Awake Fiberoptic Nasal Intubation

So all the times that you practiced your craft (handling a fiberoptic scope such as during the difficult airway class weaving down the bucket with little holes; placing double lumen tubes),

all the times you’ve asked experienced providers what they did (for an awake fiberoptic intubation),

all the times you watched one (once for an awake fiberoptic oral intubation),

all the times that you performed one (under optimal conditions with a Glidescope and an asleep patient),

and all the times that you did something similar (nasal intubations),

it prepares you for this moment — for this call:

“There’s an emergency intubation for you and it must be done as an awake fiberoptic intubation nasally.”

You call your partner who’s already bedside and workout a plan

He’s optimizing the patient – Afrin drops, nasal trumpets, racemic epi nebulizer, and 4% lidocaine nebulizer

You’re ready – 7.0 oral ETT in warm saline, lubricated tube and fiberoptic scope, ketamine, precedex drip, an ENT surgeon and team for possible trach

The patient arrives, looking more perky, sats 96%, sitting up, switch monitors, fluids, ETT on the tip of the fiberoptic, suction on, sedation is in

Standing in front of the patient on the right side with the camera on the left

ETT inserted 1/3 in, cameras in, orientation, following the bubbles, past the epiglottis, vocal cords, tracheal rings

Holding still, inserting the rest of the ETT, cuff up, fiberoptic scope out, circuit on, positive end tidal CO2, sats 99%

Smooth, success 

Optimizing Patients for Urgent Surgeries – Non-Elective Surgery Triage

Urgent surgeries — such as appendectomies, cholecystectomies, are common. Sometimes the patients are healthy and other times they are a train wreck. When they are of the latter sorts, the goal should be the optimize the patient for surgery so they are prepared to undergo the stress of surgery.

Understanding the classifications of semi-urgent, urgent, and emergency surgeries informs us of the time that we have to optimize a patient. For example…

It is the weekend call shift with limited resources. The surgeon schedules a laparoscopic cholecystectomy on a patient. Great, you go and look up the patient and find out that:

  • She’s scheduled for a CABG (coronary artery bypass graft) aka open heart surgery next week
  • There’s no echo, angiogram report, no cardiology note on the patient
  • BP 160/110, HR 115
  • Diabetic
  • On the kidney transplant list

So what do you do? The surgeon insists that it is urgent and must be done that day (later you find out that he has scheduled long cases for the next day).

Well, first the goal is to optimize the BP and HR so the BP is below 140/90 and HR below 100. We titrated in metoprolol to effect. We waited for vitals to stabilize before we went. Unfortunately, the surgeon later insisted that it was an emergency case so we had to go on the weekend.

However, was it really an emergency case? Could the case go the next day when there are more resources?

Without additional information, the goal for the patient was to do a slow induction, maintain perfusion, and gentle emergence.

Based on Non-Elective Surgery Triage (NEST), the acute cholecystitis could’ve been scheduled the next day on a Monday where there are more resources.

Non-Elective Surgery Triage (NEST) Level
Non-Elective Surgery Triage (NEST) Classification

Nurse Jess in Top 30 Anesthesiology Blogs

Anesthesiology Blogs

This morning I woke up to an email sent by Anuj, the founder of Feedspot. I will admit, I haven’t heard of Feedspot before today (and maybe for you as well). I’ve never been listed as a top blog so I was surprised and honored to be awarded one of the top 30 anesthesiology blogs.

As I browsed the list, I noticed that I was the only personal nurse anesthetist blog. The rest consists of anesthesiologists and larger organization blogs. I will do my best to continue to represent the nurse anesthesia community.

As I transition from a graduate to a new nurse anesthetist in a new community, I learn a lot. Part of becoming an anesthesia professional is

  • recognizing your limitations and when you need an extra set of hands,
  • asking your colleagues for their professional opinion as you develop your anesthetic plan (especially for cases you’re less familiar with, for cases with different surgeons, for cases with different patient populations),
  • asking for mentorship and help for improving your weaknesses, and
  • knowing that the health field will change.

For example, the United States has a shortage of several anesthetic drugs. And there’s an opioid epidemic that has torn this country apart. The healthcare costs continue to rise, and the length of stay continue to decrease. To help prevent potential complications such as respiratory depression and opioid addiction and to improve pain management strategies, I believe that it begins preoperatively with the patient, continues intraoperatively, and postoperatively.

After the Enhanced Recovery After Surgery (ERAS) protocol came out for colorectal surgery, many more ERAS protocols have developed for different surgeries (and each institution has their protocols). The ERAS peaked my interest in providing opioid-free anesthesia. Part of that process requires providing blocks (or ‘numbing’) for a specific area of the body. Tom Baribeault, one of the founders of the Society for Opioid Free Anesthesia (SOFA), spoke at the University of Michigan-Flint’s anesthesia conference last year. He added fuel to this fire.

After speaking with several of my colleagues who already provide opioid-free anesthesia, reading peer-reviewed journal articles, and completing the American Association of Nurse Anesthetists (AANA) course on enhanced recovery after major abdominal surgery, I set off to do just that. In between my cases, I’ll follow up with the patient and the post-anesthesia recovery unit (PACU) nurse and see how the patient did. I will continue to improve this technique.

In the end, the goal is to provide safe and effective patient care for every patient.