Why (and how) anesthesiologists intubate completely awake patients
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- Опубліковано 16 чер 2024
- Did you know that anesthesiologists sometimes choose to intubate patients while they’re completely awake? In this video, I describe why and how awake intubations take place, including narration of a brave anesthesiologist who intubates himself (not me).
0:00 Start
0:35 Anesthesiologist intubates himself
3:44 Why awake?
6:57 Making it comfortable
10:44 Technical pointers
Music:
Subtle Swagger by Ron Gelinas: / atmospheric-music-portal
The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional.
#Anesthesiology #Residency #MedicalSchool - Наука та технологія
"I have intubated myself" is a very weird flex, yet somehow genuinely impressive.
Even as a retired RN, I had an anxiety attack watching this! Maybe when I was younger I wouldn’t have but that takes nerves of steel to intubate oneself! The worst I’ve ever done was draw my own blood!
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 actually had this done! It was quite the experience. I remember being asked to gargle the lidocaine and then at one point i remember coughing and it felt like I was coughing through a straw so i knew at that moment the ET tube was in.
I was happily unconscious and unaware of an intubation problem before having my gallbladder removed. The anesthesiologist was waiting for me to wake up so he could inform me that I'm difficult to intubate. I mentioned it to my surgeon in the follow up visit and she said, vaguely, "oh yeah something wasn't where we thought it would be" and informed me that it caused the surgery to be a half hour longer than expected. In case anyone's wondering about life without a galllbladder - it's great! No issues at all. I eat whatever I want.
I'm sure you eat what ever you want and it shows.
Last year, I had had to have an AVM surgery prior to some extensive OHS surgery, and the anesthesiology plan was to have an awake intubation to reduce stress on my heart. An anesthesiologist fellow spent about 45 minutes explaining in detail the how's and why's, so I went from being totally freaked out by the idea to really feeling comfortable about the whole plan. But when I went in for the actual surgery, I guess the plan had changed because they knocked me out before I could say boo. In any case I am so grateful for the doctor who took the time to make me comfortable with what sounded like a horror show!
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.
In the ambulance we routinely intubated conscious patients in the 1970s prior to having paralytics and sedation. The patients were often in florid pulmonary edema. It’s so much better today.
This guy is a legend but so are you Dr Feinstein, learned a lot about anesthesia watching your videos!
I get so excited when I see 1
Of your videos in my feed. Hats off to the Doctor that intubated himself! Holly smokes I can't imagine that. I can't imagine being intubated while awake period. Your so rt though. Explaing to pts what your doing while doing something makes a huge difference. Your pts are so blessed to have u! I'd ask for your autograph then have it tattoo on arm. Thanks for a awesome video! 😊😊❤❤
Absolutely impressive, much less traumatic these days . Never knew about the injection into the trachea .
My dad was intubated for an endoscopy I think when he has cancer. They kept it in (forgot why). They had him write down things that would make him more comfortable.
#1 was removing the tube.
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.
Great topic and wonderful information. Love the detail you go into for things like this.
Hey Max,
As always, very informative. Thanks.
Wow, that was so cool and amazing, I love anesthesia, I learned a lot! I really enjoy donating to the anesthesiologist Foundation, since it was hard for me to go to college because of my cerebral palsy, I really wanted to be an anesthesiologist! It takes a special person and skill to be an anesthesiologist or CRNA and you’re one of them! I look up to all anesthesiologist and CRNA ! You rock man
I love you max, I’ve watched you for years (this is a new account) and you have helped soothe my nerves before my surgery’s. I had emergency Dental Surgery today and watching you helped a lot. So thanks.
Excellent presentation. Thank you for the simplified content.
That anesthesiologist is cool as all hell!!!
Hello Dr. Feinstein, the slow motion was a very funny blooper. I thought you were doing a remix.
It is very amazing and humbling to see that intubation, being only one part of the whole package of care, in itself requires so much skill and education. I thought I could not revere the specialty anymore than I do, then I see another new video and I'm in awe a whole new way. Thank you so much for your care and your videos.
