BCC4: Sean McManus on The Ultimate Induction

The Ultimate Induction

The Ultimate Introduction

Outline

• Essentials of Critical Care airway management in the age of information overload

• Two memorable 2013 airway cases

– Tricky Trauma

– Mediastinal Mega Mass

• Techniques for your induction tool box

Personal Perspective

• 12 Years covering Anaesthesia & ICU in FNQ– Trauma

– Sepsis

– Obstetrics

– Paediatrics

– Tropical Medicine

– Occasional retrieval

• Tertiary referral 400km away

Personal Perspective

• Senior role in College of Anaesthetists

– Assess overseas trained Specialists

– Inspect hospitals for training accreditation

– Give expert opinion to Coroner in cases of anaesthetic misadventure

Personal Perspective

• Training future airway managers– ANZCA

– ACEM

– CICM

– ACCRM

• Upskilling– Rural Generalists

– Paramedics

– Residents

Personal Perspective

• Anaesthesia Outreach to Cape York– Weipa, TI, Cooktown

– Dental & ENT

– Large Paediatric Case Load

• Overseas Aid Work with Interplast– PNG, Sri Lanka, Fiji

– Cleft Lip & Palate

– Head and Neck

– Mostly Paediatric

The Ultimate Induction

• Two rules– air goes in and out

– blood goes round and round

• Many different recipes– Pick your own

– As long as the cake rises………………..

• Expertise comes down to time at the wheel

Downhill Experts

Induction in Critical Care

• A different contract with the patient than inducing anaesthesia

1. Keep the alive

2. Keep them comfortable

3. Prevent recall

4. Make them unconscious

• Awareness of induction is not the worst possible outcome

Induction in Critical Care

• Data (e.g. NAP4) highlights difference between OT and ICU/ED

• Often no bail out option

• Many things are done by experts are intuitive

• Induction is a complex process, need to fly at high altitude

Cautionary tales from 2013

Tricky Trauma

Patrick

• Executive Director of Medical Services is riding to work on his Motorbike

• Hit at 0745 5 km from CBH

• Brought in to ED

– # Pelvis

– # Ribs

– Pain ++

Patrick

• To OT for urgent pelvic Ex Fix

• Arrives in induction bay

• And said……………………

What I should be feeling

What I really felt

What are our options?

• RSI and look?

• Video Laryngoscope?

• Awake FOI?

• Avoid GA?

Meanwhile

Discussed plan with Patrick

• Decided FOI was not reasonable

– Pain, Opioids, Moderate Hypoxia

– Unable to sit up

• Plan

A. Modified RSI +/- bougie

B. Videolaryngoscopy

C. Blind bougie +/- proseal (if still not in trachea)

D. Prearranged second consultant backup

Plan A……….

• Normal modified RSI

• Attempted laryngoscopy

– Proper Grade 4

– Narrow crowded teeth

– Early use of bougie – unable to find trachea

– Abandoned while sats still OK

– Bag & mask

– Pulse Ox lag ++++

Plan B…………….

• Attempt with Videolaryngoscope

– Unable to get into mouth

– Pulled apart – no joy

– Bailed 2nd time

– Able to bag/mask

– Called for assistance

Plan ??????????

• Second Anaesthestist inserted Proseal

• Attempted to use FO scope down Proseal to guide bougie – unsuccessful

• Things are starting to look ugly

15 Years of Anaesthetic Adventures

• Airway not ideal……………

• Air going in and out

• Relatively short case

• Decided to accept the supraglottic airway

Elaine Bromiley

A failure of airway management

• Anxious in my first week back as a consultant

• Unfamiliar with the VDL

• The second consultant was not involved in the airway management planning

• I bailed on my own plan – never got to C

Lessons Learnt

• It is better to be lucky than good!

• Accepting a less than perfect airway is sometimes appropriate– Air goes in and out

– Repeated goes at the larynx is not wise

– FOI can be tricky in trauma

• Maintaining situational awareness and dynamic decision making ability

Dynamic Decision MakingIn

pu

t

Decision Action

Objectives Preconceptions

Workload

Influences

SkillTraining

Experience

RegulationsRules

S.O.P.S

Analysis

Feedback for Evaluation

Captain Julian Hipwell, Cathay Pacific Airlines

Checklists

Information Overload

M.A.I.D.E.For Every Induction

• Monitoring

• Assistance

• Intravenous access

• Drugs

• Equipment

Monitoring

• Check it is connected and reading

• NIBP Cycle time

• Arterial line?

