Airway management principles/drugs

[ROCyourROLLium]

Hello, CA1 here. Long time lurker and first time poster. I've seen a few airway mis-adventures this year, especially on the floor and ICU and wanted to know your thoughts.

1. RSI. When do you do true vs modified? From what i've seen and read, if patient has poor pulmonary reserve and starts de-satting while waiting for paralysis to kick in then it is OK to give gentle breaths. Do you give breaths or always wait for because fear of aspiration? What is the risk benefit of A) Waiting for paralysis to fully kick in, B) giving some gentle positive pressure breaths while waiting, C) Taking a look and trying to intubate before patient fully paralyzed?

2. Paralysis. From reading and clinical experience, paralysis helps with ventilation and intubation. Say I only gave hypnotic and having hard time ventilating/intubating. Would you then work your way down difficult airway pathway or would you give paralytic? From what i've read it seems that you would probably give paralysis to ICU and floor patients whose clinical condition will only worsen and won't benefit from waking up? I feel that is pretty cavalier to do outside of the OR. Thoughts?

Thanks!

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[POW16]

Fellow CA-1 here,

1.Ventilating and oxygenating the patient always trumps aspiration risk. Unless the patient is a complete pulmonary cripple, he should recover from pneumonitis or pneumonia. Sometimes I don't wait until paralysis has fully kicked in. Your view will only improve as you instrument the airway.

2. Why would you not give paralytic for a floor or ICU intubation? Unless the patient is coding. That will only make your conditions better in a less than ideal environment (aka not the OR) The patient requires MV so it's fine if he's paralyzed. It will wear off eventually and the team can switch to PSV or whatever.


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[Robotic Wis-Hipple]

If you make the decision to put the patient to sleep, give paralytic. The decision point is asleep VS awake not asleep vs asleep + NMB. The witholding of NMB, depolarizing or non is academic dogma that exists in Anesthesia and is obviously rampant in medicine/ICU intubations. The truth is; your first look is your best look, a fully relaxed patient is easier to intubate and ventilate (may need oral airway), and most importantly, the patient is very likely not returning to spontaneous ventilation from the propofol (or etomidate) before falling off the O2-Hgb dissociation curve anyways (and the exact same thing occurs with sux despite people preaching that if you give sux and fail to acquire the airway the sux will wear off in time to bail you out - predominantly false, see attached graph, and note the time to return of twitch height with sux that is already too late was at 1mg/kg). So if you have decided to sleep them, push the paralytic, waiting to see if you need it is simply wasting apneic time.

 

[pgg]

I nearly always give relaxant with induction. Very few exceptions - and those aren't related to anticipated/feared difficulty with the airway.

Induction then "proving" mask ventilation is a false path. It doesn't make sense to me. First look is the best look and the sooner it comes, the better.

The risk for aspiration increases with time unconscious without a tube in place, and biggest trigger for aspiration is airway instrumentation in a non-paralyzed, inadequately anesthetized patient. Lengthening the time from induction to optimal intubating conditions by delaying administration of relaxant, all for the (probably naive) hope that succ will wear off in time to save brain cells if you can't secure the airway, is a shaky plan.


IMO there's a place for "modified" RSIs, namely the patients you know are going to drop like a rock the instant they go apneic. In these patients I will mask as soon as they are asleep/apneic, but I still chase the propofol with succ and flush it in. I don't think low pressure small TV breaths with good technique add risk during a RSI.

 

[BLADEMDA]

B.S.E. data



Watch 12:15-16:00

 

[BLADEMDA]

R.I.P. John Hinds

 

[criticalelement]

If you make the decision to put the patient to sleep, give paralytic. The decision point is asleep VS awake not asleep vs asleep + NMB. The witholding of NMB, depolarizing or non is academic dogma that exists in Anesthesia and is obviously rampant in medicine/ICU intubations. The truth is; your first look is your best look, a fully relaxed patient is easier to intubate and ventilate (may need oral airway), and most importantly, the patient is very likely not returning to spontaneous ventilation from the propofol (or etomidate) before falling off the O2-Hgb dissociation curve anyways (and the exact same thing occurs with sux despite people preaching that if you give sux and fail to acquire the airway the sux will wear off in time to bail you out - predominantly false, see attached graph, and note the time to return of twitch height with sux that is already too late was at 1mg/kg). So if you have decided to sleep them, push the paralytic, waiting to see if you need it is simply wasting apneic time.

