Management of the Super Obese- Unofficial SAM BMI Record- 163.

 Awake Intubation .

       In 2007 This 945 lb. case was reported by Cleveland Clinic Anesthesiologists Dr. John Doyle and Dr. Andrew Zura , Rakmachandran M ,Lin J, Cyinski J B, Parker B, Marks T, Feldman M, Lorenz RR  who appear to have the record for a published and peer reviewed case of Super Obese Airway management.

       This massive 22 year old individual required a tracheostomy for hypercarbia with failed  CPAP therapy was reported in the Journal of Clinical Anesthesia : 2007;19:367-369. 

       The management was carried out by an awake approach with , first an attempt at awake flexible Fiberoptic endotracheal tube placement , which failed to achieve the safe advancement of the endotracheal tube. This failure was caused by poor patient compliance and epistaxis. Then a size 5 Proseal Laryngeal Mask Airway was placed successfully and provided a passage way for a Flexible scope passage with an Aintree exchange catheter loaded on to it. The flexible scope was then removed and the 7.5 mm I.D. endotracheal tube  was then passed over the Aintree catheter by a "railroading" technique. 

       The GlideScope was not attempted in this individual so its possible utility is not determined. GlideScope use in Massive obesity has been reported by Dr. John Doyle elsewhere .

GlideScope Obesity Record BMI - 125 . Report from SAM FORUM Feb 13, 2015

GlideScope Intubation of Patient with BMI 125 - Denver Colorado

The SAM forum has recently had an unofficial challenge series describing High BMI individuals treated by SAM members. The Patients included :

1. The Key Case posted by Felipe Urdaneta was a Thyroidectomy case booked for a Thyroidectomy , possible neck dissection. This patient was ultimately  intubated using an awake flexible scope technique . The patient was extubated with Remifentanil drip sedation. The patient became confused enough to break the special service Bariatric bed but survived the event.

2. Richard Shockley recollected a case with a BMI 99.

3. The Record Case so far was reported by Sara Cheng MD , Denver Colorado.

Sara was in her first Post Residency year, when she was called to MICU for a stat intubation at 4AM. The super obese patient  had deteriorated under BiPap to a PACO 2  of  100 . 

This hypercapnia was causing CO2 Narcosis.

The BMI calculated to be 125.

The patient was intubated sitting up with Sara Cheng in front of the patient using a GlideScope 

No additional Medication was used.

This technique has been called the Tomahawk Procedure .

GlideScope "Tomahawk"  Technique

1. Patient in a sitting position,  laying on the side , or supine.
2. Pacey Topicalization Technique ---2% Lidocaine Gel / 2% Lidocaine liquid mixture. 3 way stopcock and 2- 10 cc syringes used to mix 15 cc total volume with some air to create foam.
3. Deliver Foam to the oropharynx where it will spread throughout the pharynx.
4. Invert the GlideScope screen so that right and left sides are correct.
5. Hold the GlideScope like a Tomahawk in the Right hand
6. Use a Verathon rigid stylet and an appropriate size tube- consider a Parker tube if available.
7. Introduce the GlideScope but, as always do not insert it too far or lift too vigorously.
8. Introduce the ETT and extract the stylet as the tube tip passes the cords .