Awake intubation question

WntrMute2 · Nov 22, 2004

I recently witnessed an awake intubation on an elderly female patient. The patient's dx was CHF and possible aspiration/pulmonary edema. After suffering from increasing respiratory distress while on the telemetry floor, she was transferred to the ICU. I had the opportunity to follow her progress. Within 30 minutes of entering the ICU, she underwent an awake intubation. Although she received approx 8 mg Versed and 2 mg morphine (I think?), there was no succinylcholine on the ICU floor, which is what the CRNA requested. Since the patient was rapidly desating and going into bradycardia, the CRNA made a decision to do an awake intubation. The patient was not paralyzed at this point. After intubation, the respiratory therapist assisted with respiration. Shortly after this time, the patient's belly significantly expanded outward and, while being suctioned, significant amounts of a pink, frothy substance was expressed. It even looked like there may have been tissue mixed in. The patient then coded twice.

My questions related to this experience are as follows:

1) is it typical to keep succ on the ICU floor for emergency intubation or do you use something else--perhaps Nimbex (sp?)

It is prudent NOT to administer a paralytic during floor intubations. The idea is to keep the patient breathing in the event you are unsuccessful in securing the airway. An apenic patient that can't be ventilated is usually a dead patient. Also, please note that a paralyzed patient is STILL AWAKE unless a hypnotic is given also. Sux is frequently the wrong choice in ICU situation, the prolonged bedrest will increase the number of receptors at the NMJ and lead to hyperkalemia maybe cardiac arrest. I've seen it.

2) What is the significance of the belly expanding shortly after intubation and manual bagging? The CRNA was pretty confident that the tube was placed correctly since he didn't hear any gurgling in the LUQ.

The significance is that the esophagous was intubated, not the trachea. ETCO2 should confirm tracheal placement in all but dead patients. Pretty confident doesn't count. The subsequent arrests should also raise the question. Did the O2 sat increase, were there BBS?

3) How can you tell the difference between aspiration (that may have severely damaged the lungs) and pulmonary edema that was suctioned out in a profuse amount.

Nothing quick and easy, a history and possibly a chest X-ray. Lasix will usually improve a simple case of PE but not aspiration.

I really appreciate your analysis of this situation and look forward to learning from your comments. Thanks in advance, Stephanie

apaisRN, RN, CRNA · Nov 22, 2004

We have an intubation med kit that lives in the Pyxis. Off the top of my head I know it contains Versed, sux, vec, and etomidate. I usually grab some fentanyl and propofol too because some of the pulmonary fellows (who are the intubators) like those drugs. I rarely see pts paralyzed - nearly always we can get them relaxed enough with propofol and etomidate.

Tenesma · Nov 22, 2004

the use of paralytics in floor/ICU intubations should only be used in very RARE and SPECIAL circumstances, and MOST DEFINITELY NEVER USE SUX!!!!!!

if the esophagus was intubated that would explain the belly and the code...

but if the trachea were intubated, there can still be explanations for the belly and the coding....

1) belly: after manual bagging prior to intubation, it is easy to insufflate the stomach... also in the setting of the patient attempting to breathe against the RT or the vent, you may see some discoordinate movement of the diaphragm that may make the belly appear to be getting larger

2) the code: (of course the Intubator should RE-EXAMINE the airway to make sure they see the tube between the cords with the cuff below the cords - just to double-check), but it is very common for sick people after intubation to have cardiovascular collapse... The patient is using all of his/her catecholamines to continue breathing, you intubate them and take that work away from them, they drop their catecholamine output and have significant vasodilation - similar to a sympathectomy. The other thing is that there might have been a narcotic overdose..

3) suctioning... people with CHF commonly will pour out secretions from the ETT tube - suctioning isn't going to help as much as a good PEEP will help. So just PEEP them at 5-15cm (as their hemodynamics tolerate) and the secretions will get better

what would i have done with the same scenario

1) spoken with the patient to explain my desire for an awake intubation due to their underlying medical issues

2) made sure i had good venous access

3) started running either levophed or neosynephrine at a low rate - until i see their pressure slowly rising

4) no versed

5) no morphine

6) 25 to 50mcg of fentanyl

7) watch the hemodynamics/respirations - titrate levophed up as needed

8) 10-40 mg of propofol

9) as the patient appears to drift away I intubated with a straight blade (i prefer the Miller 3 vs Miller 2) - primarily because if they start coughing or fighting it is easier to keep a good view with the Miller holding the epiglottis out of the way - with the Mac blade you will lose your view with every cough or sputter

10) treat tachycardia w/ esmolol - and then give low dose versed.... generally patients with respiratory failure due to CHF are already hypercarbic enough that their brain doesn't need more than 1 or 2mg of versed...

