well and the patients remain calm and comfortable throughout.

A bit of advice - if your program is like many others, the FOI are not usually done by students. So speak up when you have the chance and try as many as you can prior to graduating - you don't want the first time you do one to be during an emergency when you're the only airway expert around. Good luck!

fastosprintini · Jul 3, 2006

Does anyone here routinely use ketamine with their awake foi? Ive never done it, but my classmate just did and said it was awesome. How exactly do you use it, and/or what other tricks/recipes do you have for an awake foi?

ketamine (1mg/kg)is a mixed bag when it comes to awake foi's, although the pt. holds still the increased secretions make the view worse.

i usually pretreat with glycopyrrolate and try to anaesthetize with inhaled lidocain, a lingual nerveblock with a spinal needle and 2% lido.

i have to admit that i haven't done awakes for almost two years as we got bullards and use them almost exclusivly...

fasto

apaisRN, RN, CRNA · Jul 3, 2006

ketamine (1mg/kg)is a mixed bag when it comes to awake foi's, although the pt. holds still the increased secretions make the view worse.
i usually pretreat with glycopyrrolate and try to anaesthetize with inhaled lidocain, a lingual nerveblock with a spinal needle and 2% lido.
i have to admit that i haven't done awakes for almost two years as we got bullards and use them almost exclusivly...
fasto

I thought you said you were a nursing student.

gaspassah · Jul 3, 2006

i dont usually use much more than about 5 mg versed titrated. i usually do the transtracheal nerve block with superior laryngeal nerve block and lido 4% nebs/

catcolalex · Jul 3, 2006

try a precedex gtt, 1 mcg per kg load over 10 min then .2-.7 mcg/kg/min, analgesia, no resp depression etc.

underdog · Jul 4, 2006

By no means am I an expert at awake FOI, as I have only done about five of these. I did however do one just the other day. Patient was a 74 yo male who was riding a four-wheeler ATV and did not see a barbed wire fence. He ran right into it and ended up with a DEEP laceration from ear-to-ear. Mandible was clearly visible, and he was within 1/2 cm from lacerating BIG RED!! Amazingly, the patient was A&OX3 in ED with very good hemostasis. Upon interview he stated that it was difficult to take a deep breath and to swallow. He also had a full thickness laceration to the middle of his tongue with significant edema from biting it.

For fear of losing airway once he was put to sleep, I opted for an awake nasal FOI with general surg on standby for emergent trach/cric. Gave him 0.2/0.2 mg of Robinol in divided doses. Packed both nares with cocaine pledgets soaked in 4% lido and phenyleperine spray. Titrated in Versed 5mg and Fentanyl 100 mcg. Did not buck/gag/cough one bit until tube was passed through the cords. I guess it is better to be lucky than good sometimes;)

Focker, CRNA · Jul 4, 2006

Just wanted to say that this is an awesome thread, I havn't done an awake foi yet, havn't even seen one. Did you guys get to practice with foi in a sim lab or something similar before trying it in clinical setting, or was your first foi on an actual patient?

WntrMute2 · Jul 4, 2006

In school I was able to do a couple of dozen. We had a spine surgeon at our primary site that liked them done on all his cervical spine patients. As a practicing CRNA I do them aboout once a month on patients that I put to sleep and then do a FOB placement of an ETT. Any patient that doesn't need a rapid sequence intubation is a candidate. Pick your surgeon tho as some get their panties in a wad if you delay them. Awake patients are even easier as their breathing efforts keep the tissues from collapsing. Once i started doing asleep ones regularly, the MDAs were only too happy to allow me to to do the truely needy ones.

miloisstinky · Jul 4, 2006

At our hospital, we service the jail for Los Angeles county! Therefore, we get tons of jaw fractures (wired shut), facial traumas that require awake foi. I got some sim training, but coming in early and practicing for 20-30 minutes straight immediately before, as well as adequate preparation (anesthetizing and drying out the airway) seems to be key. They are fun to do, but very challenging and scary (to me), but they are still a gold standard fool-proof way to secure an airway.

I would love to be excellent at them, but it seems its something you must do regularly to be really good at, asleep elective foi (as wntrMute2 said)may be a nice thing to do to keep up your skills, so when you REALLY need one to save your ***, you wont be in a world of hurt.