I dont agree.... bad things can happen in the wrong hands if a non depolarizer is given and a mis adventure of any sort occurs. A depolarizing muscle relaxant for that matter as well.. Off the floor intubations are accomplished with as little as possible that you can get away with... For me, I give a small injection of propofol(if needed) and instrument the airway and put the tube in.. if the patient is fighting too much and there is no contraindication i may push some sux against my will... If the whole scenario looks ugly... obese patient, inexperienced staff assisting you, ng/og tube in place,,, ill numb up the airway and do a fiberoptic. and ive done it... another trick is awake glidescope if the scenario looks ugly after generous topicalization.

 

[Mman]

If you make the decision to put the patient to sleep, give paralytic. The decision point is asleep VS awake not asleep vs asleep + NMB. The witholding of NMB, depolarizing or non is academic dogma that exists in Anesthesia and is obviously rampant in medicine/ICU intubations. The truth is; your first look is your best look, a fully relaxed patient is easier to intubate and ventilate (may need oral airway), and most importantly, the patient is very likely not returning to spontaneous ventilation from the propofol (or etomidate) before falling off the O2-Hgb dissociation curve anyways (and the exact same thing occurs with sux despite people preaching that if you give sux and fail to acquire the airway the sux will wear off in time to bail you out - predominantly false, see attached graph, and note the time to return of twitch height with sux that is already too late was at 1mg/kg). So if you have decided to sleep them, push the paralytic, waiting to see if you need it is simply wasting apneic time.

A very smart attending in residency suggested to me that if you gave your induction dose and could not ventilate, your next try of oral airway or LMA or whatever and then eventually try to intubate. If you can't intubate, you're going to give the succinylcholine anyway to try to improve conditions for intubation. So just push the damn succinylcholine right away and give yourself your best bet from the start. If you can't get anything for ventilation or intubation and are screwed, at least it will be wearing off that much faster if you have to awaken them.

Waiting to push the succinylcholine until you've already struck out on lots of other options is a road that leads to a bad place.

 

[Robotic Wis-Hipple]

I dont agree.... bad things can happen in the wrong hands if a non depolarizer is given and a mis adventure of any sort occurs. A depolarizing muscle relaxant for that matter as well.. Off the floor intubations are accomplished with as little as possible that you can get away with... For me, I give a small injection of propofol(if needed) and instrument the airway and put the tube in.. if the patient is fighting too much and there is no contraindication i may push some sux against my will... If the whole scenario looks ugly... obese patient, inexperienced staff assisting you, ng/og tube in place,,, ill numb up the airway and do a fiberoptic. and ive done it... another trick is awake glidescope if the scenario looks ugly after generous topicalization.

Again, I'd argue that if you are pushing prop plus/minus relaxant you've already burned that bridge. This obviously doesn't apply to the coding or obtunded patient that is already on a MAC of CO2 or with brain hypoxia already, in those scenarios I'd agree that they don't need anything, but I'd also point out that you're tubing them because they're in arrest/resp failure/outright apnea anyways so there is no bridge..... And cases where the airway is alarming your decision point is awake vs not awake, I'd agree with awake fob/glidescope, but if I induce I'm giving sux pending contraindications which are rare.

 

[pgg]

R.I.P. John Hinds

Terrible loss.

 

[ROCyourROLLium]

thanks everyone for input. Is there a situation where you would not want to use paralysis (assuming you choose asleep rather than awake intubation)? Even with obtunded patient who doesn't need much anesthesia, it seems that paralytic would always help conditions (plus maybe 1 or 2 of midaz if you are going to paralyze?)

Sorry to hear about Dr. Hinds.

 

[criticalelement]

, but if I induce I'm giving sux pending contraindications which are rare.

You are not wrong.

The less you give the better off site emergency intubations. SO i usually omit sux and give a stunning dose of propofol, not even an induction dose just a tiny dose to stun the patient and then intubate.

 

[pgg]

Midazolam and succinylcholine is a nice out-of-OR emergency combination.

Most of these patients are unlikely to have recall no matter what you do. Induction isn't high on the list of their needs. A little something for amnesia is good.

But I think the succ is almost always a good idea, barring contraindications.