11) confirm ETT with end-tidal CO2 or even better in this patient - if i suspected pneumonia, i would just bronch them after intubation (which is also a good confirmation maneuver) suction them clean and send samples for culture from the infected lobe...

my 2 cents

by the way, I have intubated over 1000 times in floors and in ICUs and in the ER, and I have NEVER EVER needed to use SUX, and I have used other muscle relaxants only 3 times that i can remember.

gaspassah · Nov 22, 2004

i agree with wntr on several points.

1. even thought the icu is a controlled environment it's usually best not to paralyze because rarely is there someone standing there that can do a cricothyrotomy if need be.

however, if you are going to paralyze i think you must take into account many factors, sux wears off the quickest in the event of not being able to secure the airway, but i does increase K+ levels, so dialysis/renal pts are a poor choice as are pts bedridden for significant amounts of time, and patients that you dont want to increase intrathorasic, intracranial or intraoccular pressure.

in my opinion sux is both good and bad... it depends.

for the pul edema, usually pink and frothy in chf and if bad enough it seems like there i liters of it coming out when you suction. some sort of ph testing could lead you to a more reliable answer. pul edema fluid would most likely resemble body fluid ph, gastric aspirate would be highly acidic.

if the gut expands probably in the wrong hole, or air was insuflated during manual bag/valve mask ventilation. if belly expanded after the tube was placed and the condition worsened, then you must leave open the option that the tube was in the wrong hole. there is no shame in putting the tube in the wrong hole, the shame is in not recognizing it. when i was in icu we usually placed an ngt shortly after intubation to decompress the abd. gold standard for tube placement is end tidal co2. for someone with chf in pul edema it may be difficult to auscultate bbs with any degree of certainty, but should still be done.

as for nimbex (cisatricurium) good drug for renal/liver pts as it's mechanism of metabolism is hoffmans elimination and ester hydrolysis. this means the liver and kidneys play no role in metab or excretion. drawback is it takes about 2-4 minutes to work. not particularly good in emergent situations.

RSI (rapid sequence intubation) criteria can be met with rocuronium with 1 mg/kg but be prepared for the patient NOT to breath for about 20-40 minutes.

ketamine may not have been a bad choice for this patient, although it usually causes a release of catacholamines, in patients with chronic chf the heart tends to be less easily stimulated by catacholamines. ketamine causes bronchodilation, increase in sympathetic tone and helps to maintain respirations (1 mg/kg for induction.)

ps i see tenesma and i posted closely together. tenesma ( glad to see you lurking around again)

just my humble .02

EricTAMUCC-BSN, BSN, RN · Nov 23, 2004

We generally use nimbex, fentanyl, and versed than a CO2 detector and CXR for placement like Wntrmute2 was saying. Those are good questions that I have also wondered about myself, thanks for asking.

jwk · Nov 23, 2004

Within 30 minutes of entering the ICU, she underwent an awake intubation. Although she received approx 8 mg Versed and 2 mg morphine (I think?), there was no succinylcholine on the ICU floor, which is what the CRNA requested. Since the patient was rapidly desating and going into bradycardia, the CRNA made a decision to do an awake intubation. The patient was not paralyzed at this point. After intubation, the respiratory therapist assisted with respiration. Shortly after this time, the patient's belly significantly expanded outward and, while being suctioned, significant amounts of a pink, frothy substance was expressed. It even looked like there may have been tissue mixed in. The patient then coded twice.
My questions related to this experience are as follows:
1) is it typical to keep succ on the ICU floor for emergency intubation or do you use something else--perhaps Nimbex (sp?)
2) What is the significance of the belly expanding shortly after intubation and manual bagging? The CRNA was pretty confident that the tube was placed correctly since he didn't hear any gurgling in the LUQ.
3) How can you tell the difference between aspiration (that may have severely damaged the lungs) and pulmonary edema that was suctioned out in a profuse amount.

1) Interesting how different practices do things differently. During a near-code, it is often not necessary to use any muscle relaxants for intubation. A full code doesn't require any. However, I will respectfully disagree with Tenesma that Sux is contraindicated in these cases. We treat most of our urgent intubations in the ICU just like a rapid sequence induction - pre-oxygenate as much as possible, and either some versed, low-dose propofol, or perhaps etomidate, and then Sux more often than not. Many intubations can be done without a muscle relaxant, but that doesn't mean that using them is poor practice.

2) If things happened as you described it, I would say this is a case of dangerous incompetence. If they didn't check breath sounds and use some sort of EtCO2 device to confirm tube placement, they have committed malpractice, plain and simple. This is a standard of care - "pretty confident" isn't even close to being good enough. I think the end result for this patient pretty much speaks for itself.

3) Although not absolute, fluid from pulmonary edema is often described as "pink frothy", while gastric contents often have that lovely yellow tinge from bile. However, you could easily have a mixture, so I wouldn't depend on this. Peas and carrots in the lungs are a good tip-off however.

