a scenario

[MErc44]

The other day during a prolonged extubation, I was asked what to do when a patient needs to be reintubated after having received reversal agents for non depolarizing blockers. I didn't have an answer to the question and was told to look it up. So far haven't found anything. How would you guys go about handling this?

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[periopdoc]

I too would tell my resident to go look it up.


- pod

 

[rsgillmd]

I'll never miss being a resident.

Usually, if you're reintubating, you are unable to support ventilation by mask effectively. You need to get the tube in quick. I would give propofol and sux, realizing the sux will take longer than usual to wear off. Obviously, you don't push reversal again.

I have a small but important disagreement with this answer. Sux may take longer than normal to wear off, but not necessarily. The duration of action of Sux is unpredictable. This is in the books, but I don't recall the exact source right now.

In my limited experience of having to reintubate some patients I have seen it wear off within 8-10 minutes (normal). The longest I saw it take to wear off was in the 15-20 minute range (I don't remember exactly at this point).

 

[jwk]

I have a small but important disagreement with this answer. Sux may take longer than normal to wear off, but not necessarily. The duration of action of Sux is unpredictable. This is in the books, but I don't recall the exact source right now.

In my limited experience of having to reintubate some patients I have seen it wear off within 8-10 minutes (normal). The longest I saw it take to wear off was in the 15-20 minute range (I don't remember exactly at this point).

If you have to reintubate urgently for whatever reason, worrying about how long whatever muscle relaxant I've used is going to last probably won't be high on my list of concerns.

 

[Jeff05]

sux will take longer to wear off - as pseudocholinesterase is inhibited by your reversal agent (neostigmine).

if hemodynamics permit, i would give an induction dose of propofol and intubate. if you can't, you can give more NDMB or use sux.

 

[rsgillmd]

If you have to reintubate urgently for whatever reason, worrying about how long whatever muscle relaxant I've used is going to last probably won't be high on my list of concerns.

I never said it was high on my list of concerns. I was trying to address the original poster's question because a similar question showed up on the AKT, if I recall correctly.

Residency is about teaching both theoretical and practical aspects. I happened to have paid attention to how long my patients took to recover. Nothing wrong with that. My observations were crude also. I was just looking for spontaneous respirations -- not rate or TV. If you really want to be theoretical, then I would say attach twitch monitors to check for return.

Additionally just because you are reintubating doesn't mean it has to be emergent. One of my patients was s/p thoracotomy. My attending and I both thought he would do fine so we took out our double lumen tube. However, he was hypoventilating and after a while we just reintubated him with a single lumen tube before we left the OR to go to ICU.

 

[ozzie20]

Using Sux post reversal will prolong sux according to the books, looked it up, pp 229 of morgan, as well as prolonging pseudocholinesterase. I'd agree with above poster that stated that you should use propofol to sedate, reintubate, and if necessary use sux knowing that it will be prolonged.

In my opinion the original question doesn't have enough information. You ultimately need to know why the patient needs to be reintubated. Are they hypoventilating? Did they not get enough reversal? Do they have hepatic/renal failure thus prolonging drugs in the system? These questions I'd say need to be answered before I move on to the next step.

 

[Planktonmd]

I am not sure why people think that you need to give a muscle relaxant to re-intubate a patient!
Just give an induction dose of whatever induction agent you like, give some Lidocaine IV if you really want to, then just put the tube in.

 

[Noyac]

I am not sure why people think that you need to give a muscle relaxant to re-intubate a patient!
Just give an induction dose of whatever induction agent you like, give some Lidocaine IV if you really want to, then just put the tube in.

Muscle relaxants may still be needed in some cases as you well know. But over all your approach works fine.

 

[Planktonmd]

Muscle relaxants may still be needed in some cases as you well know. But over all your approach works fine.

True,
In some patients you do need muscle relaxants to get good intubating conditions but these are the same patients that you should not extubate until you are really sure they can fly on their own.

 

[proman]

True,
In some patients you do need muscle relaxants to get good intubating conditions but these are the same patients that you should not extubate until you are really sure they can fly on their own.

This makes no sense to me. I imagine that you use relaxants in >90% of your intubations. You probably don't need to, but they optimize conditions and increase the success rate of a DL. In a patient who has failed extubation, why would you attempt a no relaxant approach that has a lower success rate? Granted many patients who fail extubation become hypercarbic and don't require much, the need to give a relaxant for a possible reintubation has never been a factor in deciding to extubate.

 

[Planktonmd]

This makes no sense to me. I imagine that you use relaxants in >90% of your intubations. You probably don't need to, but they optimize conditions and increase the success rate of a DL. In a patient who has failed extubation, why would you attempt a no relaxant approach that has a lower success rate? Granted many patients who fail extubation become hypercarbic and don't require much, the need to give a relaxant for a possible reintubation has never been a factor in deciding to extubate.

I am sorry for not making sense to you, so let me give it a second attempt:
I am trying to say that if a patient had a marginal airway and you had a crappy view on laryngoscopy despite your use of muscle relaxants then you should not extubate this patient unless you are almost certain that they are ready.
If you follow this simple logic then you should be able to lower the number of patients with marginal airway that you extubate prematurely and as a result you should lower the need for muscle relaxants to re-intubate since the ones you extubate early would be mostly the easy airways that could be intubated without a muscle relaxants.