 

[Wiscoblue]

Last night I got called to the ER by one of our younger ER docs. He had a 59 year old man with what he said was epiglottitis. He wanted me to come down and hold his hand while he intubated. I went down there. This was a fat guy with no neck and he did seem like he was having a hard time breathing. Interestingly, he had had this problem for 3 days and he had eaten a burger and fries 2 hours prior to coming to the ER. Didn't look like epiglottitis to me. No drooling, no leaning forward. He was laying on his back and didn't look too uncomfortable. I had brought a laryngoscope and bougie down with me to the ER. Anyway, I took a 2 second look down his throat, awake, with my Mac 3 blade, no local and I could see his larynx. I told the ER doc to go ahead. He gave him what he called the 3-2-1 drug. 300 of fent, 200 of ketamine, 100 of sux. Then he intubated him with the gli-duh-scope. Easy intubation but it took for ever. It would have taken me 20 seconds with prop/sux and with less risk of aspiration.


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[Ezekiel2517]

thanks everyone for input. Is there a situation where you would not want to use paralysis (assuming you choose asleep rather than awake intubation)? Even with obtunded patient who doesn't need much anesthesia, it seems that paralytic would always help conditions (plus maybe 1 or 2 of midaz if you are going to paralyze?)

Sorry to hear about Dr. Hinds.

If you already chose asleep, then angioedema or any situation you're concerned about swelling in the airway. If the pt is spontaneously breathing and not blue, it's best to keep them that way until you know for sure what you're up against.

 

[vector2]

He gave him what he called the 3-2-1 drug. 300 of fent, 200 of ketamine, 100 of sux.

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This might be one of the dumbest things I've ever heard of. Granted you pre-looked with your blade, but in any other case with a difficult airway the ER doc has essentially ensured that a fat dyspneic no-neck with possibly already heavy secretions is going to be apneic for 15-30 minutes and even more drooly.

 

[Chloroform4Life]

Last night I got called to the ER by one of our younger ER docs. He had a 59 year old man with what he said was epiglottitis. He wanted me to come down and hold his hand while he intubated. I went down there. This was a fat guy with no neck and he did seem like he was having a hard time breathing. Interestingly, he had had this problem for 3 days and he had eaten a burger and fries 2 hours prior to coming to the ER. Didn't look like epiglottitis to me. No drooling, no leaning forward. He was laying on his back and didn't look too uncomfortable. I had brought a laryngoscope and bougie down with me to the ER. Anyway, I took a 2 second look down his throat, awake, with my Mac 3 blade, no local and I could see his larynx. I told the ER doc to go ahead. He gave him what he called the 3-2-1 drug. 300 of fent, 200 of ketamine, 100 of sux. Then he intubated him with the gli-duh-scope. Easy intubation but it took for ever. It would have taken me 20 seconds with prop/sux and with less risk of aspiration.


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Did you topicalize before looking with your mac3 in what I assume was an awake patient?

 

[pgg]

It's a different world down in the ER.

 

[Ronin786]

Last night I got called to the ER by one of our younger ER docs. He had a 59 year old man with what he said was epiglottitis. He wanted me to come down and hold his hand while he intubated. I went down there. This was a fat guy with no neck and he did seem like he was having a hard time breathing. Interestingly, he had had this problem for 3 days and he had eaten a burger and fries 2 hours prior to coming to the ER. Didn't look like epiglottitis to me. No drooling, no leaning forward. He was laying on his back and didn't look too uncomfortable. I had brought a laryngoscope and bougie down with me to the ER. Anyway, I took a 2 second look down his throat, awake, with my Mac 3 blade, no local and I could see his larynx. I told the ER doc to go ahead. He gave him what he called the 3-2-1 drug. 300 of fent, 200 of ketamine, 100 of sux. Then he intubated him with the gli-duh-scope. Easy intubation but it took for ever. It would have taken me 20 seconds with prop/sux and with less risk of aspiration.


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300 of fentanyl and 200 of ketamine sounds pretty paradoxical to me.

 

[Arch Guillotti]

Last night I got called to the ER by one of our younger ER docs. He had a 59 year old man with what he said was epiglottitis. He wanted me to come down and hold his hand while he intubated. I went down there. This was a fat guy with no neck and he did seem like he was having a hard time breathing. Interestingly, he had had this problem for 3 days and he had eaten a burger and fries 2 hours prior to coming to the ER. Didn't look like epiglottitis to me. No drooling, no leaning forward. He was laying on his back and didn't look too uncomfortable. I had brought a laryngoscope and bougie down with me to the ER. Anyway, I took a 2 second look down his throat, awake, with my Mac 3 blade, no local and I could see his larynx. I told the ER doc to go ahead. He gave him what he called the 3-2-1 drug. 300 of fent, 200 of ketamine, 100 of sux. Then he intubated him with the gli-duh-scope. Easy intubation but it took for ever. It would have taken me 20 seconds with prop/sux and with less risk of aspiration.


