Your SpO2 dropped because the blood pressure was up and oximeter was on same arm. You can tell by the flat trace turning back into a normal pulsatile trace. It also averages the last 20-30 seconds so wouldn't immediately improve as soon as you squeeze the bag. I think the positioning was the issue here, difficult to say with the blurry face but can't see that he would appear difficult with DL if properly positioned. Although if you have the glide scope in the room I'd probably just use that in an RSI. Thanks for sharing!
50 mgrs of rocuronium is suboptimal dose for IRS ( if you use in that patient 1 mg/kg or 1,2 mg/kg) , in that case with maxilar and orbital fractures we should consider use videolanigoscopy as first option in our airway management plan
I believe the basic airway positioning was missed here, specifically the chin lift, head tilt, and jaw thrust for better ventillaion and to align the oral, pharyngeal, and laryngeal axis. Instead of using multiple mattresses, a head ring would have been a better choice. Additionally, a shoulder roll could have helped achieve better neck extension. The anesthesia mask you selected would be more suitable for patients with a Mongolian-type nose with a short bridge. For your patient, a snuggy silicone mask would have provided a better fit. That being said, anesthetic management always depends on the situation at hand, and your actions were clearly in the best interest of the patient. You successfully managed the case, and congratulations on saving the patient 👏 👏
Honestly, at first thank you for providing such cases. It will help people to recognise key factors in such circumstances. But really I have seen a lot of points, where you can do better. 1. Patient positioning. And I don’t mean the position for the intubation. It is the position for preoxygenation. The patient seems young, not obese and you have an hypoxemia beginning arround 1-1.5min after the induction of the anaesthesia, what means your preoxygenation was poor. That should and must not happen. If done correct, this would not occure. You are giving away arround 400-500ml FRC by not using an Anti-Trendelenburg-Position, so that means a lot of time. What was your etO2 before starting the RSI? Was it arround 85+? If it was the case in this young man‘s case, a hypoxemia would not occure that fast. 2. Why not using the videolarnygoscopy as primary device for intubation? There is no contraindication for it. You want the best circumstances for the highest first pass succes. 3. Your using of your medication is poor. The man seems arround 75-85kg. If I am seeing this right, you are using a 5ml syringe with rocuronium, which means 50mg of it. This is not a proper dose for RSI. Correct dose would be arround 0,9 - 1,2 mg/kg bodyweight, which means at least 75mg, if he weighs that much. 4. The measure of the blood pressure on the arm you use for giving the drugs can be a potential pitfall. If set to automatic measurement and it starts where you are infuse the drugs, it can delay their effect. 5. I am not sure why you are using pressure on the criccoid. There is no scientific evidence that the use of it will prevent aspiration. It is obsolet. 6. Why did you not make use of fentanyl or sufentanyl? It helps to provide a significant decrease of stimulus done by the laryngoscopy and even lowers the amount of propofol needed for anaesthesia. If you are doing this as a „classical“ RSI, the not using of a opioid seems understandable, but questionable. Kind regards
I could not agree more: - Preoxygenation and intubation in Anti-Trendelenburg-Position with tight-fitting face mask and high oxygen flow until you get around 85-90% expired oxygen concentration - Muscle Relaxation with 1 mg/kg ideal body weight of rocuronium - Videolaryngoscopy at first attempt in rapid sequence intubations - No cricoid pressure except external laryngeal manipulation for improving visibility / routing of ET
Thank you. All agreed. But would request that you record an emergecny case and share as a follow up so that we can all comment on how perfectly it went! ;)
@@nysoravideo Don‘t get your comment right. Maybe my english is a little bad. You suggest that I record an emergency case and you want to comment on it, is that correct? The hospital I am working for will not allow that kind of thing. Please correct me, but do you think my comment is too negative? Maybe you are a little thin-skinned, but this is just an assumption. If the emergency is your answer for the potential suboptimal handling in that case, maybe you should adjust your procedures. Just then you have to do your job right. Don‘t get me wrong, I like your work, your sharing of regional anaesthesia technics, everything you do for the World of Anaesthesia, but if you upload videos like this, you have to live with the comments. My criticism is objective and relevant, personally I lack at the right words, so there are maybe misunderstandings. Sorry for that. I don’t comment on RUclips-Videos a lot, but it is matter of the heart for me to say things, which could be done in a better way, because everybody will learn from it. All the things I mentioned to improvise to perform a RSI, I use them in my daily routine as an anaesthesiologist. Therefore sorry for harsh words, but this is just my opinion. I am looking forward for the release of new videos. And I hope I won‘t be banned. Improvement is only possible through objective criticism and daily routine. Kind regards
Hello , can you make some videos regarding paediatric cases , difficult intubations in neonates , neonate with diaphragmatic hernia ……. Like those scenarios. Thank you 😊
@3:25 it's mentioned here in the video that an oral airway could be used if ventilation is difficult, but it should be clarified that in this situation (RSI) one would not attempt ventilation which would otherwise defeat the purpose of the RSI
This is interesting. I often worried about this, however, low pressure, low volume careful ventilation can oxygenate and buy time. It's not optimal but a compromise. If ventilation is easy, it is likely going through the glottis, but no guarantees. Hi flow oxygen is also another option, my favourite.
