single breath induction technique

[ethilo]

Just got back from an anesthesia conference where a couple people made mention of the vital capacity single-breath induction technique. Just wondering if anyone out there has experience using it and prefers to use it in their practice?

Any tips/tricks with it? I've actually tried it a couple times on adults that were otherwise healthy, coupled with an IV induction. I feel like I get intubating conditions much more rapidly than just an IV induction alone. The thing I think to consider would be the pre-oxygenation is not as complete and comprehensive as having sequential 100% tidal volume breaths for a few minutes.

Overall, I don't think it's worth incorporating in my daily practice as I have to coach the patient how to breathe and I think the time spent just doing standard preoxygenation and IV induction is fairly minimal.

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[Mman]

Just got back from an anesthesia conference where a couple people made mention of the vital capacity single-breath induction technique. Just wondering if anyone out there has experience using it and prefers to use it in their practice?

Any tips/tricks with it? I've actually tried it a couple times on adults that were otherwise healthy, coupled with an IV induction. I feel like I get intubating conditions much more rapidly than just an IV induction alone. The thing I think to consider would be the pre-oxygenation is not as complete and comprehensive as having sequential 100% tidal volume breaths for a few minutes.

Overall, I don't think it's worth incorporating in my daily practice as I have to coach the patient how to breathe and I think the time spent just doing standard preoxygenation and IV induction is fairly minimal.

it's like a cool parlor trick that has almost no relevance to daily practice Only time I do any sort of mask induction on adults is when I want to keep them spontaneously ventilating. When you consider the time you have to take charging the circuit with 8% sevo and coaching the patient on how to correctly do the single breath it does not save any time compared to an IV induction and as you note you are not preoxygenating them either.

 

[Urzuz]

Completely useless. Just push the propofol bro.

 

[Arch Guillotti]

useless

 

[DrZzZz]

Had an attending in training who liked to do single breath inductions for kids who were not quite old/tough enough for a preop IV, but also old enough to make a game of it. Worked well for that specific population, helped take their mind off being scared of surgery. But I don't see a reason to ever bother with it outside of that population. Like someone said above, more of a parlor trick than anything else.

 

[jwk]

It’s kinda like doing closed circuit anesthesia. Interesting to understand the concepts but fairly impractical to do routinely.

 

[coffeebythelake]

Nevermind single breath induction technique,, the use of any inhalation induction should be a rare occurrence when better IV options exist. (Incidentaly I did do an inhalation technique recently for a patient w severe biventricular heart failure as I wanted to keep pt spontaneously breathing). Seems like a huge waste of sevo too. High flows, priming the circuit and open to OR

 

[nimbus]

Colleagues who were formerly navy say they used to do it for kicks.

 

[Katheudontas parateroumen]

Done it for peds but like others have said, it's more just for the concept and fun, no real clinical use that I can think of? I don't do many inhlational inductions in adults, how is the stage 2, how long does it typically take, and is it more hemodynamically stable since the pt kind of does their own auto-regulation of how much they need to fall asleep?

 

[repititionition]

Done it for peds but like others have said, it's more just for the concept and fun, no real clinical use that I can think of? I don't do many inhlational inductions in adults, how is the stage 2, how long does it typically take, and is it more hemodynamically stable since the pt kind of does their own auto-regulation of how much they need to fall asleep?

I find there are so many people who have never done inhalational, or primarily inhalational, inductions in adults who are scared of the perceived risk of stage two.

I do one weekly, at least, and love them.

Sick people breathing 1% sevo while you place an a-line generally have train track vitals and then need a TINY amount of hypnotic and opioid to bump off the last few synapses into intubating conditions once you’re ready.

I have never seen anything like what most people would describe as stage two phenomena while doing this.

 

[coffeebythelake]

I find there are so many people who have never done inhalational, or primarily inhalational, inductions in adults who are scared of the perceived risk of stage two.

I do one weekly, at least, and love them.

Sick people breathing 1% sevo while you place an a-line generally have train track vitals and then need a TINY amount of hypnotic and opioid to bump off the last few synapses into intubating conditions once you’re ready.

I have never seen anything like what most people would describe as stage two phenomena while doing this.

agree, sevo inductions for adults can be very smooth.

 

[lovemango]

Sick people breathing 1% sevo while you place an a-line generally have train track vitals and then need a TINY amount of hypnotic and opioid to bump off the last few synapses into intubating conditions once you’re ready.

I have never seen anything like what most people would describe as stage two phenomena while doing this.