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How do you take a look with a laryngoscope in an unsedated patient?

 

[Robotic Wis-Hipple]

It's a different world down in the ER.

True, and I get that. But imo if an EM physician calls an Anesthesia physician down there for backup they should accept that Anesthesia is then the consultant who is "running" it. I understand that it's their show down there, but I don't like the idea of being forced to watch them do something I don't agree with just to serve as standby rescue. If things go poorly you absolutely have a culpability and I can see the anesthesia doc getting nailed for being a willing participant. Of course, nobody is required to follow a consultants advice and I'd rather be called to play backup than get called too late for cleanup duty so some compromise is needed but I still think we need to take a more active role when we get called down there for our expertise.

 

[Mman]

How do you take a look with a laryngoscope in an unsedated patient?

It's fairly easy if you spray a little topical on their tongue and ask them to close their eyes, open their mouth and stick out their tongue. I just tell them I'm going to use a metal tongue depresser to look at the back of their throat. I just don't want their eyes opening and seeing the size of the larygnoscope.

I've only done it without topical on patients that are obtunded.

 

[deleted547339]

True, and I get that. But imo if an EM physician calls an Anesthesia physician down there for backup they should accept that Anesthesia is then the consultant who is "running" it. I understand that it's their show down there, but I don't like the idea of being forced to watch them do something I don't agree with just to serve as standby rescue. If things go poorly you absolutely have a culpability and I can see the anesthesia doc getting nailed for being a willing participant. Of course, nobody is required to follow a consultants advice and I'd rather be called to play backup than get called too late for cleanup duty so some compromise is needed but I still think we need to take a more active role when we get called down there for our expertise.

Agree. I'm EM. It drives me crazy to call anesthesia down to hold my hand. If I'm calling a consult, it's because I need help. Some attendings like to do this, but I think it's crazy.

An exception to this is when I'm calling ENT thinking they may end up needing a slash trach if something goes wrong.

Also, to address the OPs comment: there are a lot of good reasons to do a modified RSI - the two most obvious reasons to bag are severe acidosis or hypoxia. I tubed a patient last night and the best SAT I could get was about 92% on bipap. You better believe I bagged her before I took a look. If you don't bag a DKA patient with a pH of 6.8, they will almost certainly die.

 

[Arch Guillotti]

It's fairly easy if you spray a little topical on their tongue and ask them to close their eyes, open their mouth and stick out their tongue. I just tell them I'm going to use a metal tongue depresser to look at the back of their throat. I just don't want their eyes opening and seeing the size of the larygnoscope.

I've only done it without topical on patients that are obtunded.

I know how to numb up an airway. Wiscoblue stated that he didn't use local.

 

[pgg]

I used to let myself get pulled into those situations because I'm basically a nice easy-going guy. But I've since realized that "come hang out nearby in case something goes wrong" is not a consult, and if I'm not being consulted, why should I go anywhere?

If I'm being consulted for a procedure, it's mine to lead. I don't staff other attendings for airways or lines. I generally don't even staff other services' residents for airways or lines - if there's learning to be had, surely one of my residents can use the rep.

 

[Wiscoblue]

I don't use local. I ask them to open their mouth and stick their tongue out and take a deep breath and say aaaaah as I'm slipping my blade in over the back of his tongue. Takes two seconds. Patient gags a little bit, but by then I've already seen all I want to see. I do it all the time. It's not as bad as some would like to believe.

And, since I had taken a look, I knew I could intubate the guy in a pinch if the ED guy struggled. So I let him do his thing. Too bad I never got paid for holding his hand since I passed up on the intubation.


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[nimbus]

And, since I had taken a look, I knew I could intubate the guy in a pinch if the ED guy struggled. So I let him do his thing. Too bad I never got paid for holding his hand since I passed up on the intubation.


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That's jacked. Hope he doesn't make a habit of it. If you're going down, you should stick the tube in and get paid.

 

[deleted59964]

I don't use local. I ask them to open their mouth and stick their tongue out and take a deep breath and say aaaaah as I'm slipping my blade in over the back of his tongue. Takes two seconds. Patient gags a little bit, but by then I've already seen all I want to see. I do it all the time. It's not as bad as some would like to believe.