• ETCO2

Assistance

• Need skilled help

• Two questions to assess level of experience

– Cricoid pressure?

– Pass the bougie?

• Critical Care Induction will often require another doctor

– Delineate roles

Intravenous Access

• Often overlooked in a crisis

• In non-haemorragic induction, don’t need huge bore

• Must run freely

• Low threshold for replacing

Drugs

• What you will use plus emergency drugs

• Endless debate about best induction recipe

• Ketamine/Rocuronium seems reasonable in shock

• Use what you know best

• Don’t skimp on paralysis

Equipment

• Airways – 3 options– Through Cords (ETT)

– Over Cords (LMA)

– Under Cords (Crico)

• Laryngoscopes– Classic

– Video

– Fibreoptic

• Positive Pressure– Bag/Mask

– O2 outlet

• Negative Pressure– Sucker under head

• Adjuncts– Guedel

– Bougie

Sounds Sweet?

Mega Mediastinal Mass

Mega Mediastinal Mass

• 39 year old lady from TI admitted to ICU on the 16th of April with stridor

• Seen in Feb by the respiratory team for investigation of a mediastinal mass

• FNA done, awaiting result

Mega Mediastinal Mass

• Deteriorated over the last few days, presented to TI hospital acutely distressed

• Flown to CBH ED, survived a CT chest

• Admitted to ICU overnight

CT Report

• “A large mass extends from the anterior mediastinum into the middle mediastinum, and superiorly towards the left, partially compressing the left pulmonary artery. There is severe compression of the trachea from the carina to the thoracic inlet, with a minimum diameter of 3.6mm”

ICU Ward Round

• Seen by team at 8am Monday morning

• Awake, maintaining airway sitting up, unable to lie flat

• Appeared likely to obstruct at some time during the day

Plan?

• Thoughts……………………

• Options………………………..

• The only thing going through my head was…..

We consulted Townsville

• Definitive diagnosis via mediastinal biopsy

• Possible Cardiothoracic resection

• Probable Radiotherapy

• Advised us to secure her airway for transfer….

Mission Impossible?

What are the options?

• Standard Induction – “Sux and see?”

• Awake FOI – Smallest bronchoscope is 4mm

• Gas induction?

• Retrieval with ECMO/CPB?

Group Mined

• Collaborative decision making

• Robust discussion with trust

• Anaesthesia, Intensive Care, ENT and General Surgery

• We came to a consensus…………..

This is a crisis, a large crisis

In fact, if you got a moment, it's a twelve-storey crisis with a magnificent entrance hall, carpeting throughout, 24-hour portage, and an enormous sign on the roof, saying 'This Is a Large Crisis'.

A large crisis requires a large plan. Get me two pencils and a pair of underpants.

“Two pencils and a pair of undies”

M.A.I.D.E.For Every Induction

• Monitoring

• Assistance

• Intravenous access

• Drugs

• Equipment

First use of ‘Staged Intubation’

• Airway too narrow for anything other than a wire

• Big team involved, clear communication of plan

• Principle was to keep patient awake and in control of her own airway for as long as possible

Precarious Position

• Three senior anaesthetists + two techs

– FO Scope

– Staged Extubation Kit

– Drugs and Monitoring

• Theatre cleared of all unnecessary personnel

• ENT surgeons scrubbed and standing by

Steady, steady

• Regulation topicalization and fibreoptic visualisation of cords

• Through cords and guidewire fed down bronchoscopic biopsy channel

• Position confirmed with Image Intensifier

Point of no return

• IV Induction

• Bougie fed over guidewire

• Size 6 Microlaryngoscopy ETT railroaded over bougie into right main bronchus

• Confirmed with subsequent brochoscopy

Transferred to Townsville

• Poorly differentiated tumour

• Extubated after 22 days post radiotherapy

• First time it has been done (we think), submitted for publication

• Rejected!

Additions to your toolkit

Anaesthetists Trade Secrets

• New Zealand Crisis Algorithm– Assume nothing

– Trust no-one

– Give oxygen

• We always ventilate in RSI

• Cricoid pressure tells everyone the airway is important, but doesn’t really help the patient

Anaesthetists Trade Secrets

• Dealing with a beard

Anaesthetists Trade Secrets

• Optimal Positioning

– ‘Sniffing the morning air’

– ‘Drinking a pint of lager’

• Need flexion of cervical spine

• Only use for Voluven

Proseal-Bougie Technique

• http://b.vimeocdn.com/ts/429/815/429815739_1280.jpg