I happened to be intubated awake once... one of my worst experience ever along with having a naso-gastric tube inserted awake.
It happened about 20 years ago but I do still remember the experience.
My throat was sprayed with some lidocaine (I guess) and left some minutes to let the anesthetic to take effect.
After that I remember this tube passing through my throat, I remember I coughed and had the instinct to vomit and then I suddenly fell asleep.
Thanks general anesthesia! :)
Thank you Dr. Ian.
Max, you owe him a lunch for sure.
I'm gagging, just watching that nice job. Thanks max.
Your the best
This is one of my questions. Thanks for the video
Good job explaining the procedure!🌷🌿
Wow, that man is a rockstar! This is a great channel!
that was an epic slow motion explanation!
Hey dude wanna see something cool? Also the slow motion is actually artsy and I love seeing your face so no worries. I have been spreading the word that you are one of the best teaching MD for laymen and semi laymen viewers like Paramedics or first responders.
I wonder if some medical TV drama has had a doctor go "I gotta intubate myself!", since it's apparently very possible in real life.
Great stuff! Always appreciate these kind of deep dives into something so cool, yet so commonplace in your field of work.
This is now on my Bucket list to try
great vid! entertaining & educational! 👍🏻
He got more balls than I do. Hats off to you.
I have had multiple episodes of anesthesia awareness (waking up mid-surgery) and was intubated. Surprisingly, my chest hurt more than my throat. I learned quickly to advocate for proper pain management as an emergency nurse.
If I were a patient, I would sit up then run out of the hospital screaming.
Me too!
Nope. I had this done once for a TEE. It was the scariest and most uncomfortable procedure I've experienced. Never again.
The is no way in HELL anyone is doing that to ME while I am awake!! It makes my blood run cold just thinking about it.
As someone with a freak lidocaine insensitivity, this is something I hope I don’t have to experience.
Great example of a glidescope. Thank you! For those of us with fused cervical and spinal vertebrae, the laryngoscope is impossible to use without breaking our necks. Glidescopes are essential.
I had polypectomy surgery yesterday and my anesthesiologist was great . His assistant poked me needles in my palm and he later came into the operating room and redid poking all by himself into my forearm so that I don’t feel more pain when he injected meds. Great guy he cared for his patients. I did feel more pain in my forearm when he injected medicines and am sure the pain would have been much worse if it was on my palm.
I have a chronic condition, and during the last 5 years I have had many procedures under general anesthesia to try to cure it (almost done). The first few months they intubated me for each procedure, but then they started using airway protection devices. I also had to have oral surgery during this time period, and had nasotracheal intubation. Can you please do a video showing how that is done? Thanks.
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.
How does this work for patients who don’t respond to lidocaine? I have EDS, giving me both a difficult airway and a resistance to local anaesthesia. I coped ok with awake oesophageal manometry, but I’ve always wondered what they would do for patients like me if sedated intubation wasn’t possible!
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)
New fear unlocked, thanks for that! lol, but very interesting, thanks! I think I'd have to have a heavy anti-anxiety dose for getting this done being awake, and I don't have anxiety.
Definitely exceeds the upper limit of lidocaine administration.
How do you know? 😂
That is pretty badass Geez
Oh, hell no...
This happened to me. Initially I had no memories of it- some sort of drug-induced amnesia? Gradually the memory came back. They say I awoke fighting- I think retrospectively fighting the awake intubation maybe? Emergency, so no explanations given though I think some sedation. I thought at the time that it was odd that I was taken conscious right into the operating theatre but assumed it was because it was a small provincial hospital. Horrific but life-saving.
I watch these videos to try to make sense of what happened to me and also to gain some familiarity with the cold alien environment that is the operating theatre. Thank you!
That's a good way to put it. A cold alien environment. Never never again. 😡😡😡
I can see this as a possible treatment option for paramedics with patients in moderate respiratory distress one of these days . It can be valuable in patients with low oxygen saturation levels .