Sounds slick - as long as they don't actually have epiglotitis

 

[Robotic Wis-Hipple]

Sounds slick - as long as they don't actually have epiglotitis

Or vomit up their burger

 

[deleted547339]

I used to let myself get pulled into those situations because I'm basically a nice easy-going guy. But I've since realized that "come hang out nearby in case something goes wrong" is not a consult, and if I'm not being consulted, why should I go anywhere?

If I'm being consulted for a procedure, it's mine to lead. I don't staff other attendings for airways or lines. I generally don't even staff other services' residents for airways or lines - if there's learning to be had, surely one of my residents can use the rep.

On behalf of my specialty, I apologize for the pseudo-consult of "come hold my hand while I try to manage a tenuous airway." While I understand my colleagues concern and the fact that they are ultimately responsible for the patient (since y'all would be the consultant not the primary), it's absolutely insane to "consult" someone to just be in the room.

Y'all manage a ton more airways than we do and I respect that.

 

[Wiscoblue]

I wouldn't be messing in his airway with a DL if it was epiglottitis.

I really don't mind helping out if I get a personal call from the ED doc. It's when they tell the secretary 'get anesthesia down here' what pisses me off and I'm either 'not available' or I'll just do the intubation, secure the tube and walk out. I've never said no when someone asked nicely.

 

[sluggs]

Some food for thought on induction meds and paralytics: a good number of patients in the ICU who need intubation are in at the situation where if their airway is not controlled within minutes, or at least a few hours, they will suffer morbidity/mortality. Essentially, they will die without intubation. This is a very different situation from inducing a suspected difficult airway for an elective surgery, even if the elective surgery candidate has pulmonary co-morbidities. In the latter situation, if you take a patient who is oxygenating and ventilating OK on his or her own, and you extinguish this ability with a paralytic, and then cannot intubate or bag mask, you have killed a (somewhat) healthy patient, and this violates "first do no harm". This is a situation where awake fiberoptic intubation is a safe alternative. By contrast, in an acutely decompensating patient, who is not oxygenating, ventilating, or protecting their airway, optimizing your first look with a paralytic is almost always the way to go. The two arguments you hear against paralyzing are: 1. the patient can maintain their own airway, and you are depriving them of this and 2. it may make it harder to BMV after paralysis because the epiglottis will flop down and occlude the airway. I just don't buy either of these.... 1 because the whole problem is that the patient is losing the airway and 2 because this is rare and you have rescue techniques. In my experience, which is strictly critical care, paralyzing to optimize your first look/attempt is the way to go in the ceasing patient. You should have excellent BMV skills and know how to place an LMA.
Undersedating or not paralyzing can lead to messy multiple attempts which are a huge risk if the patient is already decompensating. bronchoscope is a nice back-up tool, but the planned awake fiberoptic is not always and option when a patient is combative, unstable and desaturating....
Just my crit care perspective...

 

[pgg]

On behalf of my specialty, I apologize for the pseudo-consult of "come hold my hand while I try to manage a tenuous airway." While I understand my colleagues concern and the fact that they are ultimately responsible for the patient (since y'all would be the consultant not the primary), it's absolutely insane to "consult" someone to just be in the room.

Y'all manage a ton more airways than we do and I respect that.

I can't remember the last time the ER did this. It's usually the ICU.

 

[deleted162650]

2. it may make it harder to BMV after paralysis because the epiglottis will flop down and occlude the airway.

In my experience, paralysis makes the pt easier to bag 100% of the time.

 

[sluggs]

In my experience, paralysis makes the pt easier to bag 100% of the time.

I agree. Just citing the devil's advocate position

 

[WholeLottaGame7]

Hello, CA1 here. Long time lurker and first time poster. I've seen a few airway mis-adventures this year, especially on the floor and ICU and wanted to know your thoughts.

1. RSI. When do you do true vs modified? From what i've seen and read, if patient has poor pulmonary reserve and starts de-satting while waiting for paralysis to kick in then it is OK to give gentle breaths. Do you give breaths or always wait for because fear of aspiration? What is the risk benefit of A) Waiting for paralysis to fully kick in, B) giving some gentle positive pressure breaths while waiting, C) Taking a look and trying to intubate before patient fully paralyzed?

2. Paralysis. From reading and clinical experience, paralysis helps with ventilation and intubation. Say I only gave hypnotic and having hard time ventilating/intubating. Would you then work your way down difficult airway pathway or would you give paralytic? From what i've read it seems that you would probably give paralysis to ICU and floor patients whose clinical condition will only worsen and won't benefit from waking up? I feel that is pretty cavalier to do outside of the OR. Thoughts?