A few things that could be improven if Im not mistaken: - With orbital and maxilary fracture, a difficult airway could be expected, hence - Consider awake intubation if expected difficult airway, or even glidescope as a first try to avoid neck manipulation (Im assuming cervical injury could be a thing in this case) - I disagree with some comments here: the top of the breastbone is at the same height as the ear for an optimal ramped position while avoiding neck manipulation in a trauma scenario - Was fentanyl used or not loaded at all? The syringe was empty. I think using fentanyl during rapid sequence does not bring clear benefits and could impair hemodynamics after intubation - During rapid sequence, you should at least use 1mg - 1.2 mg/kg of rocuronium, while only 50 mg (standard 10mg/ml concentration I think) was administered. Im bad at estimating weight, but based on ventilation settings (tidal volume) I think 80-100 mg would be an appropriate dose. After 1 minute, vocal cords could still be closed after a low induction dose. - You do not want NIBP on the same arm as your IV, during the last seconds you can see a flattened O2 wave wich could provide inaccurate O2 values - SpO2 does not increases as soon as ventilation starts, it usually takes 10-15 seconds of good oxigenation to reflect an increase of SpO2. Im pretty sure you were all checking direct and indirect signs of tracheal intubation nevertheless. You can even see that capnography states etCO2 of 0 while looking at the monitor (which is also delayed by a few seconds).
From a smartphone perspective, it seems that all the struggle could have been avoided with proper positioning. Sometimes, in extreme situations, we ignore the basics!) I want to thank the entire NYSORA TEAM, and especially Dr. Hadzic, for the valuable educational content! Greetings from the Moscow anaesthesiologists 🤙🏻
You should mention difficult airway trolley as well it is crucial to heave nearby , and isn’t seen on this video. Also ramp positioning would be more appropriate in case of full stomach even for better sniffing and flexion of C0-C1 joint 😊 thanks for sharing useful video.
I think the positioning lead to the difficulty in above case , the ideal intubating position isnt achieved making visualization difficult, correct me if i am wrong, as someone mentioned why not regional anaesthesia which is more safe for ankle fracture rather than GA, thanks in advance
you intubated with propofol , alfentanil and rocuronium. soon after maintenance with SEVO. put him in PCV with FGF 1,0L and sevo 1,9. in some minutes the patient will wake up paralyzed. It will take hours to achieve 1,0 MAC of SEVO.
you intubated with propofol , alfentanil and rocuronium. soon after maintenance with SEVO. put him in PCV with FGF 1,0L and sevo 1,9. in some minutes the patient will wake up paralyzed. It will take hours to achieve 1,0 MAC of SEVO.
Not really. This ventilator (Aisys) has an automatic mode for target end tidal concentration for sevoflurane (you can see it at 7:00 - the ventilator screen in light blue, normal mode is in grey). This mode adjust automatically gas flow and fiO2 to reach in 1-2 min expected target for oxygen and sevoflurane end tidal gaz concentration. This mode is available on modern ventilator as Aisys, Flow-I, Zeus and Felix.
@@philippepenven4875 HI, Thanks for your comments but i didn't find it in the user guide. I work in the same anesthetic station Aisys CS2, weird explanation..... no gas reach a steady state in 1-2 minutes in daily clinical use.
This looks like a polytrauma patient. If we're not sure about C-spine stability, the usual head positioning to optimize intubation conditions has to be done with extreme care. Furthermore, if there's evidence of trauma to the head, I anticipate a difficult airway every time so my plan would have been video laryngoscopy from the start. I also realized that IV access, NIBP and pulse oximeter are all on the same limb. Not ideal, but if other limbs have trauma or are surgical sites, you use what you have. Should remember that pulse oximeter waveform will go down during NIBP cuff inflation which is not hypoxia. Very good video.
Thank you. Great comments. And never easy to expose real-life practice, as if everyone here recorded their cases, I doubt they would be sharing them as perfect. You think?
