'Breathing down' an adult?

[T-burglar]

You guys who have apparently paralyzed awake people, did they have recall? I don’t think a patient needs to be completely motionless to be no longer making solid lasting memories. I think once they have garbled speech they probably aren’t forming memories

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[deleted162650]

I think once they have garbled speech they probably aren’t forming memories

That hypothesis didn't work out so well for Cosby.

 

[2Fast2Des]

I’ll mix prop/roc/lido in 1 syringe for robust ASA 1/2’s. For everyone else I like separate syringes so I can get all the roc in while maintaining the ability to titrate the prop.

I also like to mask while my prop/roc are soaking in. I think it gives me valuable information come emergence time. Easy to mask = I can be a little more cavalier on extubation. Bitch to mask = I’ll be more conservative.

Those who worry about recall haven’t spent enough time in GI lab. I’m continually surprised/amazed how long a 1/2 induction dose of prop lasts. Even when they get stimulated/light enough to make purposeful movements, they don’t remember jack.

Agree even 1mg\kg of prop no recall with the GI guy shoving a probe down the pharynx and not needing a redose until almost 4 to 5 minutes later, why all of a sudden an ETT going anterior cause recall? An induction dose should more than adequately cover with some time to spare after masking and securing the tube.

 

[Twiggidy]

That hypothesis didn't work out so well for Cosby.

ImDead.com

 

[coffeebythelake]

Though you made the "high cost" claim, I went ahead and googled it. 1cc of sevo is 50 cents.

I said sevo is expensive and it is bad for the environment.
1 cc of sevo maybe 50 cents. How many cc's are you using?

Your going to open a bottle of ketamine to avoid that? And do you really think an IV agent is a better bronchodilator than one that is inhaled directly?

If you are making this argument that inhaled sevo works much better show me some evidence. Show me the study that mask ventilating a patient on sevo for a minute before intubation makes a difference in airway reactivity. You are making the argument here for this. Don't just leave it as a big question mark.

Is it? The kid is breathing out 2-3% sevo for 10 minutes here, vs masking with sevo 3% for 1 minute... buts its "much much" higher? , seems like the cost argument..

Think not in terms of sevo % but in terms of actual particles contaminating the air. You remember how sevoflurane is very insoluble in blood? That means very few particles are uptaken to reach the needed partial pressure in brain.. When you have sevo blasting at 10 LPM FGF that is a whole lot more particles.

 

[zizzer]

I'm late to the party, but since this was bumped, I'll say I prefer masking with volatile agent as well. Obviously it can be done right either way.

Some of the concerns:
Wastage of agent - It doesn't seem like much, especially if you're mask ventilating with <10L FGF.
Exposure to others - Again somewhat overstated I think. I turn it off before intubating. The exposure is minimal to others. To the person who said you could forget to turn it back on, the same could be said when not using it for BVM
Economy of movement - I guess, but it's pretty quick and seems worth it to me. Some of these same people are talking about giving additional boluses of propofol or even drawing up ketamine, so this doesn't really make sense to me. If anything, using the BVM time to start getting the effect site concentration where you want it to be means less adjusting right after intubation when you're doing other things.

 

[coffeebythelake]

I'm late to the party, but since this was bumped, I'll say I prefer masking with volatile agent as well. Obviously it can be done right either way.

Some of the concerns:
Wastage of agent - It doesn't seem like much, especially if you're mask ventilating with <10L FGF.
Exposure to others - Again somewhat overstated I think. I turn it off before intubating. The exposure is minimal to others. To the person who said you could forget to turn it back on, the same could be said when not using it for BVM
Economy of movement - I guess, but it's pretty quick and seems worth it to me. Some of these same people are talking about giving additional boluses of propofol or even drawing up ketamine, so this doesn't really make sense to me. If anything, using the BVM time to start getting the effect site concentration where you want it to be means less adjusting right after intubation when you're doing other things.

Giving an additional bolus of propofol need not involve drawing up another vial.

And how much of that sevo do you think is actually getting to the patient in the 1 min of mask ventilation you do with the gas on? You have to prime the circuit? Answer: very little.

 

[anbuitachi]

speaking of recall... when i do rapid sequence with Roc, because it usually require 2 syringes, i usually give 50mg roc upfront , no sedation, then push in the propofol, then push in the 2nd stick of roc to flush in the prop . works pretty well. zero recall

propofol is pretty good amnestic. even when i give the bit of propofols for cardioversions, they dont recall getting shocked.


in my opinion, you dont need much propofol for induction, especially mixed with other agents like lidocaine or even lit bit of midaz/fent

 

[Arch Guillotti]

speaking of recall... when i do rapid sequence with Roc, because it usually require 2 syringes, i usually give 50mg roc upfront , no sedation, then push in the propofol, then push in the 2nd stick of roc to flush in the prop . works pretty well. zero recall

propofol is pretty good amnestic. even when i give the bit of propofols for cardioversions, they dont recall getting shocked.


in my opinion, you dont need much propofol for induction, especially mixed with other agents like lidocaine or even lit bit of midaz/fent

Aren’t your cardioversuins unconscious when you shock them?

