A little neuro

[caligas]

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50 yof for 4 level thoracic fusion. Severe myelopathy. Surgery wants post induction/pre flip motors, then relaxation for exposure, then reversal for the procedure. Do you;

1) try to intubate without muscle relaxation (this is always a S show when I do it but I know all SDN folks have the magic touch)

2) use sux, myelopathy probably won’t make them arrest, probably.

3) small dose Roc, then sugam for motor, more roc for exposure, then more sugam for surgery

4) “I’m sorry, I can not accommodate this request due to the clinical situation.”

5) something else like nimbex or “something really cool that I don’t even know about”

 

[Toothpickwars]

The binding ratio for roc to suggamadex is 1mg to 3.6mg. I’d do 0.3mg/kg roc, bag for 3 min, intubate, and give 1.2mg/kg suggamedex for motors. Then just paralyze to twitches after.

Alternately, 10mg ephedrine followed by induction with 3-4 mcg/kg of remi works well for intubation.

 

[Radar26]

If you can have some time between induction and intubation then a non paralytic intubation is doable without a coughing fit. During training there was a small peds hospital where they rarely used paralytic, every kid got remi and a lido LTA instead. Seemed to work just fine.

 

[teacher2md]

Propofol/fentanyl for induction and intubation. When you DL, if the cords are still moving, come out and give another slug of propofol. Repeat as needed.

 

[MirrorTodd]

Just take 30 minutes to get the a line, roc will have worn off by then. 😉

 

[CopaceticOne]

I will do 1 or 2.

Unless the airway is questionable, I try to go with #1. Give them a good slug of fent when you start to preoxygenate. Once they say the feel it make sure a BP is checked. Then induce with Prop. Once apneic go straight to tube - no learners are getting a “first chance”.

If something is off with airway so that I think relaxation will be needed: Is the patient still actually walking around in their daily life? ESRD? What’s the K? Seldom have I not been able to use sux.

For those few patients where I clinically question using sux, I make sure they are super, super, super deep before trying to tube them. And of course could always do something like a remi bolus.

 

[Onefellswoop87]

#1 but also intubation analagous to pediatrics: Induce with IV agent of choice, mask to 1.5-2 MAC with pressors as needed, bolus of propofol, intubate. Or induce, pop in LMA, a-line, deepen gas and continue as above sentence to intubate.
A-line if still needed, baseline twitches/flip, paralyze and continue case.

 

[pgg]

All of the above is reasonable.

Also reasonable to use a lower dose of roc for intubation (ED95 is 0.3 mg/kg but you have to wait for it to work) and maybe they'll get motors without you doing anything to reverse it.

Sugammadex is titratable and overcome-able. You can give small amounts until the monitor person gets their motors back, then give more roc for exposure, then reverse again.

Or, you can intubate with a normal dose of roc, reverse fully with sugammadex, and then switch to a benzylisoq nmbd like cis-atracurium titrated to a twitch for the exposure bit, then reverse that with glyco/neo. That's more work than just roc - suga - more roc - more suga though.

 

[Arch Guillotti]

Remi/prop/ephedrine/

 

[Iso4ane]

Awake Transtracheal block (Period) And shoot through the cords after a whopping dose of prop and phenylephrine.

 

[amyl]

I intubate lots without paralytic - often do awake-ish glides for submandibular abscess, ent cancers…. I use glyco, versed, a little pdex, ketamine and let them breath the sevo to 2 Mac. Hasn’t failed me…. If theres a reason to polypharmacy I do it early….

Pdex wake ups rarely only if they’re a drunk, druggie or a big young patient who seems like they’ll be combative on emergence…. Get the gas off and wake off nitrous and pdex or very small doses of propfol.

 

[cchoukal]

50 yof for 4 level thoracic fusion. Severe myelopathy. Surgery wants post induction/pre flip motors, then relaxation for exposure, then reversal for the procedure. Do you;

1) try to intubate without muscle relaxation (this is always a S show when I do it but I know all SDN folks have the magic touch)

2) use sux, myelopathy probably won’t make them arrest, probably.

