Emergent Reintubation

Question 1

What are the primary actions for emergent reintubation management?

Answer 1

1. Provide 100% FiO₂ and sit patient upright if possible.
2. Verify SpO₂, EtCO₂, and blood pressure.
3. Call for help and obtain a video laryngoscope.
4. Communicate with the team and create a rapid plan for reintubation.
5. Support ventilation with a bag-valve-mask or anesthesia breathing circuit and mask.
6. Perform Rapid Sequence Induction (RSI): Reintubate with direct or video laryngoscopy; ensure suction is readily available.
7. If contraindications to succinylcholine exist, consider Rocuronium or Cisatracurium (not recommended for RSI due to delayed onset of 2-3 minutes); reintubate without a neuromuscular blocking agent if necessary.
8. Perform crash intubation with RSI if there are signs of cardiorespiratory decline.
9. Identify and manage the primary cause of respiratory decompensation.

Question 2

What are the secondary actions prior to extubation?

Answer 2

• Perform an endotracheal tube (ETT) cuff leak test.
• Consider reintubation with a smaller size ETT if necessary.
• Treat stridor with oxygen, racemic epinephrine, and corticosteroids.
• Reintubate with a smaller size ETT if signs of respiratory decompensation persist.

Question 3

What medications are used for Rapid Sequence Induction (RSI)?

Answer 3

For RSI:
• Propofol: 0.2-2 mg/kg IV.
• Ketamine: 0.5-2 mg/kg IV.
• Succinylcholine: 1-1.5 mg/kg IV.
If contraindications to succinylcholine exist:
• Rocuronium: 1-1.2 mg/kg IV (if no recent NMBA reversal agent given).
• Cisatracurium: 0.15-0.3 mg/kg IV (not recommended for RSI due to onset of 2-3 minutes).

Question 4

What are the treatments for postoperative stridor?

Answer 4

• Racemic Epinephrine: 0.5 mL of 2.25% solution diluted in 3 mL normal saline via nebulizer every 3-4 hours.
• Decadron: 0.15 mg/kg IV.
• Hydrocortisone: 100 mg IV.
• Methylprednisolone: 20 mg IV.

Question 5

What medications provide cardiovascular support to maintain MAP ≥ 65 mm Hg?

Answer 5

• Ephedrine: 5-10 mg IV bolus.
• Phenylephrine: 50-100 mcg IV bolus, 0.1-0.5 mcg/kg/min infusion.
• Epinephrine: 10-100 mcg IV bolus, 0.1-0.5 mcg/kg/min infusion.
• Norepinephrine: 5-10 mcg IV bolus, 0.1-0.5 mcg/kg/min infusion.

Question 6

What are common causes of emergent reintubation?

Answer 6

• Failed extubation.
• Respiratory decompensation.
• Cardiovascular compromise.

Question 7

What patient factors increase the risk of emergent postoperative reintubation?

Answer 7

• Age < 1 year or > 65 years.
• ASA III or greater.
• Excessive airway secretions.
• Hemodynamic instability.
• Laryngospasm/Bronchospasm.
• Phrenic nerve dysfunction.
• Preoperative anemia (Hct < 34%).
• Preoperative hypoalbuminemia.
• Short/thick neck.
• Tracheal pathology (stenosis).

Question 8

What anesthetic and surgical factors increase the risk of emergent postoperative reintubation?

Answer 8

Anesthetic Factors:
• Excessive fluid administration.
• Inadequate NMBA reversal.
• Multiple traumatic attempts at airway management.
• Overinflated ETT cuff.
• Oversized ETT causing swelling.
• Recent administration of excessive opioids.
• Vocal cord damage.

Surgical Factors:
• Surgical time > 3 hours.
• Adverse reaction to blood products.
• Head, neck, thoracic surgery.
• Postsurgical bleeding (esp. airway).
• Vocal cord or recurrent laryngeal nerve damage.
• Emergency surgery.

Question 9

What are the signs and symptoms of respiratory distress?

Answer 9

Neurologic:
• Altered level of consciousness.

Respiratory:
• Decreased respiratory effort.
• Hoarseness.
• Stridor.
• Subcutaneous emphysema.
• Tracheal swelling.
• Wheezing.

Question 10

What are the differential diagnoses for respiratory distress?

Answer 10

Neurologic:
• Acute cerebrovascular accident.
• Neuroleptic malignant syndrome.

Respiratory:
• Aspiration syndrome.
• Upper or lower airway obstruction.

Cardiovascular:
• Myocardial infarction.
• Postsurgical hemorrhage.

Endocrine:
• Addison disease.
• Cushing disease.
• Hypoparathyroidism.
• Hypothyroidism.

Pharmacologic:
• Opioid administration.
• Residual anesthesia.
• Prolonged NMBA.
• Serotonin syndrome.

Musculoskeletal:
• Malignant hyperthermia.

Question 11

What diagnostic tests should be performed in cases of respiratory distress?

Answer 11

• Obtain electrolytes, CBC, renal function tests, and serum albumin.
• Head CT scan.
• Chest radiograph.
• Electrocardiogram.
• Cardiac markers (e.g., troponin level).