@@nysoravideo Probably the better answer would be, I should do some solo anesthesia cases where I actually manage a few patients by myself so that I can get back up to speed on how to conduct a correctly performed rapid sequence intubation. Then maybe do a video once you have reacquainted yourself with a basic skill that you should already be an expert in.
Recently I attended a DAS talk where they discussed whether MILS was even necessary anymore (like Sellick's manoeuvre in RSI), but stopped short of recommending its removal. So we may see some changes in current recommended practice in the next few years.
@@nysoravideo Agreed, and that is very often NOT the case when this procedure is performed by experienced providers. There is zero reason to not optimize a patient, regardless of the circumstances.
I appreciate everything you do for education but this should call how to do a rapid intubation sequence wrong. It has also the education value as I see all that comments. If the patient really had a full stomach, you would have a serious problem. Thank you for sharing the video
It’s because the anesthesiologist in question has not maintained clinical currency in airway management. This is why credentialing actually matters, especially in academic centers where many attendings can go years without intubating an actual patient.
@@Bijazable this right here , solid gold. Current evidence shows us that if its available, you should use it, specially in pediatric patients and also in the management of the difficult airway, like this case. Thank you, God bless you.
@@valeriageller7436 Based on this performance, I think the attending anesthesiologists at this particular hospital who don't intubate frequently should probably just use the glidescope for all of their cases. Greetings!
maybe since he had facial fractures i would have used videolaringoscopy as first option. I wonder, you didn't insert gastric sound before intubation because of the fractures associated risk?
Too Little Head reclination ( dorsal Extension ) and probably Lack of experience of the Anästhesie resident, but a Good Video for teaching purposes or a Good scenario in this Sense, thanks anyway
@@nysoravideoYou are welcome Admir! How’s it going? If I were you, I would take a sabbatical from celebrity making, and do so some actual cases on your own. You need it brother. Greetings!
Just poor all around... I thought it was being artificially setup with awful positioning, terrible drug selection and delivery for drama.... And no, sats don't improve in 4 seconds, the blood hasn't even circulated... It was a poor waveform. But bizarre as a teaching or textbook sales strategy.
Was it the only ankle surgery or anything else added to that. Only an isolated open ankle if it was, why not go for spinal anaesthesia. Although patient history and labs are unknown, I can only speculate that spinal was not suitable or contraindicated.
The surgery was more complex. But the video is about the unexpected airway challenge, not about the choice of anesthesia. Greetings and many thanks for watching. Commenting
Thanks for sharing. My thoughs: The positioning did not seem appropriate to me, and I would have used videolaryngoscopy from the beginning. In fact, I dont use direct laryngoscopy anymore. I suppose it is mandatory in teaching facilities.
@@nysoravideo Not really but since it was an emergency case to begin with, I would have begun with the video laryngoscope in an anticipation of a difficult airway
If you do get regurgitation direct laryngoscopy is better to facilitate large volume suction and preserve the view. VL camera will get covered in gunk and become useless.
This is not how you manage a "difficult intubation" scenario. Positioning-shit. Drug dosages-shit Blade insertion-shit DL as a first choice for a potential full stomach-shit Not having an aspiration catheter near you-shit Nasogastric tube prior intubation to empty the stomach? To be honest I love your contetn but this video is a pure disaster. Oral airway for a difficult intubation scenario where you have a potential full stomach? Comon..
I really don't understand why novadays videolaryngoscopie is still not the first choice and is not used routinly. As for this case,it should have been used in first as this is definitely expected difficult intubation patient...Fast sequence induction means videolaryngoscopie for me. Correct me if I'm not right
There are two sides of that coin. The more you use video the less proficient you are with direct laryngoscopy and one fearfull day you may be rushed to a setting without video readily avaliable and your f*****. It's the same with US guided CVC. I tend to not use both to be as proficient with emergency cases as possible. This video is an example of living in a comfort zone of video. With proper head placement it should have been possible to place tube easily.
Positioning could be better but trying to intubate after only one minute following 50 mg of rocuronium in an adult patient is not long enough. You’re never going to get ideal intubating conditions going that quickly. Call me old fashioned but suxamethonium is still hard to beat in that circumstance.
Yes, ur are old fashioned. Succ got to many contrindaction and got to many complication in comparison with Rocuronium. There is only some special situation where i would take Succ.
@@setimons yeah, but look at the patient here, young adult male, looks otherwise healthy. Not many contraindications there. Sux pains are a possibility but not a major issue. For the record, I use Rocuronium for RSI’s as well so no criticism. Just that there is room for improvement and there are other options.