 

[anbuitachi]

Aren’t your cardioversuins unconscious when you shock them?

yes, but what i mean is it doesnt take much propofol to achieve it. i give less propofol for cardioversions than what i give to put down EGD scope

 

[coffeebythelake]

Aren’t your cardioversuins unconscious when you shock them?

Give just enough for them to start to yawn and a little glassy eyed.
Don't need them to be out cold.

 

[GassYous]

speaking of recall... when i do rapid sequence with Roc, because it usually require 2 syringes, i usually give 50mg roc upfront , no sedation, then push in the propofol, then push in the 2nd stick of roc to flush in the prop . works pretty well. zero recall

propofol is pretty good amnestic. even when i give the bit of propofols for cardioversions, they dont recall getting shocked.


in my opinion, you dont need much propofol for induction, especially mixed with other agents like lidocaine or even lit bit of midaz/fent

You can do it with a single 30cc syringe. But even if it comes in separate syringes I don't understand why you would sandwich it like that.

 

[anbuitachi]

You can do it with a single 30cc syringe. But even if it comes in separate syringes I don't understand why you would sandwich it like that.

make it work faster. RSI is not as fast as sux with double dose roc. i think its faster if i give roc first and prop later. does it really matter though? probably not, since its probably like a 5 second delay in terms of pushing the drug first or 2nd

dont want to do 30 cc syringe bc id have to draw the roc out of their syringes... our roc are premade

 

[zizzer]

Giving an additional bolus of propofol need not involve drawing up another vial.

And how much of that sevo do you think is actually getting to the patient in the 1 min of mask ventilation you do with the gas on? You have to prime the circuit? Answer: very little.

Yeah, you don't need another vial, but my point is that it's giving a bolus is pretty comparable to making a turn on a knob if we're talking about "wasted movement" and such.

Regardless of whatever medication I'm giving, I'm impatient and almost always try to give some form of loading dose rather than set the concentration I want to end up at and wait. I treat volatiles similarly: high concentration while mask ventilating --> intubate --> lower concentration. That way they're already "loaded" a bit (to make a comparison to an IV loading dose), and I don't have to fiddle with the concentration as much while I'm starting another IV or whatever.

Like I said, you can do it either way, but I don't find the arguments against doing it very persuasive.

Regarding the order of pushing NMBAs and induction agents, this article about ketamine and rocuronium by intensivist Josh Farkas is a pretty interesting read: https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/

 

[Radetzky]

Regarding the order of pushing NMBAs and induction agents, this article about ketamine and rocuronium by intensivist Josh Farkas is a pretty interesting read: PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation

interesting read. But does it really take him 15 s in between giving induction and paralysis? as long as you bang them in one after the other as you should in an rsi I wouldn’t think it makes any difference..

 

[GassYous]

It's because everyone outside of the OR pushes a med then flushes the line with saline before pushing another med.

 

[coffeebythelake]

What hurts more, injecting the propofol or injecting rocuronium?

 

[deleted162650]

What hurts more, injecting the propofol or injecting rocuronium?

Roc

 

[anbuitachi]

Roc

Never had a patient complain to me when roc going in

 

[coffeebythelake]

Never had a patient complain to me when roc going in

I don't give roc before propofol, but some of my colleagues who do say it burns a LOT.

 

[Hoya11]

Giving an additional bolus of propofol need not involve drawing up another vial.

And how much of that sevo do you think is actually getting to the patient in the 1 min of mask ventilation you do with the gas on? You have to prime the circuit? Answer: very little.

Masking with sevo prior to intubation produces a blood level significant enough to produce amnesia at the very least. This level of amnesia can cover you if you have multiple intubation attempts while paralyzed, and you've got your hands full enough where you dont want to draw and push more IV induction agent, or if the IV has blown after/during induction. As others have said, there is not much downside to it..

 

[GassYous]

I don't give roc before propofol, but some of my colleagues who do say it burns a LOT.

No worries, the screaming stops soon enough.

 

[MirrorTodd]

I have a hard time believing that roc burns. I've seen more than enough people give a defasciculating dose before pushing the lido, fent, prop and the only thing people complain about is prop.

 

[deleted875186]

I have a hard time believing that roc burns. I've seen more than enough people give a defasciculating dose before pushing the lido, fent, prop and the only thing people complain about is prop.

