Paralyzed with Indecision

What is the best option for intubating patients who are low probability for difficult ventilation?
Calder, I. Could safe practice be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker? Anesthesia 2008 63 (113-5) Turlough OHare PGY5 McMaster Anesthesia

Prior to administering an Anesthetic

Answer 2 questions:
Potential trouble with ventilating? Potential trouble with intubating?

Unanticipated difficult ventilation

Attempt intubation First attempt best Use NMBA or attempt mask ventilation first?

What would you do?

Hx snoring and BMI 31 (175cm, 95kg)? Hx 60yo with beard and BMI 31? Hx OSA, thick neck and BMI 31?

What would you do?

GR 3 MV GR 3/4 MV and DI BMI 30 Jaw protrusion snoring Beard Thick neck MP 3/4 Sleep apnea 57yo Odds ratios
RF 3MV 3/4MV DI

1+
2+ 3+ 4+

6
10 20 35

5
11 17 23

What would you do?

Odds ratios
RF 3MV 3/4MV DI Hx snoring and BMI 31?

1+
2+ 3+ 4+

6
10 20 35

5
11 17 23

What would you do?

Odds ratios
RF 3MV 3/4MV DI Hx 60yo with beard and BMI 31 (175cm, 95kg)?

1+
2+ 3+ 4+

6
10 20 35

5
11 17 23

What would you do?

Odds ratios
RF 3MV 3/4MV DI Hx OSA, thick neck and BMI 31?

1+
2+ 3+ 4+

6
10 20 35

5
11 17 23

What should we do?

1. if tracheal intubation is planned in a patient in whom difficulty with FMV is a possibility, should we give NMBA drugs as soon as possible? 2. not all such patients can be identified in advance
should NMBs be given routinely immediately after induction?

5 points on the use of NMBAs prior to intubation

1. Cant ventilate, then what?

In practice, patients are not woken up if we cant ventilate them
We try to obtain an airway Catastrophic hypoxia is likely to ensue if we are unable to obtain patency

2. Horns of a Dilemma
Enough hypnotic to mask-ventilate

vs.
Minimize hypnotic to maximize return of consciousness
Fear may result in under dosing

3. Is masking easier with a NMBA?

reluctance to give a NMBA when FMV proves to be difficult is more likely to result in FMV that is difficult, compounding any difficulty resulting from a relatively low dose of induction agent.

4. should difficulty occur

the absence of neuromuscular blockade may hinder rescue of the situation There is a considerable body of evidence to support the proposition that NMBs make intubation easier

5. Whats the real problem?

NMBAs can resolve some problems with BMV such as laryngospasm

5 points on the use of NMBAs prior to intubation

1. common practice when a cant ventilate scenario ensues is to attempt intubation 2. optimal revival and optimal intubating conditions are in conflict 3. the addition of NMBA to our anesthetic likely improves mask ventilation 4. the addition of NMBA to our anesthetic likely improves intubation success 5. the lack of NMBA may result in inappropriate treatment of a patient who is difficult to ventilate due to lack of relaxation (i.e. bronchospasm)

What would Calder do?

if tracheal intubation is planned in a patient in whom difficulty with FMV is a possibility
1.give NMBA drugs as soon as possible
conditions for intubation are optimized

2.not all such patients can be identified in advance

So, NMBs should be given routinely immediately after induction

What would you do?