@@nysoravideo Doesn't really seem like you're discussing anything except how anybody that criticizes you should join NYSORA's Editorial Board, or that they upload their own emergency onto youtube. I wouldn't call that "learning" or "discussing" any mistakes at hand.
@@jonathantran7102He’s embarrassed, and he should be. If I were in the credentials committee at his hospital, I’d put him on a FPPE for a couple months with him doing solo anesthesia. Clearly, he needs it.
I’m a big fan of your videos and the content you provide, and it has helped me a lot. However, this video is full of mistakes, and for a moment, I thought by the end of the video you would reveal it as some kind of prank
Don’t argue against success but I would have started from the beginning with VLaryngoscopy and instead of rocuronium as the sole relaxant I would have use 1mg of rocuronium them wait for 1 minute and them propofol and suxcylcholine 100 mg. Probably not possible to do gastric ultrasound to this patient??
Position of patient is not proper for endotracheal intubation. Ideally only 5 cm height pillow is enough to match all axis.. What was the indication to give GA..?? In India we never give GA for limb Surgeries.. Keep the Anaesthesia simple don't make it complicated.
@@nysoravideo I understand training was in progress and proficiency with all tools in all scenarios can’t be understated. There is always a better and safer way, debriefing is important. Opinions are validated with the end results. Thank you for posting good content which is thought provoking, if someone learned something new or improved upon a process that ultimately saves a patient then game set match. Thanks again.
A) I would say (if u got the time). Peoxygenation is done, when the Patient breath out(!) more than 80% of O2. You will see it, if you hold tight the mask. And that is objective. NOT 3minutes, or 10 deep breaths. B) After Rocuronium it would be good to flush it with Nacl 0,9% 20ml. It works faster, than just infusion. There is the studies.
Sellick turned over in his grave from the way you teach how to do the maneuver. Rapid intubation, it is rapid and secuence, so as not to make unnecessary movements. (Modification is empty talk!) And regular laryngoscopy in this clinical situation is completely out of place (Who checked the patient and planned the anesthesia?) Such a large number of hands and assistants only aggravates the speed of this procedure.
First NYSORA video I don't like: first the position of the head is not appropriate, second why don't use Succinylcholine???, and third is well known that Sellick maneuver can reduce the visibility of the epiglottis in a 30 percent (Miller's Anesthesiologist), fourth is time in the settings to add the Drive or Delta Pressure parameter as part of the programming of the protective mechanical ventilation.
![BLACK BAG - Official Trailer [HD] - Only in Theaters March 14](http://i.ytimg.com/vi/Du0Xp8WX_7I/mqdefault.jpg)
Your SpO2 dropped because the blood pressure was up and oximeter was on same arm. You can tell by the flat trace turning back into a normal pulsatile trace. It also averages the last 20-30 seconds so wouldn't immediately improve as soon as you squeeze the bag. I think the positioning was the issue here, difficult to say with the blurry face but can't see that he would appear difficult with DL if properly positioned. Although if you have the glide scope in the room I'd probably just use that in an RSI. Thanks for sharing!
We love this comment. Outstanding. Should join NYSORA's Editorial Board and shape the future of education - write to Darren@NYSORA.com. Greetings!
Can't tell if this is sarcasm or what 😂@@nysoravideo
I think I’ve concluded that Dr Hadzic is in fact someone who has NOT performed laryngoscopy in several decades. Greetings!
50 mgrs of rocuronium is suboptimal dose for IRS ( if you use in that patient 1 mg/kg or 1,2 mg/kg) , in that case with maxilar and orbital fractures we should consider use videolanigoscopy as first option in our airway management plan
I believe the basic airway positioning was missed here, specifically the chin lift, head tilt, and jaw thrust for better ventillaion and to align the oral, pharyngeal, and laryngeal axis. Instead of using multiple mattresses, a head ring would have been a better choice. Additionally, a shoulder roll could have helped achieve better neck extension. The anesthesia mask you selected would be more suitable for patients with a Mongolian-type nose with a short bridge. For your patient, a snuggy silicone mask would have provided a better fit. That being said, anesthetic management always depends on the situation at hand, and your actions were clearly in the best interest of the patient. You successfully managed the case, and congratulations on saving the patient
👏 👏
Honestly, at first thank you for providing such cases. It will help people to recognise key factors in such circumstances.
But really I have seen a lot of points, where you can do better.
1. Patient positioning. And I don’t mean the position for the intubation. It is the position for preoxygenation. The patient seems young, not obese and you have an hypoxemia beginning arround 1-1.5min after the induction of the anaesthesia, what means your preoxygenation was poor. That should and must not happen. If done correct, this would not occure.
