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

Diprivan/Vented · Jul 3, 2004

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.

Diprivan/Vented · Jul 3, 2004

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.

Diprivan/Vented · Jul 3, 2004

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.

Lorus · Jul 3, 2004

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..

Lorus · Jul 3, 2004

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..

rjflyn, ASN, RN · Jul 3, 2004

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:nurse:

rjflyn, ASN, RN · Jul 3, 2004

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:nurse:

purplemania, BSN, RN · Jul 3, 2004

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.

purplemania, BSN, RN · Jul 3, 2004

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.

pasgasser · Jul 3, 2004

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.

pasgasser · Jul 3, 2004

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.