It definitely burns. I’ve given it lots of time to sick patients after little prop or sedation for intubation and they wince.

 

[DrZzZz]

I have a hard time believing that roc burns. I've seen more than enough people give a defasciculating dose before pushing the lido, fent, prop and the only thing people complain about is prop.

I don't think anyone would complain if you only pushed 0.5cc prop. Volume matters, can't say it doesn't burn just because a defasciculating dose might not.

 

[abolt18]

I have a hard time believing that roc burns. I've seen more than enough people give a defasciculating dose before pushing the lido, fent, prop and the only thing people complain about is prop.

I have seen patients who are apneic with no lash reflex after propofol subsequently pull their arm away while the roc is going in. Definitely nociceptive.

 

[MirrorTodd]

I'll keep my eyes out for it. I am a resident after all so I still have a lot to see.

 

[deleted162650]

Never had a patient complain to me when roc going in

It sounds like:

“Ouch, that really burnnnnsss”

 

[dhb]

I have a hard time believing that roc burns. I've seen more than enough people give a defasciculating dose before pushing the lido, fent, prop and the only thing people complain about is prop.

Probably depends on manufacturer, ours burns for sure.

 

[FiO2@21]

I'll keep my eyes out for it. I am a resident after all so I still have a lot to see.

One of our cardiac attendings uses vec when he does his versed inductions because he feels like the roc burns enough to stimulate them.

 

[vector2]

One of our cardiac attendings uses vec when he does his versed inductions because he feels like the roc burns enough to stimulate them.

This is just a guess....but cold steel against your epiglottis with only versed on board might be a bit stimulating too

 

[FiO2@21]

This is just a guess....but cold steel against your epiglottis with only versed on board might be a bit stimulating too

Certainly feel more pressure not to muck around with the intubation. In his room I’d have esmolol drawn up for the tachycardia. It was nice not to have the fentanyl hanging around pre-incision while we’re doing the lines and TEE.

 

[kmurp]

I’ve done a halothane induction on a 70 y/o with epiglottis. Does that count?

 

[nimbus]

One of our cardiac attendings uses vec when he does his versed inductions because he feels like the roc burns enough to stimulate them.

Interesting, what was the induction/doses?

Back in the day we did cardiac inductions with versed 20mg, fentanyl 1-2mg, and vec10mg. We’d add another 5mg versed and 1mg fentanyl during the case. No gas and no propofol.

 

[GassYous]

Interesting, what was the induction/doses?

Back in the day we did cardiac inductions with versed 20mg, fentanyl 1-2mg, and vec10mg. We’d add another 5mg versed and 1mg fentanyl during the case. No gas and no propofol.

Can do it with versed 5, fent 500, roc 100

 

[nimbus]

Can do it with versed 5, fent 500, roc 100

The whole case? I’d worry about intraop awareness at that dose.

 

[Arch Guillotti]

Interesting, what was the induction/doses?

Back in the day we did cardiac inductions with versed 20mg, fentanyl 1-2mg, and vec10mg. We’d add another 5mg versed and 1mg fentanyl during the case. No gas and no propofol.

Only 2 mg of fentanyl? I heard back in the day they would give 100 cc of fentanyl on induction?

 

[nimbus]

Only 2 mg of fentanyl? I heard back in the day they would give 100 cc of fentanyl on induction?

Usually 40-60ml fentanyl for the case.

 

[drmwvr]

Only 2 mg of fentanyl? I heard back in the day they would give 100 cc of fentanyl on induction?

Seems like a lot of work...15-20 cc of sufenta was the prevailing induction at a former shop of mine. But yes.. overdoing it was the norm because 'fast tracking' (I almost giggle to type that) wasn't a thing yet. Of course an over dose of ativan or versed was the norm too and if the patient did experience awareness, they were certainly too stoned to care. There was zero recall....

 

[NoodleIncident]

I had gone exclusively mask inductions during that Propofol shortage a number of years back. Sure, it took a while longer, but I thought they went more smoothly. Now I'll give about 1mg/kg or Prop while masking with the vaporizer cranked all the way up with high FGF.

 

[coffeebythelake]

I had gone exclusively mask inductions during that Propofol shortage a number of years back. Sure, it took a while longer, but I thought they went more smoothly. Now I'll give about 1mg/kg or Prop while masking with the vaporizer cranked all the way up with high FGF.

Exclusively mask inductions? That must make your rapid sequence inductions particularly challenging.

 

[deleted162650]

Exclusively mask inductions? That must make your rapid sequence inductions particularly challenging.

Single breath technique

 

[NoodleIncident]

I avoid RSI as much as possible. I think I average 2-3/yr and that’s mainly for OB. But no, during that time of Propofol shortage I can’t recall a case that required RSI.