You are giving away arround 400-500ml FRC by not using an Anti-Trendelenburg-Position, so that means a lot of time. What was your etO2 before starting the RSI? Was it arround 85+? If it was the case in this young man‘s case, a hypoxemia would not occure that fast.
2. Why not using the videolarnygoscopy as primary device for intubation? There is no contraindication for it. You want the best circumstances for the highest first pass succes.
3. Your using of your medication is poor. The man seems arround 75-85kg. If I am seeing this right, you are using a 5ml syringe with rocuronium, which means 50mg of it. This is not a proper dose for RSI. Correct dose would be arround 0,9 - 1,2 mg/kg bodyweight, which means at least 75mg, if he weighs that much.
4. The measure of the blood pressure on the arm you use for giving the drugs can be a potential pitfall. If set to automatic measurement and it starts where you are infuse the drugs, it can delay their effect.
5. I am not sure why you are using pressure on the criccoid. There is no scientific evidence that the use of it will prevent aspiration. It is obsolet.
6. Why did you not make use of fentanyl or sufentanyl? It helps to provide a significant decrease of stimulus done by the laryngoscopy and even lowers the amount of propofol needed for anaesthesia.
If you are doing this as a „classical“ RSI, the not using of a opioid seems understandable, but questionable.
Kind regards
Amen to that!
I could not agree more:
- Preoxygenation and intubation in Anti-Trendelenburg-Position with tight-fitting face mask and high oxygen flow until you get around 85-90% expired oxygen concentration
- Muscle Relaxation with 1 mg/kg ideal body weight of rocuronium
- Videolaryngoscopy at first attempt in rapid sequence intubations
- No cricoid pressure except external laryngeal manipulation for improving visibility / routing of ET
Thank you. All agreed. But would request that you record an emergecny case and share as a follow up so that we can all comment on how perfectly it went! ;)
@@nysoravideo Don‘t get your comment right. Maybe my english is a little bad. You suggest that I record an emergency case and you want to comment on it, is that correct? The hospital I am working for will not allow that kind of thing.
Please correct me, but do you think my comment is too negative? Maybe you are a little thin-skinned, but this is just an assumption.
If the emergency is your answer for the potential suboptimal handling in that case, maybe you should adjust your procedures. Just then you have to do your job right.
Don‘t get me wrong, I like your work, your sharing of regional anaesthesia technics, everything you do for the World of Anaesthesia, but if you upload videos like this, you have to live with the comments.
My criticism is objective and relevant, personally I lack at the right words, so there are maybe misunderstandings. Sorry for that. I don’t comment on RUclips-Videos a lot, but it is matter of the heart for me to say things, which could be done in a better way, because everybody will learn from it. All the things I mentioned to improvise to perform a RSI, I use them in my daily routine as an anaesthesiologist.
Therefore sorry for harsh words, but this is just my opinion. I am looking forward for the release of new videos. And I hope I won‘t be banned.
Improvement is only possible through objective criticism and daily routine.
Kind regards
Hello , can you make some videos regarding paediatric cases , difficult intubations in neonates , neonate with diaphragmatic hernia ……. Like those scenarios.
Thank you 😊
Patient position is not optimized sir.. correct me if am wrong sir..
I believe is the right Position for an RSI or "Ileus Induction".. but still, you're right, the head is way too high and not too extended.. imo
I believe so too.. even though it's the right position for an RSI or "Ileus Induction", the head was too high and tilted too low..
Zero extension of the neck, indeed. If we were to give benefit of the doubt perhaps this is due to the patient being a trauma case.
There are studies that suggest sniffing position actually makes video laryngoscopy more difficult.
@@Andrew-el4dmIf you suspect cervical trauma with cervical spine instability, don't rely on suspicion alone-apply a cervical collar.
@3:25 it's mentioned here in the video that an oral airway could be used if ventilation is difficult, but it should be clarified that in this situation (RSI) one would not attempt ventilation which would otherwise defeat the purpose of the RSI
Hence mentioned: modified RSI
This is interesting. I often worried about this, however, low pressure, low volume careful ventilation can oxygenate and buy time. It's not optimal but a compromise. If ventilation is easy, it is likely going through the glottis, but no guarantees. Hi flow oxygen is also another option, my favourite.
