They give sedation beforehand often

@@Eman1900O sedation before self intubation? I’d like to see that

@@grantdomstead1383 no I mean this is done to patient patients but rarely. He’s an anesthesiologist so the anxiety isn’t there for this because he’s taken care of thousand of patients

@@Eman1900O The whole point of the video is to show an awake intubation, which is done for patient's who are or are likely going to be difficult to intubate.

I was getting nauseous watching him do that, especially during the injection into his neck!

I would think the awake intubation would have been A LOT more stressful on your heart due to the awareness, but I am just a peon.

After my appendix burst I had a nasogastric tube inserted (where they manage to drive it into my sinuses twice before successful placement) and had it in place for a week. Quite uncomfortable - you can feel it every time you swallow (like a fishbone stuck in your throat). I can only imagine this must be so much worse.

How do you know? 😂

They would try if the local anesthetic really doesn´t work, maybe try a different local anesthetic (although there are no regular viscous preparations for the other local anesthetics), maybe if you tolerate it place the tube without local anesthetic (it´s possible, but not nice) and ultimately - if nothing helps and I do need to do the procedure urgently - I´d either use ketamine and remifentanil titrated to effect with a surgeon standing by to do an emergency tracheotomy if anything goes wrong or preferably - if possible - refer/transfer you to a center with a heart-lung-machine (that takes over the oxygenation of your blood by placing two pipes in your groin (and yes, this will hurt), then let you sleep without intubating you, and intubate you while you are asleep in narcosis while the heart-lung-machine keeps you alive until you can be ventilated "normally" using the then places endotracheal tube). And for all those that just want to avoid an awake intubation because it sounds way scarier than it actually is: that procedure has too many dangers and side effects - and for all from the USA: your health plan almost certainly won´t cover it, and it´s expensive as hell (basically it´s half of an open heart surgery procedure, except for opening the chest)

Oh yes please, that would be so interesting to see.

Yes! I’ve had nasotracheal intubation for a surgery and I’m curious to see how that works.

The anesthesiologist talks with the surgeon - and they together decide if the endotracheal tube is placed orally (the usual case), nasally (especially if the surgery is in the oral cavity region) or if there needs to be a surgical tracheotomy done (in rare cases).

Lidocaine prep is usually not done for an RSI (rapid sequence induction) like you had - it would reduce the sensitivity in your throat to any regurgitated gastric content that you might be able to swallow on your own again, until you are in deep anesthesia and the endotracheal tube placed to prevent aspiration of gastric content. Instead the aim of an RSI is to get you into deep anesthesia and your muscles fully relaxed in as short a time as possible to prevent you pressing any gastric content up into the esophagus and trachea and aspirating it before placement of the endotracheal tube (which then prevents any gastric content from getting in your lungs and creating pneumonia).

Mary, use Google.

Please talk to your anesthesiologist of choice - there are so many factors that would influence this decision (age, location of tumor, comorbidities, length of procedure, body positioning during RT,... just to name a few).

That's a fiberoptic scope that's pointed toward me!

@@MaxFeinsteinMD ah ok. that makes sense. thanks for answering and that was a great video.

In ICU the goal is not to keep you in general anesthesia (witch needs higher doses of anesthetics), but just sedated enough so you are not stressed but still tolerate the endotracheal tube or any other devices and procedures that are necessary. Ideal would be the awake, cooperative, stress- and pain-free patient that tolerates all that´s necessary to get on with a speedy recovery. Midazolam (Versed) does have some side effects, and - at least in modern hospitals in Europe - nowadays you only prescribe it to patients that really need it (e.g. extremely anxious patients). A good talk in preparation for surgery/anesthesia about what´s going to happen is usually as effective in calming the patient as is Midazolam. Sorry to hear that you did not get your expected anesthesiologist - but that sometimes happens. I d wish you a speedy recovery!

Precedex (Dexmedetomidine) is a long acting non-reversible medication, mostly used in ICU settings. While there is little respiratory depression, you still need to titrate it to the desired sedative/anxiolytic effect, which takes sometimes quite some time to get the desired level, and it has also some cardiacvascular side effects that you want to avoid perioperatively. Conversely, for Midazolam and Remifentanil there exists a specific antidote that reverses the effects and lets you breathe again a short time after application.

