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

[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.

[stevierae]

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tube through the LMA, confirm proper placement, then use the pusher tube to hold/push the tube in place as the LMA is withdrawn.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.

Thank you--I appreciate the explanation.

[stevierae]

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....

I wondered about that, as well. Isn't that the device we use in the operating room to convert a double lumen tube (post-thoracotomy for lobectomy or pneumonectomy, or esophagogastrectomy) to a single lumen ET tube just for purposes of staying intubated overnight in the ICU? Anesthesia provider just slides old tube over tube exchanger and new tube in over tube exchanger? No fumbling, no chaos, no drama?

I hate unnecessary drama. :uhoh21:

In fact, the older I get the more I realize: ALL drama is unnecessary. More and more I want to take people by the shoulders and say, "You've done this before--HUNDREDS of times. You'll do it again--HUNDREDS of times. It's NOT A BIG DEAL."

Then give 'em a good slap.

Ahhhh. Feels good just thinking about it. Some people are far too intense.

[catcolalex]

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.

what insurance company would approve of staying overnight in an ICU for a tonsillectomy? not that it is a bad idea just not feasable.

[stevierae]

what insurance company would approve of staying overnight in an ICU for a tonsillectomy? not that it is a bad idea just not feasable.

These were KAISER deaths....ooops, I wasn't going to name names, but I guess I just did... :uhoh21:

They were YOUNG, too--it haunts me that maybe, JUST MAYBE, they might have lived (or at least not died post-op from anesthesia complications) if we had been a bit more conservative--that is. not yanking the ET tube immediatley upon completion of surgery, when they had previous histories of difficult intubations, short necks, sleep apnea and were morbidly obese...

[Dixiedi]

what insurance company would approve of staying overnight in an ICU for a tonsillectomy? not that it is a bad idea just not feasable.

A lot of pts are tossed out now days way too soon. It's pure luck that post op complications don't kill more than they do.

[rjflyn, ASN, RN]

These were KAISER deaths....ooops, I wasn't going to name names, but I guess I just did... :uhoh21:

They were YOUNG, too--it haunts me that maybe, JUST MAYBE, they might have lived (or at least not died post-op from anesthesia complications) if we had been a bit more conservative--that is. not yanking the ET tube immediatley upon completion of surgery, when they had previous histories of difficult intubations, short necks, sleep apnea and were morbidly obese...

These are the kind of patients I take care of on a daily basis in our PICU. Some children end up staying more than 24 hrs, alot depends on there airway to begin with and some even get steroids for the inflamation.

Rj:)

[stevierae]

These are the kind of patients I take care of on a daily basis in our PICU. Some children end up staying more than 24 hrs, alot depends on there airway to begin with and some even get steroids for the inflamation.

Rj:)

NO--these are NOT the type of patients you take care of daily in your PICU. That's my whole point.

These were ADULT tonsillectomies; adults who were ASA3 because they were morbidly obese, had sleep apnea (some, not all, slept with CPAPs at night) were difficult intubations in the first place (probably should have had awake nasal intubations using cocaine and probably a fiberoptic laryngoscope) but instead required multiple attempts with desaturation in between attempts before finally successful. Most also had symptomatic hiatal hernias. I am betting more than one aspirated during the multiple attempts before induction was successful, despite cricoid pressure. It happens, unfortunately.

Now, I am not an anesthesia provider, but in my opinion those people should have been left intubated overnight, admitted to the ICU, and maybe even treated with high dose steroids- maybe Solu-Medrol, instead of the usual Decadron. They weren't--they were extubated, and they died, despite all the heroic interventions in the world (including open chest cardiac massage.) To me, that's just what any resonable and prudent person would have done--conservative airway management may have saved these lives.

When I said "young," I meant in the age group of 25 to 30.

[Brenna's Dad]

It's my understanding that most of the time, the distal end of the airway is inserted into the esophagus and the patient is ventilated through the fenestrations.

If you want to exchange over the combitube, therefore, the distal end of the combitube must be in the trachea (which usually is not the case.) I was taught that this is one of the disadvantages with the Combi, ie. you can establish and airway, but almost always cannot exchange.

[Gotosleepy]

you can use a Cook exchanger over combitube w/ pedi bronchoscope guidance of cook catheter - then removal of bronchoscope.

[Brenna's Dad]

If the distal end of the Combitube is not in the trachea, which in my understanding it usually isn't, then how can you pass a Cook catheter through the fenestrations and into the trachea for the exchange??