Thanks!

Intubations on the floor or ICU are notoriously bad, for a variety of reasons.

1) Patients are rarely "optimized," otherwise they wouldn't be needing intubation.
2) Necessary equipment or personnel may not be available.
3) Patient positioning is suboptimal.
4) Depending on where you train, ED or IM docs (or heaven forbid RT) might attempt the airway before calling you.
5) This means there is barely a Plan A, much less a Plan B, C, or D.
6) You've taken a floundering patient, hypoventilated them for awhile, chewed up the airway, and now you walk into the middle of it.

So a few pointers:
1) Figure out how urgent the situation is. Does this patient need to be intubated in 5 seconds (rare), 5 minutes, 0.5hrs, or 5 hours?
2) Based on (1) and a quick history and some quick data (last K+, at least), come up with a Plan A, B, C, at least, if not D. This might be DL, Glidescope, LMA, trach, or whatever. Paralysis vs no paralysis. Ventilation vs no ventilation. Etc etc.
3) Make sure you have all the equipment you need. Suction, oral airways, working blades, tubes, Ambu, etc. A lot of times you'll be the first to think of this. I started dragging a Glidescope to floors/ICUs that didn't have them, and it saved me multiple times.
4) Positioning! At least a shoulder roll if possible. Another trick is to slide them up on the bed so that their head is actually over the corner of the bed; with some incline this can get them in a decent sniffing position.
5) Control the room, as much as possible. Call a timeout, figure out names, who's doing what, etc.
6) Make sure there's a follow-up plan with the primary team. Vent settings, that they're getting sedation set up, etc. Also hemodynamics.

Random thoughts:
1) Coding patients don't need anything, they're already dead.
2) Paralysis is better than no paralysis. Sux if possible, roc if not (though RSI dose roc can get you into a heap of trouble in the wrong situation).
3) Don't go crazy on the anesthetic. A little propofol chased with phenylephrine or some midaz are usually more than enough. Ketamine also good for certain situations.
4) A lot of patients will crump after you intubate, either from knocking out their sympathetic drive or from the decreased preload from PPV. Be ready with phenyl or epi.
5) I find these intubations to be interesting, in a way. No two are alike and they all have their own peculiarities. It can also differentiate the people who can plan and adapt from those who can't. Lots of thinking involved with some of these.

Favorite ICU intubation story from residency: 0300 on a Saturday, called to MICU. Arrive to find 60-70y gentleman, sitting straight up in bed. Sats around the same as his age. Mentating appropriately, somehow (hypoxic preconditioning?). MICU fellow trying unsuccessfully to bronch him, but can't "get around the corner." Why? Hx of head/neck cancer s/p surgery and radiation, hx of post C-spine fusion, no flex/ext, limited mouth opening (of course). Good news is, he has no gag reflex because all of the nerves in his mouth have apparently been severed/burned away. Able to squeeze a Glidescope in sideways and then turn 90deg. CRNA pulls forward on the Glidescope and I steal the FO from the MICU fellow and use it as a steerable stylet for the tube. Through cords, done. Spontaneously breathing, maybe a little midaz after through the cords? Can't remember. There's a big blood clot acting like a ball-valve in his right mainstem that they then start trying to break up.

Back story was the guy had had some ortho procedure (hip?) earlier in the week, transferred on Wednesday for hypoxia and concern for difficult airway. ...Yes, in house for >72hrs during the week, and they decide to wait to let us know until 0300 on the weekend when things start going south...

If there's one thing to take home from this thread and the hemodynamic management thread, it's that anesthesia just has a very different way of thinking about things than most other specialties. We like anticipating problems and therefore we like having options. Lots of access (a-line, CVL, PIVs), lots of data (ABGs, lytes, etc), lots of plans (A, B, C, D).

 

[fakin' the funk]

From what i've seen and read, if patient has poor pulmonary reserve and starts de-satting while waiting for paralysis to kick in then it is OK to give gentle breaths. Do you give breaths or always wait for because fear of aspiration?

Treating the HAPPENING-RIGHT-NOW risk of hypoxia/anoxia from a desaturation event always trumps the still-theoretical-at-that-point risk of regurgitation, the even-less-likely risk of pulmonary aspiration, and the even-less-likely risk of significant pneumonitis/ALI/ARDS/death from aspiration.

 

[ROCyourROLLium]

thanks to all for input! very helpful