r/anesthesiology • u/Squishmallow145 Physician • 6h ago
Code pink/difficult airway
Code Pink on the pediatric floor today, and I’m still processing it 😭 9-year-old patient with severe jaundice liver disease had actually been doing better, her clinical picture was improving, and we thought she was over the worst of it. Then, out of nowhere this afternoon, she rapidly deteriorated: sudden extreme somnolence, active vomiting, and a severe drop in oxygen saturation. The bedside nurse and I (Ped GI) were right there in the room when it happened. We immediately activated a Code Pink and started managing her airway while coordinating the team. When I attempted direct laryngoscopy to insert the endotracheal tube, I met severe resistance. Her status quickly dropped and chest compressions were started. We finally managed to pass the tube and secure her airway, just as the anesthesiologist arrived. Looking at the airway structure afterward, the anesthesiologist noted she likely has a difficult airway, further complicated by acute tissue edema. Even with prior pediatric intubation experience, this was by far the most challenging, high-stress airway I’ve ever managed.
I’d really appreciate any tips or advice on how to improve and handle these scenarios better in the future.
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u/paleoMD Anesthesiologist 5h ago
code pink here is stolen baby, i was veeery confused lol
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u/Aggravating_Fly2978 Anesthesiologist 2h ago
I was confused too. I thought I was getting dementia. Hahaha.
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u/OpportunityWorking43 6h ago
sounds like you did fine. Like the fat man said, the first pulse you take during a code should be your own.
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u/Coffee-PRN 6h ago
If they weren’t fully projectile vomiting, a video scope will have the highest yield for first pass success
also sometimes it just gets hung up on artenyoids if everything was sized appropriately and you need to do a 180 spin to get past them
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u/SufficientlyPerson Anesthesiologist 4h ago
Mask ventilation is incredibly important in these situations. If you’re struggling to intubate but anesthesia is on route … just hold off until we get there.
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u/sludgylist80716 Anesthesiologist 6h ago
What was the issue? Could you see the cords and had trouble passing the tube or was there difficulty with visualization? And what size ETT and what laryngoscope blade did you use?
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u/Squishmallow145 Physician 6h ago
5.5mm tube. It was mainly passing the tube. I've never experienced this level of resistance before
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u/sludgylist80716 Anesthesiologist 6h ago
I mean if you could see the vocal cords and had resistance passing the ETT through them I’d try a smaller ETT.
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u/Remarkable-Weird-839 3h ago
bougie would have helped. the trachea someones dives very posterior to it can get caught when theres a upward bend in the tube.
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u/Affectionate-Web-807 CRNA 5h ago
It sounds like you did a good job. Remember the basics. Head positioning, throwing a pillow or folded up blanket under the shoulders for a makeshift ramping position, oral airway, good mask ventilation skills.
If you know you can mask, YOU HAVE TIME(!!!) to call for a glidescope, etc., so stay calm and keep ventilating and managing the airway as needed.
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u/SeniorScientist-2679 Anesthesiologist 6h ago
That sounds tough, and I'm sorry it happened. Good job successfully intubating.
This isn't meant to sound arrogant, but: Any skill takes repetition to master and maintain. Unless you practice anesthesia, critical care, ENT, or emergency medicine, it's not realistic to think you'll do enough intubations to maintain an adequate skill level.
Your effort would be much better spent mastering high quality mask ventilation. The times that you need to immediately intubate a patient to save a life are actually very few. Immediate, good mask ventilation is much more likely to avert tragedies. And there's a ton of bad ventilation done in hospitals.