Airway Emergency: Start With The Basics of Airway Management
A case of “can’t intubate- can’t ventilate is discussed which illustrates the importance of always using good techniques of basic airway management. Read More …
Close Call In Honduras With A Nosebleed
During a recent volunteer medical mission to Honduras, we had a close call with a blood clot in the airway following nasal surgery. This article discusses that event. Read More …
Finding PEEP In a Bottle (of Water): Thinking Outside The Box
As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.
Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.
Let me give you an example of one rather exciting case from early in my volunteer experience in which I had to reinvent PEEP using some suction tubing and an irrigation bottle filled with water.
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MacGyvering In Anesthesia
I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day. The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.
As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as producing PEEP from some suction tubing and a bottle of water. (see story here)
But being able to improvise is just as important in the settings of the more modern hospital. This article describes two examples of having to improvise for an anesthetic. Read More …
Hair Style Can Impact Intubation
Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.
On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. For example, there is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Read More …
Intubation With Airway Bleeding and Massive Emesis
During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? This article discusses two prior cases and offers suggestions on intubation when massive emesis or blood interfere with visualization. Read More …
Avoiding Pediatric Drug Errors
Pediatric medication errors are distressingly common. This article discusses various ways to reduce the risk of administering an incorrect medication dose to a child. Read More …
Difference in Manual Ventilation: Self-Inflating Ventilation Bag vs. a Free Flow Inflating Bag
Ventilating with a bag-valve-mask device requires a good mask seal against the face in order to generate the pressure to inflate the lungs. But it also requires knowledge of how to effectively use the ventilation device to deliver a breath. This article discusses the difference in the use of a self-filling ventilation bag and a free-flow ventilation bag. Read More …
Ventilation Perfusion Mismatch
There are 2 types of mismatch: dead space and shunt. Alveolar gas exchange depends not only on ventilation of the alveoli but also on circulation of blood through the alveolar capillaries. This makes sense. You need both oxygen in the alveoli, and adequate blood flow past alveoli to pick up oxygen, other wise oxygen cannot be delivered.
When the proper balance is lost between ventilated alveoli and good blood flow through the lungs, ventilation/perfusion mismatch is said to exist. The ventilation/perfusion ratio is often abbreviated V/Q. V/Q mismatch is common and often effects our patient’s ventilation and oxygenation. Read More …
Intubation With A Curved Blade
Direct laryngoscopy depends on being able to bring the 3 axes of the airway into alignment to see the larynx. Straight and curved blades use different techniques for bringing the larynx into view. Curved blades are commonly used, especially by beginners because they are more forgiving of less than optimal placement and provide more room to pass the tube. However, it’s important to use them correctly. This article will discuss intubation technique using a curved blade. Read More …
Help! My Anesthesia Machine’s Not Working!
There is nothing quite as scary as being in the middle of administering an anesthetic and having your anesthesia machine fail. In my 36 years of anesthesia practice I’ve had this happen to me a few times. Knowing how to quickly troubleshoot your machine, and knowing how to protect your patient are important, potentially life-saving skills. It helps to have thought through the steps to rescue the situation before it happens to you. This article discussed the steps you should take if your machine fails. Read More …
Codeine Risk In Children, Especially Those With Sleep Apnea
Although the initial FDA warnings about potentially fatal codeine overdose in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. This article reviews some of the risks of using codeine in the pediatric population as well as the patient’s at highest risk for potentially fatal respiratory depression. Read More …
Intubation: Step By Step
Fall is the time of year when new students commonly begin to learn how to intubate. My first intubation was one of the first times I literally held someone’s life in my hands. I was nervous. The anesthesiologist teaching me tried to not look too anxious as I awkwardly grabbed my laryngoscope blade, fumbled while opening the patient’s mouth, and cautiously maneuvered the endotracheal tube into the trachea. It felt like time stopped until the tube was in place, after which the three of us (me, my teacher and my patient) all took a deep breath. Since then, over the last almost 37 years, I’ve intubated thousands of people in the U.S. and, as an international volunteer, eight countries.
So I thought it would be helpful at this time of year to discuss a step-by-step approach to intubation with the commonly used curved blade. Intubation, like a dance, is composed to steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly together. The description and illustrations below are excerpted from my book Anyone Can Intubate, where you can find more detail about this and many other topics. Read More …
Tips To Teaching Intubation
With fall comes the new crop of trainees eager to learn how to intubate. There will also be a new group of instructors teaching their first students to intubate. Teaching intubation skills on living patients, even those that have practiced on a manikin, can be challenging. It’s important to anticipate the common errors so we can safeguard our patients. Read More …
Alert: We May All Be Over-Inflating Our LMA Cuffs!
The laryngeal mask airway, or LMA, is so commonly used, and so apparently safe, that it’s easy to become complacent. Research is showing that it’s apparently very common for us to over-inflate our LMA cuffs — to the potential harm of our patients. This article discusses some of the risks of overinflation, the predispositions to overinflation, and some of the strategies to avoid it. Read More …
Avoiding Difficult Intubation Of The Easy Airway
We’ve all done it. It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. This article discusses the various ways you can adjust patient positioning and use your equipment to make intubation easy. Read More …
Intubating An Infant or Toddler
This article discussion some of the key points to intubating an infant or small child safely. Providers who infrequently care for infants and children less than two years of age are often rightfully anxious when faced with a sick child, especially if airway management is required. This is especially true if the child is less than one. Healthy respect is certainly indicated because airway complications are one of the leading causes of pediatric cardiac arrest.
Intubating an infant or small child is more of a challenge than an older child or adult both because of their anatomical differences as well as their physiologic predisposition for hypoxia. However, anyone who can intubate an adult can also intubate an infant or toddler safely if they take these differences in anatomy and physiology into account and are gentle and methodical in their approach.
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Mask Ventilation: Avoiding Hand Fatigue
Those of us who ventilate patients have all been there. We’ve been ventilating a patient with a bag-valve-mask device during a prolonged and difficult intubation process and our hand holding the mask starts to cramp. When ventilating a patient with a mask, it’s important to know how to open and airway and provide positive pressure breaths. However, it’s also important to know how to do so in a way that conserves your grip strength. Ventilating with a mask can be very tiring to your hand. Prolonged “masking” can tire your hand to the extent that you lose grip strength and coordination — making maintenance of an open airway harder to sustain over time.
Here we discuss tips on how to ventilate effectively while avoiding hand fatigue. Read More …
Positioning The Head For Intubation
This article discusses the different ways of placing the patient in the sniffing position and the advantages and disadvantages of each to improve first pass intubation success. Position of the head and neck for intubation can make intubation easy, or hard.
Many years ago our operating room administration Removed the towels we had been using to position the head for intubation. It may be an exaggeration to say that chaos ensued, but it felt like that.
For the next several days our anesthesia providers had trouble intubating. We likened it to an expert golfer who, when suddenly faced with a new set of golf clubs of slightly different weight and length, suddenly has to relearn the game. It made us realize that how we position the head in the sniffing position often sets us up for either an easy or for a more difficult intubation if you don’t realize what’s happening during the positioning. Read More …
Potential Tongue Ischemia with LMA Supreme
When we place anything in the mouth, be it an endotracheal tube, oral airway or LMA, we are typically extremely careful to protect the teeth. We take care to avoid cutting the lips with the teeth. But we often take the safety of the tongue for granted. I recently recognized a potential problem while using an LMA supreme that could have caused tongue ischemia if not recognized and corrected. Read More …