A few things that could be improven if Im not mistaken:
- With orbital and maxilary fracture, a difficult airway could be expected, hence
- Consider awake intubation if expected difficult airway, or even glidescope as a first try to avoid neck manipulation (Im assuming cervical injury could be a thing in this case)
- I disagree with some comments here: the top of the breastbone is at the same height as the ear for an optimal ramped position while avoiding neck manipulation in a trauma scenario
- Was fentanyl used or not loaded at all? The syringe was empty. I think using fentanyl during rapid sequence does not bring clear benefits and could impair hemodynamics after intubation
- During rapid sequence, you should at least use 1mg - 1.2 mg/kg of rocuronium, while only 50 mg (standard 10mg/ml concentration I think) was administered. Im bad at estimating weight, but based on ventilation settings (tidal volume) I think 80-100 mg would be an appropriate dose. After 1 minute, vocal cords could still be closed after a low induction dose.
- You do not want NIBP on the same arm as your IV, during the last seconds you can see a flattened O2 wave wich could provide inaccurate O2 values
- SpO2 does not increases as soon as ventilation starts, it usually takes 10-15 seconds of good oxigenation to reflect an increase of SpO2. Im pretty sure you were all checking direct and indirect signs of tracheal intubation nevertheless. You can even see that capnography states etCO2 of 0 while looking at the monitor (which is also delayed by a few seconds).
VL is first choice in many hospitals now in the UK
That is great to hear that the means are available for such. Thank you for the feedback!!!
@@nysoravideoEven in Belgium! Imagine that Admir! Greetings.
From a smartphone perspective, it seems that all the struggle could have been avoided with proper positioning. Sometimes, in extreme situations, we ignore the basics!)
I want to thank the
entire NYSORA TEAM, and especially Dr. Hadzic, for the valuable educational content!
Greetings from the Moscow anaesthesiologists 🤙🏻
You should mention difficult airway trolley as well it is crucial to heave nearby , and isn’t seen on this video. Also ramp positioning would be more appropriate in case of full stomach even for better sniffing and flexion of C0-C1 joint 😊 thanks for sharing useful video.
I think the positioning lead to the difficulty in above case , the ideal intubating position isnt achieved making visualization difficult, correct me if i am wrong, as someone mentioned why not regional anaesthesia which is more safe for ankle fracture rather than GA, thanks in advance
True. A common mistake, increasingly more often being done due to the availability of video laryngoscopic equipment that "saves the day". Greetings
you intubated with propofol , alfentanil and rocuronium. soon after maintenance with SEVO. put him in PCV with FGF 1,0L and sevo 1,9. in some minutes the patient will wake up paralyzed. It will take hours to achieve 1,0 MAC of SEVO.
@@alextarno
They use target et control, the flow and sevo settings are automatically adjusted until it reaches target 1.9. Everything is fine
I ask about sevo in induction , does its uses in full stomach or no
Cricoid pressure and BURP maneuver is not the same.
you intubated with propofol , alfentanil and rocuronium. soon after maintenance with SEVO. put him in PCV with FGF 1,0L and sevo 1,9. in some minutes the patient will wake up paralyzed. It will take hours to achieve 1,0 MAC of SEVO.
Not really. This ventilator (Aisys) has an automatic mode for target end tidal concentration for sevoflurane (you can see it at 7:00 - the ventilator screen in light blue, normal mode is in grey).
This mode adjust automatically gas flow and fiO2 to reach in 1-2 min expected target for oxygen and sevoflurane end tidal gaz concentration.
This mode is available on modern ventilator as Aisys, Flow-I, Zeus and Felix.
@@philippepenven4875 HI, Thanks for your comments but i didn't find it in the user guide. I work in the same anesthetic station Aisys CS2, weird explanation..... no gas reach a steady state in 1-2 minutes in daily clinical use.
@@alextarnoadjustable end tidal target mac is an additional feature you can pay for on the aisys c2s
This looks like a polytrauma patient. If we're not sure about C-spine stability, the usual head positioning to optimize intubation conditions has to be done with extreme care. Furthermore, if there's evidence of trauma to the head, I anticipate a difficult airway every time so my plan would have been video laryngoscopy from the start.
I also realized that IV access, NIBP and pulse oximeter are all on the same limb. Not ideal, but if other limbs have trauma or are surgical sites, you use what you have. Should remember that pulse oximeter waveform will go down during NIBP cuff inflation which is not hypoxia.
Very good video.
Thank you. Great comments. And never easy to expose real-life practice, as if everyone here recorded their cases, I doubt they would be sharing them as perfect. You think?
@@nysoravideo Probably the better answer would be, I should do some solo anesthesia cases where I actually manage a few patients by myself so that I can get back up to speed on how to conduct a correctly performed rapid sequence intubation. Then maybe do a video once you have reacquainted yourself with a basic skill that you should already be an expert in.
Recently I attended a DAS talk where they discussed whether MILS was even necessary anymore (like Sellick's manoeuvre in RSI), but stopped short of recommending its removal.
