Questions of the Week for 1/16/2024

Author: Christian Gerhart

Q: You are intubating a patient and are only able to obtain a grade 3a view on video laryngoscopy. You have trouble passing the endotracheal tube and decide to switch to a bougie, but it gets caught up on the posterior arytenoids and you cannot reach anterior enough to pass it through the cords. What techniques can you use to troubleshoot this?

• Answer

  The bougie out of the package is a straight device which lacks the curvature necessary to reach an anterior airway. An option is to pre-bend the bougie to create the curvature necessary to reach more anterior airways. If the bougie is not pre-bent and during the intubation you find yourself in need of the ability to reach a more anterior airway, an option is to bend the bougie on the bed as seen in this video from George Kovacs https://www.youtube.com/watch?v=tEMCZG1hXsw&t=12s.

Q: You are able to pass the bougie but are struggling to pass the endotracheal tube over the bougie through the cords. What is the most common cause of this and how can it be solved?

• Answer

  A common reason that there is difficulty passing the endotracheal tube over the bougie through the cords is that the bevel gets hung up on the arytenoids. A simple solution to this is to retract the endotracheal tube and rotate it 90 degrees to the left. This will generally change the angle enough to relieve the hold up from the bevel of the tube. Some authors recommend using this maneuver on all intubations (including without a bougie) in order to avoid this problem. See the video from George Kovacs for more: https://www.youtube.com/watch?v=bJuLgeSnK54.

Q: You are intubating a patient with a massive upper GI bleed. Describe your set up for the intubation.

• Answer

  Airway decontamination is key for this case. This intubation necessitates double suction, preferably with a large bore suction such as the Ducanto suction. A large bore endotracheal tube can be connected to the suction if a Ducanto is not available as seen in the attached article. Consider placing a nasogastric tube prior to induction if the patient tolerates it. Another option is a delayed sequence intubation using ketamine to facilitate this if deemed necessary. If time allows, a dose of a promotility agent such as erythromycin (250 mg IV) or metoclopramide (10mg IV) can be administered to assist with gastric emptying. Consider intubating this patient in a “ramped” or head of bed elevated to 30-45 degrees position to prevent aspiration. As always, aggressively pre-oxygenate the patient.

  More here: https://emcrit.org/emcrit/intubating-gi-bleeds/

Q: Describe your approach to airway decontamination during the intubation when approaching this airway.

• Answer

  This airway would likely be best approached with suction assisted laryngoscopy and airway decontamination (SALAD). There is a high risk that video laryngoscopy could be limited if the airway is not properly decontaminated and leading with suction is key as seen in the video below. If an NG tube is not already in place, consider cannulating the esophagus with a suction to prevent continued contamination. As mentioned before, two large bore suctions would be ideal for this situation.

  https://www.youtube.com/watch?v=Jaq-vHbcGi0

  https://emcrit.org/salad/

Q: You are caring for a 3-year-old child who presents in respiratory distress and needs intubation. What laryngoscope blade should you use?

• Answer

  A size 2 Mac or Miller would be preferred for this intubation. Generally, for pediatric patients over 2 years a size 2 blade is usually a good option until around age 10. Historically, a Miller blade has been preferred for this age group given the floppier epiglottis, however some authors have suggested that either a Miller or Mac has similar efficacy. Importantly, many EM providers are more facile with a Mac blade and so it may be preferred to use a Mac in this scenario.5,6 If you are in a pinch and cannot remember, the correct blade size can be measured from the patient’s upper incisor to the angle of the mandible.7

Q: What type and size of endotracheal tube should you use for the above patient?

• Answer

  For a 3-year-old patient, either a size 4 or 4.5 cuffed endotracheal tube (ETT) would be most appropriate. The age-based formula is (Age + 16)/4 for UNcuffed ETTs. For cuffed ETTs, remember to subtract 0.5 from this. Math is hard in an intense situation, which is why it may be helpful to use a phone app or other resource such as the book we have at SLCH.

Q: Despite multiple attempts the patient above cannot be intubated and you are unable to oxygenate/ventilate them despite trying bag-valve mask and an attempt at an LMA. How should this airway be managed?