Thank you for talking through up front what the video contains. I enjoy most of your content, but know this would be difficult to watch for me. I won't be watching this one, but look forward to your next video.
There are reasons to die before having things done to you. This is one of them
Thank you. That's what I always said. I would rather be dead than have intubation and catherization again. It was forced on me when I was unconscious. Never never again.😡😡😡
Breath sounds are equal and bilateral on the patient...and that patient is me. On the next episode, we will demonstrate the appropriate use of the foot in the Sellick Maneuver when both hands are in use during self-intubation.
My friend (brave af) had to have this done due to a neck fusion and TMJ complications. Terrifying procedure
I’m having surgery day after tomorrow, hope they do this after I’m out. I’ve always had it this way during my past surgeries! Last one was November 2019.
This is giving me anxiety. I would never allow an anesthesiologist to intubate me awake. It is bad enough waking up from surgery with an endotracheal tube down my windpipe.
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 😂
Over all my anesthesia experiences i have learned...ketamine is a much easier way for me personally to get put under vs. Straight propofol...i always feel like im falling into a tunnel otherwise
Noti gang 💯
Wow
I had fiber intubation for a sinus surgery. Coolest thing ever. I remember feeling both lungs inflate when he got the tube in. I gave him a thumbs up and went to sleep.
I am terrified, and amused.
I’ve had this happen because I have a difficult airway due to the way I was born. I already hate the part where I go into the OR and wait to be hooked up before going under, it was even worse when you add in the awake intubation.
I was intubated through the nose (in Europe), and it felt far more pleasant than what this looked like... No syringe required! It was all they way through the vocal cords down to the carina, then the anesthesiologist asked me to give a thumb up, and I was given propofol. No relaxation drugs were given (I dislike them), only Lidocaine (as spray), and it worked out fine. I lost my ability to speak as the tube passed the vocal cords, but they informed me of that before the process started.
I was also allowed to watch the monitor while the tube made its way down, which was fascinating, and likely more calming than any drug. The only surprise - though not a problem - was how long it took, around 20 minutes from the first spray-dose of Lidocaine.
Dr Max, I would like to learn about allergic reactions to anesthesia.
Mary, use Google.
"we are just going to stick a SMALL needle through your trachea for numbing". That's a big bunch of nope!
I had a surgery to repair a hiatal hernia, and implant a linx device on my esophagus. I had to have a rapid intubation as they were worried I might aspirate during the procedure. I had no lidocaine prep for this. It happened so quickly, I went under before I experienced any discomfort, other than the pressure on my larynx just prior to insertion.
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).
If you have the patient sit up and look at the ceiling, if possible, you can get the tube down without any anesthesia.
As someone with sensory processing disorder seeing the gauze in the back of the mouth completely triggered my gag reflex but ironically seeing the needle to the throat was very calming 😂. I’d be the weirdo who preferred the seemingly more painful option as apposed to the seemingly less painful one because for me the experience is completely the opposite as a result of my SPD and I find it so strange trying to communicate that to people without SPD 😂.
Could you make a video comparing elective vs emergenecy intubation?
What is that chime at 12:42? I think I remember hearing it in other videos too.
Great video. How do you maintain airway access when the surgical site is in the upper airway?
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).
heck no,! done an NPA on myself (lay description - nasal airway is a short tube that goes to the back of the throat but does not go past the vocal cords and down the trachea) and that was more than enough for me. We just did it to show medics - civilian and military to teach them you can do it on awake conscious patients. Self intubation, hard no!
Fascinating. Intubation is so damn cool. It was also one of the most painful and scary things I’ve ever felt. I was intubated while unconscious from a suicide attempt. However, I woke up during the procedure bc I thought I was being strangled to death. I tried to punch the respiratory therapist in fight or flight mode. When I woke up days later on the ventilator, I felt like I couldn’t breathe and was trying to scream so bad. Them pulling it back out hurt like a bitch
My mother had this done several times. She had a cervical meningioma. They didn’t want to have to hyperextend her neck. She was awake and paralyzed for several seconds while they put the tube in. She still has nightmares about it and says it was the most horrific experience of her life. She had it done four times.
