A 60-year-old woman has a right hemi-hepatectomy for invasive cholangio-carcinoma. She has been admitted to your unit for postoperative care

c)        On day 6 she has a massive melaena requiring urgent endoscopy in the Intensive Care Unit. She requires endotracheal intubation. How will you perform this?

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College Answer

There probably will be hypovolaemia, a potentially full stomach, hepatic, renal dysfunction and encephalopathy. The safest method of intubation is mandatory.

Consider: Preparation of intubation (what equipment, help, drugs,), what monitoring, description of probable rapid sequence induction with cricoid pressure.

Discussion

This is another one of those "how would you prepare for intubation" questions.

  • Preparation of equipment
    • Laryngoscope is check and working
    • there is a backup laryngoscope with a macintosh blade
    • there is a fully charged videolaryngoscope available
    • monitoring equipment is online and attached tot he patient
  • Preparation of staff
    • skilled staff are available, and briefed about the procedure
    • backup is available, in the form of a senior anaesthetist
  • Preparation of drugs
    • propofol
    • fentanyl
    • muscle relaxant (suxamethonium is preferred)
    • reversal agent (sugammadex)
  • Preparation of patient
    • assess the level of cooperation to be expected (eg. delirium)
    • get consent
    • explain procedure
    • position the patient comfortably
  • Specific features of the procedure
    • rapid sequence induction with cricoid pressure and no bag ventilation
  • Post-procedure considerations
    • Any hepatic or renal dysfunction will delay the clearance of anaesthtic agents, and will delay extubation