Adult Inhalational induction

Discussion in 'Anesthesiology' started by apma77, May 15, 2008.

  1. apma77

    apma77 Senior Member
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    ive read of single vital capacity breath inhalational sevo inductions...

    what are pros and cons (other than slow induction) ????

    would this be a good idea in a combative patient without iv access??
     
  2. coprolalia

    coprolalia Bored Certified
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    No, for the single reason that it requires patient cooperation.

    -copro
     
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  3. Jeff05

    Jeff05 Senior Member
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    most of the kids i mask down are not cooperating.

    i have masked down mentally ******ed adults and once a lady with the
    worst case of needle phobia, ever. no problems, they're down in about 5 breaths.
     
  4. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Doing mask induction on an uncooperative adult transforms your anesthetic into a veterinary procedure, it can be done but it is a brutal act and not very elegant.
    If things are that bad and your patient is just determined not to let you anesthetize him/her, you might want to consider an IM Ketamine dart, at least you don't have to attack the patient and hold him/her down, and the risk of you getting hurt is considerably less.
     
  5. coprolalia

    coprolalia Bored Certified
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    A) Kids are small. You can fight with a kid and win. Most "mentally ******ed" (I'm assuming Down's) adults are cooperative (at least the ones I met). In the uncooperative ones (including kids), I would never try a mask induction. That's what IM ketamine is for.

    2) Kids also have a greater surface area to weight ratio, which results in more rapid uptake and distribution of the anesthetic and faster induction time.

    III) Single breath induction? Theoretical, but not probable. And, it require breath holding at maximal inspiration.

    Furthermore, remember that the question was asked in regards to an uncooperative adult patient using single breath induction technique.

    Lastly, mask induction using large doses of sevoflurane, as is currently common practice, actually may not be as safe as many practitioners think. Not saying we stop doing it; just making everyone aware that this shouldn't be the first choice in a kid that can otherwise tolerate having an IV placed (I have this "discussion" all the time with Peds attendings who are so deeply set in their ways).

    -copro
     
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  6. coprolalia

    coprolalia Bored Certified
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    AH! Plank, you beat me to it.

    -copro
     
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  7. Planktonmd

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    Mask induction on adults is an acceptable induction method although the transition between the different levels of anesthesia happens more gradually than with IV induction, and this increases the likelihood of bad things that happen at light anesthetic levels like vomiting, laryngospasm, airway obstruction.....
    These bad things happen way more frequently in adults than in kids when you are doing inhaled induction.
     
  8. Jeff05

    Jeff05 Senior Member
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    1. i don't know any kids under 5 that would even think about letting you place an IV.

    2. read your own articles copro...
    The association of anesthetic agents with both seizure activity and with epileptiform EEG patterns is longstanding, with information on enflurane induced electrocortographic seizure activity dating back at least 27 years (6). After a decade of clinical use of sevoflurane, and a considerably longer duration using isoflurane and enflurane, there is no evidence that potent agent induced epileptiform EEG patterns have caused cerebral injury in any patients, even those that had actual clinical seizures. Considering the information we have cited, our reply to Wappler and BishoffÂ’s questions is that the rapid, smooth, and predictable sevoflurane induction technique that we recently advocated (7) is safe, and that the sevoflurane concentration required to elicit non-ictal epileptiform activity is not particularly relevant because such EEG activity is not associated with the risk of epilepsy, provoked seizures, nor their sequelae.

    3. DARTING a human is NOT a vet procedure!?!?
     
  9. Planktonmd

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    We are talking about adult inhalational induction, and on pediatric floors kids of all ages get IV's regularly.


    Yes, darting is a vet procedure but it's more civilized than having to hold a resisting adult down by several people and force a mask over his face while he tries to reach for your neck for several minutes.
     
  10. jetproppilot

    jetproppilot Turboprop Driver
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    I've done several........all were on cooperative ASA 1 knee scopes.

    Used it as the sole agent before LMA placement.....outta boredom more than anything else.

    They arent induced with one breath....thats BS....but it is pretty quick.

    Then hyperventilate them with the sevo cranked up all the way until you deem it time to slip in the LMA.

    Give toradol 30 mg IV and 30mg IM.

    And some antiemesis stuff.

    Nothing else.

    Works pretty good if you are shooting to bypass PACU.....or if youre at a surgery center turning 50 cases a day where its important to keep your discharge flow rolling......at least for knee scopes.

    Pretty fun. Works well. Patents are comfortable enough that a cuppla percocets in day surgery keeps'em happy.