Interesting, do you have them hold the mask or use facestraps while you're doing the A-line?

 

[drmwvr]

Sick people breathing 1% sevo while you place an a-line generally have train track vitals and then need a TINY amount of hypnotic and opioid to bump off the last few synapses into intubating conditions once you’re ready.

Define 'sick'... breathing 1% sevo for an A line?

 

[repititionition]

Define 'sick'... breathing 1% sevo for an A line?

last one had a AV area of less than 0.5 and had lived through the Spanish flu.

And I may have had the sevo at 0.8%, I don’t remember. And sure, you can argue that if they’re that sick they shouldn’t have anything before getting any anesthesia. But my experience with these is consistent.

I think it’s important to recognize that these people don’t have a half mac of sevo on during this. They’re breathing 1% sevo (give or take), but their neurological and CV exposure to volatile are unlikely to get above 0.3 mac during the timeline that I’m talking about for truly sick patients.

In this last case, a-line was in and secured in about 5 minutes. Patient at that point was drowsy but would open eyes to command. Gave 25 of fentanyl and 40 of propofol in divided doses. Squirt of phenylephrine. Intubated. Chart looks like I made it up the lines are so straight.

I believe that the stability comes from the fact that loading conditions change so slowly with these inductions that there is much more opportunity for the patient’s physiology to self-regulate/compensate. I find this is also a great way for you to test how they will handle further anesthesia, as etSevo of 0.5% or so is about the minimum cardiovascular derangement you get while providing “any” anesthesia.

I’m not preaching. If you don’t like it no need to use it, but I find it very useful.

 

[repititionition]

Interesting, do you have them hold the mask or use facestraps while you're doing the A-line?

face straps

 

[Gern Blansten]

it's like a cool parlor trick that has almost no relevance to daily practice Only time I do any sort of mask induction on adults is when I want to keep them spontaneously ventilating. When you consider the time you have to take charging the circuit with 8% sevo and coaching the patient on how to correctly do the single breath it does not save any time compared to an IV induction and as you note you are not preoxygenating them either.

Agree with this assessment. It was cool when it was first described years ago. The hassle factor of all of it makes it too much trouble. Parlor trick is a good description.

 

[deleted875186]

last one had a AV area of less than 0.5 and had lived through the Spanish flu.

And I may have had the sevo at 0.8%, I don’t remember. And sure, you can argue that if they’re that sick they shouldn’t have anything before getting any anesthesia. But my experience with these is consistent.

I think it’s important to recognize that these people don’t have a half mac of sevo on during this. They’re breathing 1% sevo (give or take), but their neurological and CV exposure to volatile are unlikely to get above 0.3 mac during the timeline that I’m talking about for truly sick patients.

In this last case, a-line was in and secured in about 5 minutes. Patient at that point was drowsy but would open eyes to command. Gave 25 of fentanyl and 40 of propofol in divided doses. Squirt of phenylephrine. Intubated. Chart looks like I made it up the lines are so straight.

I believe that the stability comes from the fact that loading conditions change so slowly with these inductions that there is much more opportunity for the patient’s physiology to self-regulate/compensate. I find this is also a great way for you to test how they will handle further anesthesia, as etSevo of 0.5% or so is about the minimum cardiovascular derangement you get while providing “any” anesthesia.

I’m not preaching. If you don’t like it no need to use it, but I find it very useful.

I don’t know, I’ll put this on my list of things I will never be gutsy enough to try.

Put the a line in completely awake with local, then give small dose of hypnotic till asleep with vasopressors running. I see no reason to risk an airway event, or cardiovascular collapse, or patient getting combative or something, while I’m at the other end of the table fiddling with an a line.

 

[DrOwnage]

last one had a AV area of less than 0.5 and had lived through the Spanish flu.

And I may have had the sevo at 0.8%, I don’t remember. And sure, you can argue that if they’re that sick they shouldn’t have anything before getting any anesthesia. But my experience with these is consistent.

I think it’s important to recognize that these people don’t have a half mac of sevo on during this. They’re breathing 1% sevo (give or take), but their neurological and CV exposure to volatile are unlikely to get above 0.3 mac during the timeline that I’m talking about for truly sick patients.

In this last case, a-line was in and secured in about 5 minutes. Patient at that point was drowsy but would open eyes to command. Gave 25 of fentanyl and 40 of propofol in divided doses. Squirt of phenylephrine. Intubated. Chart looks like I made it up the lines are so straight.

