Nasal Intubation - Office-based Anesthesia Services- Dental office CRNA - video Dailymotion

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00:00All right we're doing a nasal intubation here in the dental office for this

00:06patient. I gave her Versed Fentanyl. Here comes some ketamine. I try not to use

00:12paralytics on these for obvious reasons. I want her spontaneously breathing the

00:16whole time. So there was a pretty high dose of ketamine there because I have to

00:19rely on my ketamine, my Versed, and my fentanyl and a big dose of propofol to

00:23get her off to sleep. So big deep breath. Big deep breath. Give me two more of

00:28those. Really big deep breath. Hold that there. She's been pre-oxygenating now for

00:32about three minutes, which is what we like. Big deep breath in through the nose, out

00:38through the mouth. All right then I will let that ketamine kind of kick in a bit. All

00:46right here we go. Start to push some propofol. Big deep breath for me. In through

00:51the nose, out through the mouth. Big deep breath. Good. And here it goes. Good. Here comes the probe.

01:00I'll give 20 cc's of this because like I said I need her to be really deep on this

01:05as I try not to paralyze on this. So she should go acne here shortly. Good. Just like that. I'll let the probe kind of kick in.

01:19It's very similar to when you do an LMA. You give all the probe, you kind of give it a

01:24second to do its thing before you start to mess around. So I'll take this really

01:29thing for up just a bit. So she's gone acne for the most part. I'll put her

01:35oral airway and then we have our suction always ready. Make sure that's good to go.

01:39Good. This on her eyes. Good. Now, kind of short neck here. Let's see if I can bag her a little bit.

01:56And you can come closer. And I want you to see. See me get some fog in the mask here.

02:04As I bag her. This is obviously with no paralytic. There we go.

02:10Good.

02:14So she's a pretty easy back considering the circumstances. And I'm gonna wait till she's

02:23even easier. Cause it's almost like when you give paralytic and then you feel them relax.

02:27That's kind of how these patients are too. Now I feel her relaxing for me. And that's

02:31really just the propofol really doing its thing. And I'm giving her more oxygen because

02:37she is bigger. So I'll do that there. I'll bring this here. You have the McGill's, okay,

02:44just in case we need them. Turn this on. I'll leave that right there for now.

02:55And then we'll have suction just in case we need it. This will go. I pretty much use this side always.

03:01And I seem to have pretty good luck with it. There we are. Now, nasal load tube is in.

03:09Now let's see where we are. So if you want to come around this way, show the screen here. So there's

03:16our glottis and we have our cords right there. See, we can't push this guy right into it. See that? And now,

03:27sometimes you get caught up here and it's pretty common. I twist. So pull back just a little and

03:31watch me do this twist. I twist. See how that goes on? Visualization, we're in. I'll take this out.

03:39She tolerated that pretty good. That was because I had such a high dose and go back that way.

03:43I had such a high dose of non-paralytic. So this kind of goes to show you can paralyze patients,

03:48you can intubate patients without paralyzing them. You don't necessarily need to paralyze them every

03:52single time. Now, this is a different circumstance. It's a more of a, I don't want to say controlled

03:57environment, but we, uh, we kind of know ahead of time what we're doing here. And I've done this once

04:03or twice, so I kind of know what to expect, but even in the OR, you don't necessarily have to paralyze.

04:07So let me put this on here like this. Good. Breathe up a little bit. Good. And let's wait until we get

04:15some CO2 there. Good. Can you point that to the monitor? So those are my bottles there. 74 heart

04:24rate, 126 blood pressure. I mean, CO2 is coming. We're in a really good spot here. You can come back

04:29to me. So now what I do, I'll let you guys watch me secure this. Do me a favor. I'm going to have you

04:36just hold it right there at the nose. Don't let it go. Yep. Just like that. Hold it right there.

04:41And I'm just going to grab my tape here. Good. Good. Good. So I always put one piece of tape

04:49like this around the tube, over the nose, and you can let go now. Perfect. I always want something

04:56touching the skin. If this was to, if we were to, you know, something wasn't happening, this whole thing

05:02fell, I at least have something touching the skin. So now what I'll do, I use this

05:10or the forehead. Because all these little connections here have pretty sharp edges,

05:17not sharp enough to cut, but enough to leave like an abrasion. I'll make sure all my connections are

05:22tight. Tight. Good. And this is what I like doing most about this. It's just the head wrap here. One.

05:33Here comes two.

05:38And over time, this will loosen up. So maybe in a couple hours, this might get loose and I'll just

05:44come back and redo it here. So while I'm doing all this, I'm also thinking of her breathing. So if you

05:48show the monitor there, she hasn't started breathing for me. And I know that because I don't see any CO2

05:55and I really don't see any chest right. So keep that on the monitor there. I'm going to give her

05:58one or two breaths here, just to get some, uh, just to get a little bit of oxygen in there. I don't

06:03want her CO2 to go too much, but there, that's CO2. That's the CO2 that I'm giving her or the breath I'm

06:09giving her showing you CO2. So that's that. You can come back to me. Um, and that's pretty much it.

06:16That's it. That's, we have a secure airway. Now we're just waiting for her to breathe.

06:20This is my McGrath that I use here. I'll keep all my dirty stuff here, take my gloves off,

06:26and I'll give her just a touch more probe because even though I want her to come back breathing,

06:30I don't want it to come back all at once. And then she starts to, you know,

06:33buck on me and go crazy. So I'll just hit it with a little bit of that. Um, keep this close.

06:39Keep this here. That's it. You can stop it.

Nasal Intubation - Office-based Anesthesia Services- Dental office CRNA

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