I would have not allowed it after the first time. I had only one surgery (my first) and I'm still haunted by it.☹️☹️☹️☹️
I feel claustrophobic just thinking about being awake for intubation...
Dr. Max: I'm about have that done to me, could be this morning. Gallstones. I love the ear "hat".
Why do patients have to take off jewelry? I had surgery Monday and was told it's not particularly what I thought, that is, to protect against theft. I has to do with conductivity?
A little odd but I once had to do a conscious nasotracheal intubation on an ICU pt. who also happened to be my Father. Went well and I'm not even an anesthesiologist.
👏👏👏
I haven't heard you talk about the special difficulties that arise when people have no functional version of key CYP enzymes (I am absent at least 5). Or conversely that have hyperfunctioning versions.
Im going to have surgery before july hopefully for Barretts with dyspepsia. They tried doing it under light sedition but it didn't work. I need to have endoscopic mucosal resection , but really didn't want to go under a full GA but my anxiety is way too bad the doctor said he needed to do it under GA. Can high anxiety affect anesthesia?
I generally like and get knowledge from your videos, but anybody comes near me with the laryngoscope while I am awake and alert is going to find themselves in a Jerry Springer stage like situation
It was educational, however I would not want to be awake… I can’t gargle 🥲
I got lidocane for a cortisol injection and it really burned. Does it tend to do that or mabye it was just a weird fluke?
Speaking of RT I'd love to know any considerations you'd have giving anesthetic for RT, like in the case of paed RT. What level of sedation do you go to?
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).
No, never do that to me awake. Surgery is fine just make sure I'm. i just fired a cardiologist that did a heart cath on me awake and not numb.
Intubating yourself is a massive show of big balls lol
I could never do it, even with lidocaine!
Similar to when I had to have a TEE. It wasn’t pleasant but a little IV Versed helped a lot.
After my mitral valve repair I awoke intubated and that’s no fun, either. Had to stay that way for a few hours until completely awake. It wasn’t super uncomfortable, but it would have been nice to have a pen and paper in the CCU.
A person being intubated while being awake would cough and would likely start to vomit.... a really disturbing thought. Am I right?
I just had major surgery about a month ago and they changed the anesthesiologist at the last minute (and failed to give me Versed). So in ICU why do they use a lower dose of Propofol while you're intubated (and the horn goes off when you bite the tube)?
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!
What's the C-MAC ANBG7 machine that's recording you from elsewhere?
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.
Can I be awake for ACL surgery?
Damn doc, I wanna hang out with you😂
If he did that so easily and atraumatically then why did it feel like a rusty nail was used to intubate me during my general anesthesia? I had a urological procedure in my lower abdomen. I had almost no pain from the biolateral incisions but mythroat hurt like hell for several days.
I was gagging for him
As long as it's not as bad as getting an ng tube, I think I could handle it. I had to get 2 done in 1 day before (first one wasn't placed right) and if you've ever seen the puking scene from Team America: World Police, you'd know how it went xD
I'm afraid it's even worse than getting an NG tube.
No mention of Precedex? You only mentioned midazolam and remifentanil
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
In Israel we have injectable cannabis... How do you feel about using cannabis as a general anaesthetic?
Not that films and television are a reliable source of medical information, but in emergency room scenes you often see intubation of conscious people with no preparation of any kind. If true, wouldn't that be terrifying for the patient and very difficult for the physician? If not true, what really happens?
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...
Just curious-does the lidocaine suppress the gag reflex?
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
How do you not immediately just gag and throw up? I can barely touch the back of my tongue without gagging, how’s a long tube supposed to get down there?
All that lidocaine!
I would die. Never! Terrifying!!!!!
How do you deal with someone with a severe gag reflex ?
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
Would you hyper-oxygenate the patient prior to doing an awake intubation?
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).
Meanwhile, I gagged twice just watching that self-intubation
No way you better put me out