So we may see some changes in current recommended practice in the next few years.
The issue here is poor positioning.
Agreed! Unfortunately, that is often the case. Greetings and thank you for watchign!
Agree! Unfortunately, this is very often the case, particularly in emergency cases
@@nysoravideo Agreed, and that is very often NOT the case when this procedure is performed by experienced providers. There is zero reason to not optimize a patient, regardless of the circumstances.
U have to remove this video as soon as possible ! This is not good for young anesthesiologists to watch
Actually u have to do an awake fiberoptic intubation, if u have maxillary fractures!
Maybe should have stuck to regional for this one
I appreciate everything you do for education but this should call how to do a rapid intubation sequence wrong. It has also the education value as I see all that comments. If the patient really had a full stomach, you would have a serious problem. Thank you for sharing the video
Cricoid pression is it still used to Newsday
Why you guys didn't use videolaryngoscopy in the first place? Serious question.
Vidéo laryngoscope is more expensive than laryngoscope,the last is usually uesed firstly.
It’s because the anesthesiologist in question has not maintained clinical currency in airway management. This is why credentialing actually matters, especially in academic centers where many attendings can go years without intubating an actual patient.
@@Bijazable this right here , solid gold. Current evidence shows us that if its available, you should use it, specially in pediatric patients and also in the management of the difficult airway, like this case. Thank you, God bless you.
@@valeriageller7436 Based on this performance, I think the attending anesthesiologists at this particular hospital who don't intubate frequently should probably just use the glidescope for all of their cases. Greetings!
maybe since he had facial fractures i would have used videolaringoscopy as first option. I wonder, you didn't insert gastric sound before intubation because of the fractures associated risk?
Too Little Head reclination ( dorsal Extension ) and probably Lack of experience of the Anästhesie resident, but a Good Video for teaching purposes or a Good scenario in this Sense, thanks anyway
Thanks for the tips!
@@nysoravideoYou are welcome Admir! How’s it going? If I were you, I would take a sabbatical from celebrity making, and do so some actual cases on your own. You need it brother. Greetings!
Just poor all around...
I thought it was being artificially setup with awful positioning, terrible drug selection and delivery for drama.... And no, sats don't improve in 4 seconds, the blood hasn't even circulated... It was a poor waveform.
But bizarre as a teaching or textbook sales strategy.
Was it the only ankle surgery or anything else added to that.
Only an isolated open ankle if it was, why not go for spinal anaesthesia.
Although patient history and labs are unknown, I can only speculate that spinal was not suitable or contraindicated.
The surgery was more complex. But the video is about the unexpected airway challenge, not about the choice of anesthesia. Greetings and many thanks for watching. Commenting
@@nysoravideo””commenting”
Thanks for sharing. My thoughs:
The positioning did not seem appropriate to me, and I would have used videolaryngoscopy from the beginning. In fact, I dont use direct laryngoscopy anymore. I suppose it is mandatory in teaching facilities.
Why was the traditional laryngoscope used initially and not video laryngoscope?
Wouldn't using the glidescope to begin with would be more beneficial?
Do you use it routinely, instead of traditional? Greetings!
@@nysoravideo
Not really but since it was an emergency case to begin with, I would have begun with the video laryngoscope in an anticipation of a difficult airway
If you do get regurgitation direct laryngoscopy is better to facilitate large volume suction and preserve the view.
VL camera will get covered in gunk and become useless.
@@nysoravideo Perhaps the attending anesthesiolgist in the video would provide better care by just using video laryngscopy for all cases. Greetings!
This is not how you manage a "difficult intubation" scenario.
Positioning-shit.
Drug dosages-shit
Blade insertion-shit
DL as a first choice for a potential full stomach-shit
Not having an aspiration catheter near you-shit
Nasogastric tube prior intubation to empty the stomach?
To be honest I love your contetn but this video is a pure disaster. Oral airway for a difficult intubation scenario where you have a potential full stomach? Comon..
Selling Manöver is obsolete! Really a disaster
I really don't understand why novadays videolaryngoscopie is still not the first choice and is not used routinly. As for this case,it should have been used in first as this is definitely expected difficult intubation patient...Fast sequence induction means videolaryngoscopie for me. Correct me if I'm not right
There are two sides of that coin. The more you use video the less proficient you are with direct laryngoscopy and one fearfull day you may be rushed to a setting without video readily avaliable and your f*****. It's the same with US guided CVC. I tend to not use both to be as proficient with emergency cases as possible. This video is an example of living in a comfort zone of video. With proper head placement it should have been possible to place tube easily.