In the case you quoted, 8 of versed and 2 of MS is just about a general anesthetic for this patient, so I wouldn't truly call this an awake intubation.

One other comment regarding blade choice - the debate will forever rage about straight vs curved blades. Tenesma likes his straight blades, I wouldn't attempt an intubation without my Mac. Half of my group uses straight blades (the "professional" blade to them). Half of us use curved blades (anyone can muscle a tube in with a straight blade - it takes skill and finesse to do it with a curved blade ) The important points are 1) know how to use both blades and 2) get really, really good with one of them, and use it all the time.

Pete495 · Nov 23, 2004

I usually stay out of the technical threads because I am not as educated as most of you yet, but I just couldn't resist a couple of comments.

In my experience, 8mg of versed is a whopping dose. As a CVSU-RN, I've given 4mg of versed for intubations several times, and had to battle blood pressure for the next hour after the anesthesia provider left, and typically they did not have any neo or anything with them, and they run out of the room w/ their tail b/w their legs. In one instance, it was after I told them the patient didn't tolerate versed, so you can imagine, I was quite pee-ode. So my point is, why give so much versed if you know their blood pressure is going to end up in the crapper? In a pt. in CHF w/ resp. exacerbation, I could see this happening fairly quickly.

Also, I don't know any anesthesia providers who do broncosopies directly after an icu intubation, unless there is a plan and a pulmonologist wants it done. IN any case, a CO2 detector should suffice enough. Also, I've seen so many patients drop their blood pressure after intubation, and typically I'm the one stuck trying to get it back up, while the anes. provider high tails it out of there. I'm not saying that is the case with all. In fact we have some good anes. providers that always bring neo with them just in case, and will stick around til b.p. is back up.

Also, I haven't been in an experience where an anes. provider hangs levo or neo before intubating on a floor. Is this common practice? Just curious. If the patient is stable obviously you wouldn't need it, but I just wondered if this was something that was being done?

Again, I don't mean any disrespect. just trying to learn a little from the experts.

Tenesma · Nov 23, 2004

Pete...

i feel bad for your exposure to anesthesia providers as it appears they are always "running with their tails between their legs" while you have to fix all of the problems...

1) why would the anesthesia provider have to bring the neo... shouldn't an ICU have that available and ready, especially in an unstable patient who is about to be intubated... it sounds like it should be either in the room or hanging already...

2) i don't need a pulmonologist to perform a bronch, in fact I can bill for bronchs as well as any other anesthesiologist who provides services to an ICU. In a patient with a suspected pneumonia with respiratory compromise, i think it isn't unreasonable to obtain a sputum culture via bronchoscopy - and if there is no CO2 detector around, this serves as an excellent method to confirm intubation if there is no other way to confirm and XRAY is delayed.

3) maybe the reason you are always fighting BP issues is because there is no levo or neo dripping upon intubation... and of course, you are absolutely right, this would be used for unstable patients....

yoga crna · Nov 23, 2004

I think it is important to look at what you are trying to accomplish and then select the technique and medication to make that technique safe for the patient and easy for the practitioner.

I have always been reluctant to use succinylcholine in emergency intubations. Rapid sequence technique with cricoid pressure has been shown to be marginally effective in preventing aspirations, because cricoid pressure is not performed properly. I am also curious why some of you are advocating use of Nimbex. I use it everyday in clinical practice and find that you need 3-5 minutes for good relaxation for intubation. That is certainly not an ideal drug to use when time or aspiration are an issue.

One of the best things I ever learned in my long career is how to do awake blind nasal intubations. I don't have much opportunity to do them now, but I still try all of nasal intubations blind (with patient paralyzed). If I had a busy ICU practice, I would brush off that technique and use it, along with fiberoptic nasal intubations. To my mind, it would be better than using a muscle relaxant.

Yoga CRNA

mwbeah · Nov 24, 2004

I also respectfully disagree with tenesma, sux doses may be reduced on the floor and contraindicated in certain situations, however I have to find a reason NOT to use sux in order to secure an airway. It is the GOLD STANDARD for emergent situations (unless the patient meets the criteria not to use it, ie extended bedrest, paralysis, burns, etc.). Remember everything is situation dependent and as long as you are actively thinking and can adjust fire accordingly while sticking to the fundamentals of airway management then you should do fine on the floor.

If the patient is nonresponsive then they get "metalnephrine", that is the laryngoscope and then the ett.

My methods include cricoid, propofol (reduced dose), sux, tube. Of course I have S.O.A.P on the floor (suction, oxygen and PPV source, airway instruments and devices and pharmaceuticals)

Mike, CRNA

jwk · Nov 24, 2004

If the patient is nonresponsive then they get "metalnephrine", that is the laryngoscope and then the ett.

Very closely related to laryngotensin......