BCC4: Sean McManus on The Ultimate Induction

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In this talk from BCC4; McManus, an anaesthetist with over 12 years experience in critical care, distills valuable knowledge about airway management.

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BCC4: Sean McManus on The Ultimate Induction

  1. 1. The Ultimate Induction
  2. 2. The Ultimate Introduction
  3. 3. 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
  4. 4. Personal Perspective • 12 Years covering Anaesthesia & ICU in FNQ – Trauma – Sepsis – Obstetrics – Paediatrics – Tropical Medicine – Occasional retrieval • Tertiary referral 400km away
  5. 5. 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
  6. 6. Personal Perspective • Training future airway managers – – – – ANZCA ACEM CICM ACCRM • Upskilling – Rural Generalists – Paramedics – Residents
  7. 7. 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
  8. 8. 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
  9. 9. Downhill Experts
  10. 10. Induction in Critical Care • A different contract with the patient than inducing anaesthesia 1. 2. 3. 4. Keep the alive Keep them comfortable Prevent recall Make them unconscious • Awareness of induction is not the worst possible outcome
  11. 11. 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
  12. 12. Cautionary tales from 2013
  13. 13. Tricky Trauma
  14. 14. 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 ++
  15. 15. Patrick • To OT for urgent pelvic Ex Fix • Arrives in induction bay • And said……………………
  16. 16. What I should be feeling
  17. 17. What I really felt
  18. 18. What are our options? • RSI and look? • Video Laryngoscope? • Awake FOI? • Avoid GA?
  19. 19. Meanwhile
  20. 20. Discussed plan with Patrick • Decided FOI was not reasonable – Pain, Opioids, Moderate Hypoxia – Unable to sit up • Plan A. B. C. D. Modified RSI +/- bougie Videolaryngoscopy Blind bougie +/- proseal (if still not in trachea) Prearranged second consultant backup
  21. 21. 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 ++++
  22. 22. Plan B……………. • Attempt with Videolaryngoscope – Unable to get into mouth – Pulled apart – no joy – Bailed 2nd time – Able to bag/mask – Called for assistance
  23. 23. Plan ?????????? • Second Anaesthestist inserted Proseal • Attempted to use FO scope down Proseal to guide bougie – unsuccessful • Things are starting to look ugly
  24. 24. 15 Years of Anaesthetic Adventures • Airway not ideal…………… • Air going in and out • Relatively short case • Decided to accept the supraglottic airway
  25. 25. Elaine Bromiley
  26. 26. 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
  27. 27. 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
  28. 28. Dynamic Decision Making Input Feedback for Evaluation Decision Analysis Action Influences Objectives Preconceptions Workload Skill Training Experience Regulations Rules S.O.P.S Captain Julian Hipwell, Cathay Pacific Airlines
  29. 29. Checklists
  30. 30. Information Overload
  31. 31. M.A.I.D.E. For Every Induction • Monitoring • Assistance • Intravenous access • Drugs • Equipment
  32. 32. Monitoring • Check it is connected and reading • NIBP Cycle time • Arterial line? • ETCO2
  33. 33. 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
  34. 34. Intravenous Access • Often overlooked in a crisis • In non-haemorragic induction, don’t need huge bore • Must run freely • Low threshold for replacing
  35. 35. 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
  36. 36. 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
  37. 37. Sounds Sweet?
  38. 38. Mega Mediastinal Mass
  39. 39. 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
  40. 40. 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
  41. 41. 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”
  42. 42. 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
  43. 43. Plan? • Thoughts…………………… • Options……………………….. • The only thing going through my head was…..
  44. 44. We consulted Townsville • Definitive diagnosis via mediastinal biopsy • Possible Cardiothoracic resection • Probable Radiotherapy • Advised us to secure her airway for transfer….
  45. 45. Mission Impossible?
  46. 46. What are the options? • Standard Induction – “Sux and see?” • Awake FOI – Smallest bronchoscope is 4mm • Gas induction? • Retrieval with ECMO/CPB?
  47. 47. Group Mined • Collaborative decision making • Robust discussion with trust • Anaesthesia, Intensive Care, ENT and General Surgery • We came to a consensus…………..
  48. 48. 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.
  49. 49. “Two pencils and a pair of undies”
  50. 50. M.A.I.D.E. For Every Induction • Monitoring • Assistance • Intravenous access • Drugs • Equipment
  51. 51. 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
  52. 52. 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
  53. 53. Steady, steady • Regulation topicalization and fibreoptic visualisation of cords • Through cords and guidewire fed down bronchoscopic biopsy channel • Position confirmed with Image Intensifier
  54. 54. 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
  55. 55. Transferred to Townsville • Poorly differentiated tumour • Extubated after 22 days post radiotherapy • First time it has been done (we think), submitted for publication • Rejected!
  56. 56. Additions to your toolkit
  57. 57. 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
  58. 58. Anaesthetists Trade Secrets • Dealing with a beard
  59. 59. Anaesthetists Trade Secrets • Optimal Positioning – ‘Sniffing the morning air’ – ‘Drinking a pint of lager’ • Need flexion of cervical spine • Only use for Voluven
  60. 60. Proseal-Bougie Technique
  61. 61. • http://b.vimeocdn.com/ts/429/815/42981573 9_1280.jpg

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