Do you use video laryngoscopy routinely? Greetings
@@nysoravideoAdmir, the “greetings” schtick isn’t cute anymore, it’s cringe. Just stop doing it. God bless.
@@nysoravideo No, but you clearly should.
I always use VL!
Difference between VL and airtack about its curvature have the same
Positioning could be better but trying to intubate after only one minute following 50 mg of rocuronium in an adult patient is not long enough. You’re never going to get ideal intubating conditions going that quickly.
Call me old fashioned but suxamethonium is still hard to beat in that circumstance.
Yes, ur are old fashioned. Succ got to many contrindaction and got to many complication in comparison with Rocuronium. There is only some special situation where i would take Succ.
@@setimons yeah, but look at the patient here, young adult male, looks otherwise healthy. Not many contraindications there. Sux pains are a possibility but not a major issue.
For the record, I use Rocuronium for RSI’s as well so no criticism. Just that there is room for improvement and there are other options.
I'm a rather young anesthesiologist and after discovering the hated by all sux I fell in love with it
suxamethonium 10 x 0 ROCURONIUM
Always VL directly in cases like this. You wasted precious time there! I am an Anaestesiologist with 40 years of experience
I love your regional videos but everything you guys did was wrong.
Thankyou. Can you detail the mistakes so that we all discuss and learn from it?
@@nysoravideo Doesn't really seem like you're discussing anything except how anybody that criticizes you should join NYSORA's Editorial Board, or that they upload their own emergency onto youtube.
I wouldn't call that "learning" or "discussing" any mistakes at hand.
@@jonathantran7102He’s embarrassed, and he should be. If I were in the credentials committee at his hospital, I’d put him on a FPPE for a couple months with him doing solo anesthesia. Clearly, he needs it.
I’m a big fan of your videos and the content you provide, and it has helped me a lot. However, this video is full of mistakes, and for a moment, I thought by the end of the video you would reveal it as some kind of prank
Thank you very much sir 🙏
Most welcome
@@nysoravideoSeriously Admir?
Don’t argue against success but I would have started from the beginning with VLaryngoscopy and instead of rocuronium as the sole relaxant I would have use 1mg of rocuronium them wait for 1 minute and them propofol and suxcylcholine 100 mg. Probably not possible to do gastric ultrasound to this patient??
Position of patient is not proper for endotracheal intubation. Ideally only 5 cm height pillow is enough to match all axis..
What was the indication to give GA..??
In India we never give GA for limb Surgeries..
Keep the Anaesthesia simple don't make it complicated.
For that intubation my residents would get the worst mark
thank you dear Hadzic
Good luck
Always welcome
Maybe remedial training might be a better path to success instead of luck in this particular scenario. Greetings!
I honestly want to know why would you even try performing a DL in a patient with a maxillar fracture?
Shot gun approach?
@@nysoravideo I understand training was in progress and proficiency with all tools in all scenarios can’t be understated. There is always a better and safer way, debriefing is important. Opinions are validated with the end results. Thank you for posting good content which is thought provoking, if someone learned something new or improved upon a process that ultimately saves a patient then game set match. Thanks again.
@@nysoravideoShotgun approach? Sounds very scientific. Greetings!
What if there was no video laryngoscope, as we don’t have available?
You position the patient properly and you proceed
Wramping is not ideal in my idea.
What's difficult with the airway?? Lol
The operator
A) I would say (if u got the time). Peoxygenation is done, when the Patient breath out(!) more than 80% of O2. You will see it, if you hold tight the mask. And that is objective. NOT 3minutes, or 10 deep breaths.
B) After Rocuronium it would be good to flush it with Nacl 0,9% 20ml. It works faster, than just infusion. There is the studies.
.....and in clinical practice, the rapidity of full paralysis is highly variable.
disappointing that succinylcholine choline is no longer used.
“There is the studies” is my new favorite phrase! Greetings!
Sellick turned over in his grave from the way you teach how to do the maneuver. Rapid intubation, it is rapid and secuence, so as not to make unnecessary movements. (Modification is empty talk!) And regular laryngoscopy in this clinical situation is completely out of place (Who checked the patient and planned the anesthesia?) Such a large number of hands and assistants only aggravates the speed of this procedure.
First NYSORA video I don't like: first the position of the head is not appropriate, second why don't use Succinylcholine???, and third is well known that Sellick maneuver can reduce the visibility of the epiglottis in a 30 percent (Miller's Anesthesiologist), fourth is time in the settings to add the Drive or Delta Pressure parameter as part of the programming of the protective mechanical ventilation.
Completely agree with everything you said.