• Answer

  For children under the 8 to 12-year age range a needle cricothyrotomy is recommended in this situation. There is some variation in the guidelines for how to approach a can’t intubate, can’t ventilate situation in children. Some authors suggest that over age 8, it is acceptable to use a surgical cricothyrotomy, whereas others do not recommend this until age 12. Recall that the anatomy can be challenging at younger ages making it difficult to locate the cricothyroid membrane. This can be performed by aspirating with a syringe and passing a large bore angiocath into the trachea. It may be easiest to use the angiocath from the triple lumen catheter central line kit to ensure it is a syringe-needle combination that you can aspirate through during insertion and which does not have a stopper on it as some new angiocaths do. This can then be connected to either a bag using a 3 cc syringe and a 7.0/7.5 ETT adapter or to a jet ventilation set up.

  https://criticalcarenow.com/practical-plan-for-needle-cric/

Q: You are taking care of a 67 yo male with a history of heart failure with reduced ejection fraction and hypertension who presents with an acute decompensated heart failure exacerbation as evidence by pulmonary edema on imaging and a ten-pound weight gain since his last admission. He also has an acute kidney injury. He receives 40 mg of IV Furosemide but has not urinated after an hour. What should you do next?

• Answer

  Increase the dose of Furosemide. Recall that loop diuretics act as “threshold drugs”, meaning that they have an “all or nothing effect”. Once the threshold dose to obtain a response is reached, there is generally no increase in efficacy above this dose. Importantly, there is typically no effect prior to reaching this threshold. The DOSE trial9 was a prospective, double-blind RCT of over 300 patients, which examined diuretic dosing in decompensated congestive heart failure. Patient were assigned to either a low dose (IV dose equal to oral loop diuretic equivalent), high dose group (2.5 times patient’s previous oral dose equivalent) or continuous IV infusion. The high dose group seemed to have a faster resolution of symptoms with a decrease in serious events, despite an association with a transient worsening in creatinine. The Journal of the American College of Cardiology (JACC) recently published a review article on this topic.11 They recommend that if the patient has not reached the target urine output within two hours (usually about 300 mL in two hours or 150 mL/hr) then the dose of Furosemide should be doubled and administered again. This process can continue up to a maximum dose of somewhere between 200-300 mg (though this maximum is not clearly defined).

  This is a helpful guide from the University of Michigan.

  https://www.ncbi.nlm.nih.gov/books/NBK589894/

References:

1)      Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015;25(4):346-362. doi:10.1111/pan.12615

2)      Krishna SG, Bryant JF, Tobias JD. Management of the Difficult Airway in the Pediatric Patient. J Pediatr Intensive Care. 2018;7(3):115-125. doi:10.1055/s-0038-1624576

3)      Holm-Knudsen RJ, Rasmussen LS, Charabi B, Bøttger M, Kristensen MS. Emergency airway access in children--transtracheal cannulas and tracheotomy assessed in a porcine model. Paediatr Anaesth. 2012;22(12):1159-1165. doi:10.1111/pan.12045

4)      Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31-81. doi:10.1097/ALN.0000000000004002

5)      Varghese E, Kundu R. Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children?. Paediatr Anaesth. 2014;24(8):825-829. doi:10.1111/pan.12394

6)      Passi Y, Sathyamoorthy M, Lerman J, Heard C, Marino M. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr of age. Br J Anaesth. 2014;113(5):869-874. doi:10.1093/bja/aeu228

7)      Mellick LB, Edholm T, Corbett SW. Pediatric laryngoscope blade size selection using facial landmarks. Pediatr Emerg Care. 2006;22(4):226-229. doi:10.1097/01.pec.0000210171.17892.7a

8)      Ellison DH, Felker GM. Diuretic Treatment in Heart Failure [published correction appears in N Engl J Med. 2018 Feb 1;378(5):492]. N Engl J Med. 2017;377(20):1964-1975. doi:10.1056/NEJMra1703100

9)      Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364(9):797-805. doi:10.1056/NEJMoa1005419

10)  Brisco MA, Zile MR, Hanberg JS, et al. Relevance of Changes in Serum Creatinine During a Heart Failure Trial of Decongestive Strategies: Insights From the DOSE Trial. J Card Fail. 2016;22(10):753-760. doi:10.1016/j.cardfail.2016.06.423

11)  Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic Therapy for Patients With Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(10):1178-1195. doi:10.1016/j.jacc.2019.12.059