3) small dose Roc, then sugam for motor, more roc for exposure, then more sugam for surgery

4) “I’m sorry, I can not accommodate this request due to the clinical situation.”

5) something else like nimbex or “something really cool that I don’t even know about”

I would mostly do #1 if I really thought succ was contraindicated.

Never tried #3.

For #2, how bad/how long is the myelopathy? Is succ really contraindicated?

Doubt I'd lean on #4.

If I had to intubate without paralytic, I'd use prop/remi, as there is an evidence base for remi vs succ in randomized trials showing equivalent intubating conditions.

 

[Radetzky]

Perhaps I’m missing something obvious but why do they need to be intubated for the preflip motor? Could you LMA, do the motors, then paralyze/intubate and flip?

 

[nimbus]

Perhaps I’m missing something obvious but why do they need to be intubated for the preflip motor? Could you LMA, do the motors, then paralyze/intubate and flip?

What a great idea. We’ll call it the “Radetzky sequence.”

 

[caligas]

Perhaps I’m missing something obvious but why do they need to be intubated for the preflip motor? Could you LMA, do the motors, then paralyze/intubate and flip?

This would work

 

[caligas]

I would mostly do #1 if I really thought succ was contraindicated.

Never tried #3.

For #2, how bad/how long is the myelopathy? Is succ really contraindicated?

Doubt I'd lean on #4.

If I had to intubate without paralytic, I'd use prop/remi, as there is an evidence base for remi vs succ in randomized trials showing equivalent intubating conditions.

They have considerable motor weakness. I am not sure if this truly can cause Hyperkalemia with sux

 

[dA pilot]

Perhaps I’m missing something obvious but why do they need to be intubated for the preflip motor? Could you LMA, do the motors, then paralyze/intubate and flip?

We would routinely get motors done before paralytic in this situation. Neuromonitoring would have a team of 2, they place all their monitoring equipment in preop and tape at the respective locations, I induce in the room, they place their needles, do the testing while I mask, then I paralyze. With practice, this takes no more than a minute. No need for LMA. The key is neuromonitoring to have the staff for it and be organized. A busy spine surgeon gets 2 rooms with 2 neuromonitoring teams, so neuromonitoring has the second person from the second room to help.

 

[abolt18]

We would routinely get motors done before paralytic in this situation. Neuromonitoring would have a team of 2, they place all their monitoring equipment in preop and tape at the respective locations, I induce in the room, they place their needles, do the testing while I mask, then I paralyze. With practice, this takes no more than a minute. No need for LMA. The key is neuromonitoring to have the staff for it and be organized. A busy spine surgeon gets 2 rooms with 2 neuromonitoring teams, so neuromonitoring has the second person from the second room to help.

All I can say is, I hope to never work in a place where a spine surgeon has flip rooms.

 

[DocMcCoy]

All I can say is, I hope to never work in a place where a spine surgeon has flip rooms.

The good thing about a neurosurgeon that “deserves” 2 rooms in my case they are incredibly fast and almost never need me to significantly alter an anesthetic for neuromonitoring.

 

[DrOwnage]

*All this effort to get stuff right*
neuromonitoring:“preflip signals are ****.”
Surgeon: “ok.”

During case: neuromonitoring: “amplitude decreased and remaining.”
Surgeon: *still does what they’re doing anyways* “ok we will see what happens.”

*neuromonitoring falls asleep on their extremely comfortable chair*

 

[nimbus]

*All this effort to get stuff right*
neuromonitoring:“preflip signals are ****.”
Surgeon: “ok.”

During case: neuromonitoring: “amplitude decreased and remaining.”
Surgeon: *still does what they’re doing anyways* “ok we will see what happens.”

*neuromonitoring falls asleep on their extremely comfortable chair*

Similar to when we intubate a patient without moving their head/neck a millimeter. Then the surgeon puts them in 30 degrees of flexion or extension for exposure.

 

[Maz777]

Relaxation for a posterior exposure?

Clowns. Hit the ignore button.

 

[APA 32]

I would use prop, remi 3-4 mcg/kg and ephedrine for this. Would also give some glyco preinduction as well.