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Clinical Case for Discussion: You are called at 0200 hours to anesthetize a 50-year-old man who is bleeding from his palate. He is 14 hours status-post a uvulopalatopharyngeoplasty (UPPP) for sleep apnea. He is 6 feet tall, weighs 200 pounds, and he is spitting up blood. What do you do?
Discussion: You meet the patient in the ICU. He is sitting up in bed, spitting out small amounts of blood and swallowing the rest. He has been bleeding for four hours, and the total volume of blood seen has been less than a cup. Vital signs are: pulse 100, blood pressure 160/90, and oxygen saturation 97% on room air. The airway exam reveals dried blood on the mouth and tongue, moderate edema of the pharynx, tongue, and mucous membranes, and no bleeding point is seen. Review of the chart reveals that your partner intubated the trachea with a Miller #2 blade without difficulty that morning for elective surgery. The surgeon wants the patient asleep as soon as possible. You transport the patient to the operating room, and have him breath 100% oxygen through a mask while you prepare for the anesthetic.
The A-B-C’s of Airway-Breathing-Circulation dictate that the Airway is the most important factor to consider in this case. You have the principles of the ASA Difficult Airway Algorithm (see www.ASAhq.org) committed to memory. You plan a strategy for the airway management. Per the Algorithm, you begin by assessing the likelihood of four basic problems: 1) Difficult ventilation, 2) Difficult intubation, 3) Difficulty with patient cooperation, and 4) Difficult tracheostomy. You assess that you will be able to mask ventilate this patient, but there is some chance that the blood and edema will make intubation difficult. You also consider that blood and edema could make both mask ventilation and intubation difficult. Patient cooperation is adequate, and the surgeon states that he would not have difficulty doing a tracheostomy or cricothyroidotomy.
Next you consider the choices of: a) awake intubation vs. inducing general anesthesia first, b) use of non-invasive techniques as the initial approach to intubation vs. surgical techniques like tracheostomy, and c) preservation of spontaneous ventilation during intubation attempts vs. ablation of spontaneous ventilation.
Your assessment is that awake fiber optic intubation would be difficult secondary to the active airway bleeding. Blind awake nasal intubation is a possibility, but looking at the patient, you make a different choice. You are confident that you can induce general anesthesia, use cricoid pressure, paralyze the patient, and intubate the trachea using a Miller #2 blade as your partner did the previous morning. If you have difficulty seeing the larynx, you will use a Yankauer suction to clear blood, try alternate laryngoscope blades, and support oxygenation by mask ventilation while cricoid pressure is continued. You may utilize other options as necessary, including a bougie or a light wand. If ventilation becomes difficult, you will insert an LMA. If ventilation becomes impossible, the surgeon will perform an emergency surgical airway.
You need an assigned individual to assist you during your airway management. Because there is no other anesthesiologist in the hospital, your otolaryngology colleague is the obvious assistant. Before you induce anesthesia, you bring the difficult airway cart into the operating room, as well as a tracheostomy tray for the surgeon.
You discuss this plan with the surgeon. After preoxygenation, you induce anesthesia with propofol and succinylcholine. Cricoid pressure is applied. When you insert the laryngoscope into the mouth, all you see is blood, swollen tissues, and no view of the larynx. Your next action is aggressive suctioning with a Yankauer catheter, and after repositioning the laryngoscope, you are able to see the larynx. The tracheal tube is placed, the cuff is inflated, and its location confirmed by CO2 and auscultation. You recheck vital signs, begin maintenance anesthesia with sevoflurane, and the surgery begins.
I had a case of this type twice in the last 5 months. Both cases were effective in raising the endogenous catecholamine level of this anesthesiologist. Both were good exercises in planning airway management. The most striking characteristic of each case was the amount of blood in the airway when I inserted the laryngoscope. The Yankauer suction catheter was essential, and I recommend inserting it immediately after inserting the laryngoscope.
The literature documents the prevalence of bleeding after UPPP as 1.4% (Mickelson SA, Is Postoperative Intensive Care Monitoring Necessary After UPPP?, Otol Head Neck Surg 1998 Oct, 119(4) 352-6.) The bleeding patient post-tonsillectomy is a similar presentation. Miller (Anesthesia, 2000, p 2188) writes “The incidence of post-tonsillectomy bleeding that requires surgery is 0.3 to 0.6 %. . . The extent of blood loss may not be obvious and is usually underestimated. . . Most problems before induction of anesthesia for bleeding tonsil are caused by unsuspected hypovolemia, full stomach, and airway obstruction. . . At induction of anesthesia, an additional person should be available to provide good suctioning of blood. A rapid-sequence induction of anesthesia with application of cricoid pressure and slight head-down positioning of the patient will protect the trachea and glottis from aspiration of blood.”
The ASA Difficult Airway Algorithm. . . learn it well, and be prepared to apply it in the middle of the night. Your heart rate may be faster than the patient’s.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date September 9, 2014 by Pegasus Books.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: