Intubation turning into a code blue

[ICUisLife]

I would like to ask for some of the more experienced ICU/critical Care RN's opinion. (I've only been an ICU RN for 2 yrs.)

Last night we had a 33 y.o. repeated admission for PNA, (last admission a month ago with ARDS, hx COPD, drug abuse). He was deteriorating on HFNC and Dr. elected to intubate using Etomidate and Succinylcholine. He couldn't advance into the airway, so he pulled it back out. Patient's O2 continued to drop despite bagging, and eventually dropped down into 40's-50's (within about 1-2 minutes). Pt. became bradycardic and eventually arrested. Code was called, 1 round of CPR, 1 mg Epi, then ROSC with NSR.

On second try MD successfully intubated with just a little bit of difficulty. He said that the pt. had a small oral cavity and the airway was difficult to access. He said there was no bronchodpasm or edema.

My question is, why did his O2 not come up when the Dr. pulled the tube back out and we were bagging? What could have went wrong?

Thanks for any input!

[PeakRN]

My guess if he really couldn't advance the airway is that the patient could have had a good bit of laryngospasm. I'm always a bit dubious about the excuses made about failures to intubate or place IVs, they both seem to be things where the excuse parade comes out. If the patient did have laryngospasm that would make bagging the patient more difficult. The size of the airway should have been part of his assessment prior to intubation.

If the patient was already failing on heated high flow then bagging may not have been of much benefit. With HFNCs (when maxed out) you are relying on the idea of providing near 100% FiO2 while also washing out the anatomical dead spaces and providing a small amount of PEEP. When you are now bagging you are likely to have a low percentage of oxygen (even at 15 LPM or flush many bags to not get near 100%), you do not have any of the washout, and depending on your setup you may or may not have the benefit of PEEP (in which you would also need to keep the mask sealed all of the time, not just when squeezing the bag).

We tend to use anesthesia bags during planned intubations, they will always have 100% of the gas that we are flow inflating with (for neonatal resuscitation we use a blender). They also allow us to control the amount of PEEP that we are providing.

Generally speaking if the patient is failing HFNC we will trial BiPAP or at least use it as a bridge while preparing to intubate, especially if we foresee the need to use a bronchoscope or equipment that we do not keep in our standard intubation carts.

[offlabel]

Just because someone is attemping to mask a patient with a bag doesn't mean the patient is being ventilated. Lot's of things that could have been going wrong right then, but if I had to guess, I might say he didn't wait long enough for his dose of succs to be fully working.

[canoehead, BSN, RN]

Did they use an airway while bagging? That might have helped.

[ICUisLife]

No, he did not use an airway. We switched to another bag as we thought maybe the bag/valve was malfunctioning, but it wasn't. Once he was finally intubated, bagging worked just fine.

[ICUisLife]

Offlabel: Yes, you might be right! There is definitely that possibility, that he didn't give the succs time to work.

[Cowboyardee]

Was chest rise noted during bagging? Did the patient feel difficult to bag? Did the mask appear to fit right? Was the person bagging the patient experienced at using an ambu bag?

A lot of times in these situations, the best guess would come from the person doing the bagging assuming theyre experienced. But also, a lot of the time, what exactly went wrong is and stays a mystery. Given the patient's history, it sounds like both airway problems and poor lung compliance are pretty plausible. Ask the anesthesiologist and the person bagging what they thought happened. Might also be useful to know what kinds of vent settings were used and peak and mean pressures the vent was reading after intubation to deduce more about the patient's condition at the time.

[ghillbert, MSN, NP]

- Inadequate paralytic dose or time

- Inadequate bagging/mask seal

- Need for jaw thrust

Multiple reasons it could be that you weren't able to oxygenate patient adequately with BVM. Was it an experienced provider attempting the intubation?

Probably could have grabbed the Glidescope or bougie with the first difficulty. Your best shot at intubating is the first one.

[pmath_RRT]

Poor seal with mask. Always look for chest rise. Was it difficult to squeeze the bag? Yes I would have put in an oral airway, tongue could have been occluding the airway, if this were the case it would have been difficult to bag. Also i'm afraid one of the posters is incorrect, you do get just about 100% O2 with an ambu bag plus you are getting positive pressure. The bag on an ambu bag acts as reservoir which helps you get 100% O2. 15L is simply used to keep the bag inflated, the pt is not receiving 15L, the LPM is determined how fast you are bagging (which I don't recommend bagging quickly because you will start forcing air into their stomach).

Another question I have is has your hospital removed all air flow meters? I have heard so many times people plugging the ambu bag into the air flow meter and not the O2 flow meter.

[murseman24, MSN, CRNA]

I'm going with not ventilating the patient with the ambu bag. It's actually much harder than it looks. Next time they do that look to see if there is condensation on the mask and look for chest rise. You can offer to squeeze the bag while the doc does a two-handed jaw thrust, that is very effective.

[BrittanyNicole]

Was there chest rise when bagging? I was in a similiar situation one time with a patient with a swollen airway, physician was unable to tube him, sats started dropping so respiratory was bagging him while 5 people in the room were staring at the monitor waiting for his 60% O2 sat to come up...and as it was dropping lower and lower I was the only one with actual eyes on the patient (and not the monitor) and told respiratory there was no chest rise while bagging. It was a positional issue and once he was repositioned there was finally chest rise with bagging and his 32% O2 sat finally starting coming up just as he was bradying down.

[Rosie_one]

Agree with all previous entries. Just to add. I always think back to the oxygen dissociation curve, once Sp02 is under 90%, it will drop very quickly so no surprise it got down to as low as it did. I doubt their Sp02 was above 90% to begin with. Did you preoxygen the patient with Fi02 100% I preoxygenate on BiPAP for high risk patients

Maybe the dr should of had another doc there just in case things went wrong. All high risk deteriorating patients should in my view. Maybe the dr let stressful situation get to him too.