    Try it sometime if you're bored.
     
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  11. coprolalia

    coprolalia Bored Certified
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    Were we talking about children under 5? I mask induce almost all children under five, unless they already have an IV (or port, etc.). I'm suggesting what's safest and able to be done most predictably. No one would argue that mask induction doesn't work. What the OP wants to know is if this is a good technique for an uncooperative adult. The answer to that is a resounding "no".

    I get in "discussions" with attendings all the time about mask inducing a 15-year-old because they're afraid of needles. Often, if you have a nice discussion with a fifteen-year-old, calm their fears, use some lidocaine 1%, and start a painless IV, you've done your job as being a true doctor and you've helped them grow up. If you choose to mask them down, you risk laryngospasm, emetogenesis, and a whole host of other bad things that can happen in a rammy teenager. And, now you don't have IV access to save your ***.

    First, we pre-med a lot of kids with oral midazolam. So, I wonder how much epileptiform activity we're actually missing/suppressing...

    Second, a seizure is a seizure. I appreciate this opinion here, but the fact is that we don't really know what a single seizure will do longterm. If you tell a neurologist that you're doing an anesthetic technique that elicits seizures, they're going to fry you in court if something bad happens and you get sued. Are you uncovering an epileptiform focus, or are you actually damaging the brain? You don't know. These authors don't know. I think it's incredibly arrogant for the authors above to summarily dismiss that point.

    I'm not suggesting not doing mask inductions or that they're inherently unsafe. I will tell you that I don't blast them with 70/30 N20 and 8% sevo off the starting blocks. I do pre-med them. I do slowly turn up the agent until they fall asleep. I was taught that technique by a world renowned pediatric anesthesiologist. I've never seen rigidity. I've never seen a seizure. And, I've never seen a squirmy, fighting kid. Smooth as butter.

    Certainly not a "single breath" induction, which is more a carny act than it is a safe anesthetic.

    So what? If you have a truly uncooperative patient who won't even tolerate a mask induction, what else are you going to do? A ketamine dart works.

    -copro
     
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  12. Mman

    Mman Senior Member
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    I've done a few inhalation inductions on adults, some for practice, some for cardiac reasons. They have all been done on cooperative adults that already have an IV.

    Turn on 50% nitrous for 20 or 30 seconds and then start a little Sevo. 1% for 15-20 seconds, then 2%, etc. until their eyes are closed and they are spontaneously breathing 8% sevo. Then cut the nitrous off and 100% oxygen and do whatever you want, be it some NMB or Prop to put the tube in or perhaps an LMA.

    It can't take more than 3 minutes tops from the time the mask is on their face until the time they are out. Hell, start the process while hooking up monitors and the patient will be out before the circ nurse knows you have started doing anything.
     
  13. Planktonmd

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    Could you explain the "cardiac" indications for mask induction?
     
  14. huktonfonix

    huktonfonix board certified!
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    perhaps in tamponade to maintain spontaneous respiration.
     
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  15. mille125

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    aspiration is a serious concern when using masked induction techniques in adults..
     
  16. jetproppilot

    jetproppilot Turboprop Driver
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    Not on a twenty year old college football wide receiver.
     
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  17. urge

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    Do adults aspirate more than kids during mask induction? If so, why?
     
  18. 2win

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    Plankton - don't be an ABA oral board examiner. BTW - good point!
     
  19. amyl

    amyl ASA Member
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    i mask induced a needle shy patient and then we bag masked her for three hours with the sevo running for "academic purposes." it was good practice for me as i, with little hands, can struggle a little with getting the right seal. in defense of the anes attending it was supposed to be a 45 minute ankle screw that turned into more with an inexperienced resident. she actually woke up badly, seemed disoriented and was hypercarbic. it was a great learning experience for me...of what not to do...and yes i think she was at much greater risk for aspiration. kids have floppy, relatively big epiglotti, right? so maybe less risk of aspiration is somewhat mechanical.
     
  20. militarymd

    militarymd SDN Angel
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    My inhalation inductions..

    I roll patient into room.

    Put them on the OR table.

    Put mask on face....o2 at 10 l/m....sevo at 6 %

    Instruction patient to breath normallly.

    Put on NIBP...start a cycle....put on Pulse Ox.....put on ECG......get the first reading on NIBP.

    Grab LMA and suction...

    Patient usually out by now....depending on how much screwing around I do....

    a little propofol....50 mg or so....lma in....patient still breathing

    sit down to chart....
     
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