@@tammybambini1096 if you think midazolam and remifentanil together causes more respiratory depression than dexmetomidine, which is used often in anesthesia simply for the fact the that it doesn’t cause respiratory depression, your simply wrong. And it doesn’t take that long especially if it’s an airway that you want to take your time on. Rushed anesthesia for a difficult airway is very stupid. And the side effects can be pre treated with glycopyrrolate. Have you ever actually used the drug? I do and it really doesn’t take as long as the text book says to get decent effects. If you actually used it you’d know this.

@@tammybambini1096 you must work in ICU. In anesthesia we don’t use it like they do in ICU. We use precedex all the time. We even use IV push precedex in anesthesia sometimes. I don’t have time to unpack all you said but there is no need for a reversal for precedex

Yeah

Yes, but if. you watch the video you can see he is still gagging slightly during some parts. the gag reflex is extremely hard to get rid of without general anesthesia and paralytics.

@@bettysmith4527 gagged very little. Just made a gagging sound a couple times for a second or two

@@Eman1900O UH, so basically what I said in my post?

@@bettysmith4527 yep

All that lidocaine!

Enough analgesic (lidocaine), maybe going the nasal route (sometimes easier and less gag reflex, but higher risk of nose bleeding and injuries to the nasal structures)... and a lot of time and explaining before and during procedure

An example of a TV-worthy procedure is a Rapid Sequence Intubation, done when there's a risk of aspiration (choking on stomach contents) to minimize the time between starting anesthesia and securing the airway.

Not sure if you meant this, but in many shows you can hear the doctor ask for 20 of etomidate, 100 of sux. That is the anesthetic and the fast acting paralytic. Usually patients have an i.v. already done (i.e. from the paramedics). The nurse pushes the meds and you intubate right away. It can seem like the patient is still awake, sometimes it takes time for the eyes to close and the sux does head to toe muscle spasms so the patient can be moving. In emergency situation the moment you see their eyes twitch you go in with the laryngoscope and you have airway secured by the time their toes stop twitching from sux. Of course on TV it usually does not look like real life, but I have seen some pretty close. And some very bad examples of course too. And it is kinda terrifying to intubate a coding patient. But that is the job.

Thanks for replies! I think most of us fear intubation so it's good to hear there are measures to be taken, even when the situation is totally out of our hands. Now I have to see a Rapid Sequence Intubation!

"Glad you´re alive to tell me about your experience!" Jokes aside (well, that´s the best answer to give, anyway), hypnotics (that are the drugs that make you loose consciousness) "delete" about a minute of your memory immediately before they seem to fully work to a bystander, and that´s about the time for the paralytic (the substance that relaxes all your muscles and facilitates intubation) starts to act and the endotracheal tube is placed.. In any case you can talk to them about what´s happened and why and if there is need you refer them to psychotherapy to help them with mental recovery.

@@benbookworm with RSI you sometimes can delay the interval from giving the anesthetic medications to placing the endotracheal tube a bit by doing ample preoxygenation/denitrogenisation and then apnoeic oxygenation, but that´s never shown on TV because it´s not telegenic...

unless you place a patient into an hyperbaric oxygenation chamber you can not "hyper"oxygenate a patient. But yes, you use supplementary oxygen, either by mouth or nose or by feeding oxygen through a bore/canal on the bronchoscope. If need be you can also have them already breathe oxygen assisted by a ventilator using a face mask, while you do the awake intubation (but that is rarely necessary).

You would if it could help prevent you from dying

This is horrific.

@@MarionBurgwin-bk6ey you are given sedation. A good chance you won’t even remember it if midazolam is given

@@Eman1900O I remember everything!

@@KristiBranstetter you must drink a lot every night 😂

I'm afraid it's even worse than getting an NG tube.

