Modified rapid sequence?

[periopdoc]

I know some of you guys on here aren't big fans of cricoid.

It was my task to hold cricoid on a failed-epidural -> GA C-section the other day. I held until the balloon was up and the vent connected. As soon as I let go the mouth filled w/ gastric fluid. To me this was a clear case of cricoid working, but I'd love to hear your input.

Cricoid pressure increases the risk of aspiration.

When effectively applied, cricoid pressure causes relaxation of the lower esophageal sphincter, allowing the esophagus to fill with gastric content. When you release cricoid pressure, the esophageal contents may empty into the oropharynx. Endotracheal tubes provide incomplete protection from aspiration of oropharyngeal secretions/ contents. Therefore, you have filled the oropharynx with gastric contents that can now be (micro)aspirated. Great job Buck Rogers.


- pod

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[periopdoc]

Oh and on the RSI, what more can I say than what Jet has already said except here is my RSI method.


Get a big 60cc syringe. Put induction agent of choice + lido + fentanyl (if you want) + sux into that syringe.

Place a big IV in a big vein.

ASA Monitors

+/- versed

Preoxygenate for a good 3 minutes with bed in reverse trendelenburg to increase FRC and (maybe) decrease risk of regurg on induction.

Push the whole syringe at once into a wide open flowing IV.

Intubate when the shimmy-shimmy stops.


If you fail to intubate and the patient desaturates, this becomes a routine induction and you follow your difficult airway algorithm. As has been mentioned in this thread, I can treat aspiration pneumonitis/ pneumonia. I can't treat hypoxic death of brain cells.


Oh and what is this BS about needing Versed for amnestic effect on induction. We give Versed in preop for anxiolysis. All induction agents are damn good amnestics on their own and don't need any help in that department. Are you wanting the patient to forget the preoxygenation?


- pod

 

[dhb]

lidocaine really doesn't add much.

I have never had a patient complain about the propofol sting when lidocaine was added. I don't understand people who say it doesn't work

 

[Idiopathic]

Maybe I didn't say my point well. If I have the "true full stomach" then I'll do induction/paralytic only. That is what I consider to be RSI. All the other instances aren't RSI. I've had patients complain of tinnitus/perioral numbness after IV lidocaine. Probably no where near the seizure threshold but lidocaine really doesn't add much.

wait, what? are you pushing lidocaine in holding? i give it in line with propofol or immediately preceding.

 

[periopdoc]

Cricoid pressure increases the risk of aspiration.

When effectively applied, cricoid pressure causes relaxation of the lower esophageal sphincter, allowing the esophagus to fill with gastric content. When you release cricoid pressure, the esophageal contents may empty into the oropharynx. Endotracheal tubes provide incomplete protection from aspiration of oropharyngeal secretions/ contents. Therefore, you have filled the oropharynx with gastric contents that can now be (micro)aspirated. Great job Buck Rogers.


- pod

Wow, over 24 hours since posting this and NOBODY has challenged it?!?!?

- pod

 

[dhb]

Here you are:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[Idiopathic]

Wow, over 24 hours since posting this and NOBODY has challenged it?!?!?

- pod

i dunno, arguing over cricoid pressure is kind of painful, its become so dogmatic

 

[periopdoc]

Arguing over whether CP is beneficial is getting old. However, I have not seen anyone else who argues that CP INCREASES the risk of aspiration.

With the exception of the argument that it MAY obscure the view on DL, I have not seen anyone else arguing that CP is actually harmful. I say it is harmful and should not be done.

I wonder if I should try to make that argument on the orals? At least it would fill up some time on MY terms.
-pod

 

[proman]

wait, what? are you pushing lidocaine in holding? i give it in line with propofol or immediately preceding.

Where do you get holding from? You've never started an induction and stopped for whatever reason? You've never seen awake patients get IV lidocaine? Do you disagree that lidocaine for induction is an entirely optional step that accomplishes relatively little? While lidocaine is shown to reduce pain by about 50%, we're talking about 0.8 reduction of VAS of a mild pain. Not really clinically significant.


Propofol-induced injection pain: comparison of a modified propofol emulsion to standard propofol with premixed lidocaine.Adam S, van Bommel J, Pelka M, Dirckx M, Jonsson D, Klein J.
Department of Anesthesiology, Erasmus Medical Center Rotterdam, The Netherlands. [email protected]

Propofol is well known for its association with pain on injection. The most frequently used method to reduce this pain is premixture with lidocaine. Recently, a modified lipid emulsion of propofol containing medium-chain triglycerides (MCT) with long-chain triglycerides (LCT), in contrast to the usual LCT formulation, has been advocated to alleviate pain. In a randomized, prospective, controlled, double-blind study on 222 surgical patients, we compared the effect of the two solutions on the incidence and intensity of injection pain. Patients were randomly allocated to receive either propofol MCT/LCT (group M; n = 109) or standard propofol LCT with the addition of 20 mg of lidocaine (2 mL of lidocaine 1%) to 200 mg of propofol (group L; n = 113). Pain scores were assessed using a verbal analog scale (VAS) ranging from 0-10. Group L was found to have significantly less pain on the injection of propofol (mean VAS, 2.5 +/- 2.9) (mean +/- sd) than group M (mean VAS, 3.8 +/- 3.2; P = 0.002). Regarding postoperative recall of pain on injection, patients in group L indicated significantly less pain (mean VAS, 2.2 +/- 2.4) than patients in group M (mean VAS, 3.0 +/- 2.7; P = 0.02). Premixing of 20 mg of lidocaine (2 mL of lidocaine 1%) to 200 mg of standard propofol LCT causes less pain on injection than propofol MCT/LCT and thus increases patient comfort.

PMID: 15385353 [PubMed - indexed for MEDLINE]

 

[Licoricestick]

Cause the propofol was burning excessively...Push a large undiluted dose quickly without lidocaine, you might see what I mean...There are also more freaks in the US than down under, so maybe you won't see anything...

Ahh - I'm wondering if we're talking at cross purposes. One of the earlier posts mentioned a dose of 1mg/kg of lignocaine and a comment about preventing fasiculations.

Certainly I usually use a small dose of lignocaine (depending on whom I'm working with it's either in the propofol syringe or given before the propofol - I have at least one bos of insists that anything added to propofol disrupts the lipid emulsion... despite the evidence that patients still go to sleep with lignocaine in the propofol) - but I was trying to figure out what using 1mg/kg of lignocaine as some sort of co-induction agent (with ?some effect on sux fasiculations) was supposed to do. (Yes, I know you sometimes yes lignocaine for ablation of HTN response to DL, but that didn't seem to have anything to do with patients throwing masks across the room).

That said, I have worked with one person in a previous location (when I was a med student) who NEVER used lignocaine with propofol. Certainly some patients complained on injection, but there wasn't anything as drastic as mask throwing.

 

[Idiopathic]

the lidocaine has been shown to reduce myalgias associated with sux, but not the fasciculations themselves