Cannot ventilate ?

Started by jafo1964, October 13, 2007, 10:22:43 AM

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jafo1964

While performing a ET intubation for a GA as per scientific recommendation, i follow pre-oxygenation and demonstration of adequate mask fit and ventilation after inducing anaesthesia prior to administration of relaxants.
So here is an scenario that is not uncommonly encountered
50 kg, ASA 1, Modified Mallampati Score 1, No other positive predictors of difficult airway or difficult mask ventialtion, No aspiration risk, scheduled for GA / CV.
IV line, monitors
Pre-oxygenated
Fentanyl 100mcg + Glyco 0.2 mg + Xylocard 50 mg + Thiopentone 250 mg

Mask ventilation failed
Jaw thrust and 2 person mask ventilation failed
Appropriate oropharyngeal airway in place  - mask ventilation failed

Saturation are holding due to adequate pre-oxygenation
time elapsed 3 mins

What should one do next. Give suxa as planned or do a laryngoscopy and intubate minus relaxants, try ventilation with LMA

thanks for all the input
regs

frontier

#1
hi jafo sir,
   a very good morning.your anaesthesist versus surgeon article a fantastic & funny one.is this case is a can't ventilate & can intubate scenario? as mallampati scoring is 1 you can choose either of your three options in my opinion.only remote possibility is there if you are not able to intubate after giving sux then put LMA  & ventilate.as you don't know the pseudocholineesterase  status of the patient so other two options have an edge over the intubating the patient with suxamethonium.awake intubation with the help of nerve block is a very good option if patient becomes awake.if you are in real hurry put LMA & ventilate.i fail to understand you were not able to mask ventilate which is either of the two reasons 1.tight fitting mask is not available2.airway not patent.in your case both things  were alright.with regards

cool

Dear jafo:
a good case. after quick auscultation to exclude bronchospasm, I suggest to give sux and continue to  ventilate the patient (1 min). Then try to intubate the patient.
In very emergency situation, I'll chose to intubate the patient directly using larygoscopy. If failed, using LMA.
Using Oropharyngeal Airways or Nasopharyngeal Airways together with mask to ventilate the patient, it may solve the problem.

Shooter

I agree with Cool about auscultation being the first step.
But the second step should be to rule out equipment failure and switch the patient's circut, to a wall mounted AMBU bag for example, since the failure to ventilate could be due to a malfunctioning valve in your ventilator circuit.
Intubation should be simultaneously planned, but perhaps without paralysis as this patient's airway may have collapsed due to an intrathoracic mass and will be negative pressure ventilation dependent.

Pascal

Quote from: jafo1964 on October 13, 2007, 10:22:43 AMWhat should one do next.

From your description the most likely cause of of failure to ventilate would be obstruction due to laryngeal spasm.

It should be easy to assess the circuit without calling for another one which would waste valuable time.  Self inflating bags in my view have no place except in total failure.  You cannot apply CPAP with a self inflating bag and CPAP is a valuable aid to oxygenation and overcoming laryngeal spasm.

I would assess the situation by quick laryngoscopy.  If laryngeal spasm was confirmed I would continue efforts with a mask, Guedal airway, turning the head to the side and maximum extentions while asking someone esle to give suxamathonium.  You would not need more than 25 mg to reverse the situation and get oxygen to the alveoli.  You would then be able to deepen anaesthesia and decide as to whether you would not be better off giving a non-depolarising relaxant.  You could then place the LMA.

I would not go straight to the LMA in these circumstances because if there is laryngeal spasm the LMA would simply leak and you would be worse off than with mask and airway.

I would not go for an ETT unless specifically indicated.  A LMA will cause less irritation.  And I would try to avoid passing it through cords that are in spasm.

frontier

sirs,
  definitetly  its a case of laryngospasm/i think jafo sir before inducton went for mask ventilation as a demo & everything was alright,so no question of valve or circuit related problem/first auscultation & then quick direct larynoscopy to be sure its laryngospasm followed by 20-25 mg of sux administration as IPPV can't relieve this spasm as well suggested by pascal sir.now placing ETT will be better in this scenario-failed intubation-put LMA & ventilate.regards.

BlissMD

very good train of discussion of difficult airway management vs laryngospasm and anesthesiologist's fortay

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