Hi, I would love to know what Dr. Feinstein says. My take is, theoretically it is possible but it comes with the same risks you are trying to avoid by doing awake intubation - with gas induction the patient might stop breathing and they still might have gag reflex, so you would be in a pickle. Better to just do really good lidocaine prep and intubate with patient awake. As for sevo induction in adult patient, I only did it once for a ND person who could not tolerate needles so we did it pediatric style with mask and it took about 10 minutes for him (his weight was approx. 65kg) to be unconscious enough so we could put in an i.v. line. At that point he was still breathing on his own. After that however I pushed a bit of propofol and standard dose of rocuronium and intubated in that. I know babies are often intubated in sevo only induction. Have not had the chance to do that myself yet. Sevo/Des/Iso debate - Sevo and Des seem to be better than Iso according to data. Des is environmentally numerous times more harmful than Sevo, so I would say it is good to use Sevo most of the time with potentially using Des only in a handful of cases where it would make a huge difference for the patient.

@@BarboraMedkova First and foremost, I am not a doctor. What I have read and understood about these 3 volatile substances is my limit in the understanding of these 3. However, I have, unfortunately , have had more than 20+ procedures under GA, and maintained with those 3 PLUS enflurane. Anyhow, I understand what you’re saying, but if the ET tube is secure then I would think the gag reflex becomes less of a concern if the lidocaine is performing as it normally does. If the patient does stop breathing then you still have a bag to manually assist. As far as the Sevo, Des and Iso go, I was looking for his thoughts and opinions about their uses, and what advantages and disadvantages come with them and not necessarily a debate. Just trying to understand and learn.

If you mean doing a gas induction of anesthesia prior to the intubation, no. The whole point of this is to do an awake intubation on someone with a suspected or known difficult airway and have the airway secured PRIOR to the induction of anesthesia.

@@jimeckerson4297 Sorry, I incorrectly assumed you were a healthcare worker :) You are right that you have a manual bag to assist, but awake intubation is done in instances when you suspect that the patient would have difficult airway + there would also be problem to manually ventilate. Basically you do it awake because you need the patient to breathe on their own. In cases where there is difficult airway but you know you will be able to ventilate (i.e. previous encounter with the same patient) you can normally put them under and then use the fibroscope to intubate. 20+ GA is a lot of anesthesia. Hope it at least went well. Cannot talk about Iso because we do not use it here. But the biggest advantage of Des is that it is eliminated a lot quicker than Sevo, gases bind to fats so it is especially advantageous for bigger patients and for older patients because they wake up faster and spend less time under GA. Sevo on the other hand does not disturb airway so it can be used for induction whereas Des cannot. There is surely more advantages and disadvantages, but this are the biggest.

@@jimeckerson4297 The gag reflex is a concern during placement of the ET tube, after the tube is placed the hypnotics and analgesics effectively suppress the gag reflex. In patients with a need for awake intubation you most likely have difficulties ventilating them using a bag (difficult intubation is often associated with difficult bag ventlation, as I remember in about 80% of cases) - so if the patient stops breathing you (and the patient) really have a problem. Therefore you only give mediactions that are quickly reversible - and inhalative hypnotics are not amongst them. As for DES/SEV/ISO: DES is expensive, requires special devices to apply it, is highly environmentally damaging, but has a faster time to act and also faster time to awake patient, which is clinically significant only for procedures in very adipose patients and procedures longer than 2 hours - and a good anesthesist (and a surgeon that actually keeps in the time he tells the anesthesist he will need to finish suturing) can dose the other volatile anesthetics so that this advantage disappears. So no real need to use it - Europe is phasing out DES in the next few years. SEV is cheaper than DES, needs no special equipment, is less irritating to the airway/less smelly (therefore tolerated for volatile induction in pediatrics), in itself a bit muscle relaxing and less toxic to the environment. It´s onset and offset (if the operation is not too long) is nearly as fast as DES. It´s considered to be the best "allrounder". ISO is very cheap, even less environmentally toxic, but takes longer to achieve the desired effect, and also irritates the mucus membranes (like DES). It takes longer to eliminate (especially in long cases) at the end of anesthesia and is therefore mostly used in patients already sedated or planned to be sedated after the procedure (like many ICU patients). The side effects (cardiacvascular and respiratory depression) are quite similar in all the agents.

Nope, they have very strong self-control.

And you can exercise to loose your gag reflex...