I work in a tertiary care hospital with a lot of gut surgery. Our surgeons have a dedicated team to oesophageal and upper GI surgery. And these surgeries are prone to respiratory complications. We, anesthesiologists and critical care physicans face the need for intubation in these patients.
The risk for aspiration pneumonia is high in patients who have undergone an oesophagectomy, the gastric pouch in the thorax is often dilated and the reflux of gastric liquid can enter the oral cavity very quickly.
To optimize induction and airway management in these patients I usually go through this quick check-list.
- IV erythromycin, 250 mg
- Get everything ready (large suction +++ Cr James DuCantos’ work 🙂 ) like always, and bougie ready
- Always use a neuromuscular blocking agent, my choice is rocuronium (but it’s not validated) or sux.
- I push a little bit more hypnotic than usual to make the patients really deep for the intubation, my choice is ketamine with midazolam
- Large gastric tube on suction (the nasogastric tube is around 40 cm at the nostril if the patient has a gastric pouch in his thorax)
- Syringe already on the tracheal tube
- Intubate in the semi-recumbent position or even with the patients sit. I climb on the frame of the bed and from there you’ve got a perfect line of sight on the airway !
- Be ready to put the head down to suck gastric liquid
In the (medical) critical care setting there is a strange habit in France to sparsely use NMBA for intubation. I really do not get why… but in the situation of high risk for aspiration patients I think it’s a really bad idea not to use NMBAs.
There is a debate about the Sellick maneuver – cricoid pressure. I’m not a believer of this technique. It’s currently under evaluation with a big study called IRIS in France. Frankly i do not do it.
So, that’s my induction and airway management in oesophagectomised patients. As a quick reminder I also use this strategy for patients with big pancreatic cysts, oesophagus achalasia and (sub)occlusive state patients and also those with severe nose bleed who usually swallow a lot of blood stagnant in the stomach. In this last situation pay attention to hyperkaliema and sux, especially in chronic kidey failure patients.
Thanks Thomas for the corrections !
PS après avoir vu la vidéo dont le lien est partagée par Adriana dans les commentaires et un billet sur Scancrit je me dis de plus en plus qu’une intubation oesophagienne volontaire peut être utile dans certains situations à haut risque de vomissements pour guider le flux digestif à l’extérieur du patient.