I believe that the stability comes from the fact that loading conditions change so slowly with these inductions that there is much more opportunity for the patient’s physiology to self-regulate/compensate. I find this is also a great way for you to test how they will handle further anesthesia, as etSevo of 0.5% or so is about the minimum cardiovascular derangement you get while providing “any” anesthesia.

I’m not preaching. If you don’t like it no need to use it, but I find it very useful.

This is a useful strategy. I did this a couple of times in residency with one of my cardiac attendings in the sickies. I think it works well in the bad pulmonary hypertension patients too. You induce them by having them breath volitile until they let you take over gently masking them, give them a little bit of prop (30-50) and paralytic then intubate. Works pretty damn well.

 

[Mman]

tamponade is a situation that classically works well with inhalation technique to maintain spontaneous ventilation

 

[nimbus]

We are talking about 2 different inhalation induction techniques in this thread. One is a slam inhalation induction and the other is slow and gentle.

 

[2Fast2Des]

I don't even mask ventilate after inducing... I used to try to mask inducing for fun for a little bit in the past but I got tired of smelling sevo and having to really ensure a tight seal with face straps and all that so the room doesn't get gassed. Now I just put the mask on their face, using their own mask to hold it in place, have them preO2 themselves and once the roc kicks in it's tubey time. It doesn't hurt to have a few tricks up the sleeves but mask inducing is just not worth the time unless I really need it for the case. Prop roc tube, next

 

[coffeebythelake]

I don't even mask ventilate after inducing... I used to try to mask inducing for fun for a little bit in the past but I got tired of smelling sevo and having to really ensure a tight seal with face straps and all that so the room doesn't get gassed. Now I just put the mask on their face, using their own mask to hold it in place, have them preO2 themselves and once the roc kicks in it's tubey time. It doesn't hurt to have a few tricks up the sleeves but mask inducing is just not worth the time unless I really need it for the case. Prop roc tube, next

Are you doing RSI for all your patients? If you aren't even mask ventilating before intubation that's a minute plus of apnea time

 

[2Fast2Des]

Are you doing RSI for all your patients? If you aren't even mask ventilating before intubation that's a minute plus of apnea time

No, just rocuronium... Good thing FRC gives me a few minutes of time to let things simmer. After I induce then I start opening up my blade, tube, tape, so by the time that's all set up then I'm ready to go. Technically according to JCAHO nothing is supposed to be opened up or meds drawn prior to a pt is supposed to be in the room so I'm just being compliant .

 

[coffeebythelake]

No, just rocuronium... Good thing FRC gives me a few minutes of time to let things simmer. After I induce then I start opening up my blade, tube, tape, so by the time that's all set up then I'm ready to go. Technically according to JCAHO nothing is supposed to be opened up or meds drawn prior to a pt is supposed to be in the room so I'm just being compliant .

Interesting. I don't "test to see if the patient is maskable" before I push rocuronium but I mask ventilate to maximize apnea time during intubation. Probably since j work with residents a lot we teach them these habits. I don't turn on the sevo though while masking..

 

[nimbus]

I don’t mask 90%+ of my patients at all. It is RSI. Pre-O2. Mix lido/prop/roc in same syringe. Push. Wait for apnea. Glidescope. Will occasionally see a weak vocal cord wiggle but most of the time not. If still wiggling, push tube through when it’s open.

 

[2Fast2Des]

I don’t mask 90%+ of my patients at all. It is RSI. Pre-O2. Mix lido/prop/roc in same syringe. Push. Wait for apnea. Glidescope. Will occasionally see a weak vocal cord wiggle but most of the time not. If still wiggling, push tube through when it’s open.

Same what I do. No labeling, easy and simple

 

[coffeebythelake]

Same what I do. No labeling, easy and simple

Jcaho might not be happy with this

 

[deleted875186]

Jcaho might not be happy with this

I believe JACHO says different size syringes is an acceptable labeling strategy when drawing up meds for procedures.

Not sure what they say about drawing up and immediately administering a drug.

 

[coffeebythelake]

I believe JACHO says different size syringes is an acceptable labeling strategy when drawing up meds for procedures.

Not sure what they say about drawing up and immediately administering a drug.

They ok w drawing up multiple drugs Ina single syringe? I thought thry took issue even with our hospital pharmacies compounding drugs

 

[nimbus]

Jcaho might not be happy with this

One of my partners told me I should just label the syringe “anesthesia”.

 

[GassYous]

Jcaho might not be happy with this

Who cares?