Intubation cases with no recordable pulse ox

Dr Rob Bryant of Utah shares some cracker casesRob emailed this :

“Minh

Great post on intubating the crazy sick pneumonia patient.

I have been involved in three intubations in the last month that have been as scary as the case you and Brian discussed, with the added degree of difficulty being unobtainable (N of 2) or transiently obtainable pulse oximetry, even with the use of an ear probe.

Case one.

68yo hypoxia, hypotensive pneumonia with UTI and abdo wall abscess.

2l crystalloid, multiple rounds of push dose epi with pre intubation BP of 80 systolic.

Pulse ox giving poor wave form O2 sat in mid 80’s for about 20sec before the pressure from the ear probe clip exceeded the ear perfusion pressure (my theory) and we would lose the reading.

Pt ramped, NC on, ketamine and NIV with PEEP at 15cm from vent for DSI, 20mcg of epi with roc.

Sats in the intermittently obtainable low 80’s, seemed to hold steady, residents first tube in the esophagus, re-bagged using vent (2 great RT’s in the room), second attempt with glide scope successful, matched post intubation end tidal to pre-intubation end tidal due to pt having low venous ph on 1st gas.

Case two.

70 yo female, likely severe sepsis, vasculopath with no radial pulses, automatic cuff reading in the 50’s despite full tank, good fem pulses and mentating well. Left the ED with a BP of 67syst on high dose levophed sitting up eating ice chips.

Called to ICU 30 min later, pt with agonal resps, no readable pulse ox waveform despite multiple probes and locations, and mid forearm art line with poor waveform reading in the 50’s. Still had good fem pulses.

Head of bed elevated, IV Ketamine, NC, bagged with PEEP valve at 10cm (taken from DSI bag sitting on crash cart in ICU) 20mcg epi, Rocc. , intubated with DL .

Case three.

I assisted one of my partners with a pt that had been drinking isopropyl alcohol, decompensated in ED with pressure in the low 80’s, venous pH 7.00 peripherally clamped down with mottled everything.

2l crystalloid, multiple rounds of push dose epi, and no readable pulse ox despite use of ear probe.

Head of bed elevated, 20 mcg epi, Ketamine, oral airway, bagged, pre intubation end tidal CO2 15, bagged until her lips were pink, intubated with glidescope, matched post intubation end tidal to pre intubation end tidal. Given calcium post intubation, post intubation venous gas had improved pH and BP improved. Initially grossly normal cardiac fn on US, then really crappy cardiac fn pre intubation, then sig improved cardiac fn.

 

What tricks do you have to magically obtain an unobtainable pulse ox?

What else would you do in these ‘no pulse ox situations’?

With no pulse ox, how would you gauge how long to look on your first intubation attempt?

This is a situation where it would be nice to have an art line in, all three patients were extremely hard access, and did not have useable art line data.

I am looking forward to some simple answers to these questions on the ‘die in front of you patients’

Thanks for your opinion

Rob ”

ANY SUGGESTIONS OUT THERE?

4 thoughts on “Intubation cases with no recordable pulse ox

  1. Here is a good trick about getting a pulse ox reading in the periarrest patient. Credit to Norwegian bloggers of crit care for this one!

    http://www.scancrit.com/2012/02/21/pharyngeal-pulse-oximetry/

    It works pretty well every time I have used it

    sounds like you did a superb job in these highrisk patients

    I actually run these like Koenig and Mayo describe. start epi drip, try to get art line, fluid load. If can place and start an IABP, do that.
    If this does not stabilise their dual organ failure pre intubation, then prepare for CPR perintubation. I tend to just titrate in fentanyl, let the patient know they are going to have a feeling in back of throat, then push the NMB and tube as fast as possible. Ketamine is a myocardial depressant so I have seen it cause hypotension perintubation…of course if you only use a small dose or already have epi drip going, less likely to happen.
    I think these periarrest patients, should get one shot at first pass intubation , then immediate placement of SGA and reoxygenation. If I get good ETCO2 trace with SGA, I leave it in just as I would with cardiac arrest resus.

    In the near future these periarrest patients will prob warrant a trial of ECLS rather than these high risk RSI/intubations. Or a short term supportive infusion of intravenous oxygen for the intubation.

  2. I have on occasions, taped the paed pulse ox to the corner of mouth to get it to read between the mucosal surface and skin of the lip

    One time I taped it to the bottom of an ILMA, I use the Fastrach but an AirQ would be fine.got good reading after placement of ILMA, then tubed blindly via it.

    my preferred approach for airway securing in these periarrest cases , currently , is primary RSA as first step, reoxygenate reassess then if ok, either leave SGA in and continue resus, or proceed to staged intubation via SGA.
    if Airway looks tricky, I presite a needle cannula and might even start two litres oxygen flow as part of preox.lots of data on ambulatory COPD pts with transtracheal oxygen therapy at this flow rate, very safe.

    I guess though in these high risk critical patients, a question we should always ask when weighing up how to intervene, is whether palliative cAre may well be the wiser option.just because we can, does not always mean we should. that is really an evolving dilemma for critical care especially when we take it downstairs, outside and everywhere else.

  3. Using clip, I go finger -> thumb -> toe -> ear ->nose -> ?buccal (haven’t tried this one yet with a clip).

    At my current shop, if the patient is sick and a finger isn’t giving a reliable reading, we have sticky forehead pulse ox’s that work great. We don’t do a great deal of critical care, but I don’t think I’ve yet to come across a patient too sick to get a good waveform with it.

    Before we had those, I’d then move to a peds sticker ox on the ear, nose, cheek, or forehead. I’ve been meaning to try out the pharygeal trick with an oral airway, along with placing the sticker on the thenar eminence, but haven’t taken care of a truly shocky patient in quite some time.

    All of the above locations worked when I tried them out on myself fairly recently, but the pharyngeal sat was coming up a little low (92-94%, although I also have a heck of a gag and didn’t have the airway seated properly). Anyone else notice this?

  4. Pharyngeal pulse oximetry?… cool.

    I would just make the note that not all pulse oximetry technology is created equal. There are a few brands out there that specialize in low perfusion states. I believe the equipment using Masimo SET technology would be considered the industry gold standard (No financial interests). Of course there are also a bunch of specialty probes, forehead sticky probes, etc.

    The rule of thumb I was taught in school was that with traditional SpO2 algorithms, the number displayed is only accurate down to about 70%. With the newer low perfusion technology, you can have accuracy when the arterial blood is looking pretty blue.

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