Cardiogenic shock and intubation

[Rendar5]

I’m an Emergency Physician that ran into this situation a few months back and that luckily had a good outcome but would like an anesthesiologist’s take on the matter. I had a STEMI patient come in in late one night in massive cardiogenic shock from presumed LV pump failure. SBP in the 60’s. Luckily the patient was awake (impressively enoug) and alert with no airway issues and with Interventional Cardiology maybe 5 minutes out. I was giving a careful fluid bolus and had levophed ready and just starting. I didn’t want to delay cath so patients ready to go. However cath team nurse was insistent we intubate patient before going. I honestly didn’t believe RSI would be safe in this patient let alone a sudden switch to positive pressure, nor did I think I could optimize the patient without an IABP. I refused to intubate and sent the patient. I told them to call in-house anaesthesia if they needed the patient intubated in cath lab. Patient did well but I’m not sure if it’s because of what I did or despite what I did.

So 2 questions:
1. Would you have intubated the patient in the cath lab if you were running sedation?

2. If the patient were in respiratory distress forcing the issue, how would you have gone about intubating keeping in mind the pressing need to get the patient to the cath lab

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[anbuitachi]

I’m an Emergency Physician that ran into this situation a few months back and that luckily had a good outcome but would like an anesthesiologist’s take on the matter. I had a STEMI patient come in in late one night in massive cardiogenic shock from presumed LV pump failure. SBP in the 60’s. Luckily the patient was awake (impressively enoug) and alert with no airway issues and with Interventional Cardiology maybe 5 minutes out. I was giving a careful fluid bolus and had levophed ready and just starting. I didn’t want to delay cath so patients ready to go. However cath team nurse was insistent we intubate patient before going. I honestly didn’t believe RSI would be safe in this patient let alone a sudden switch to positive pressure, nor did I think I could optimize the patient without an IABP. I refused to intubate and sent the patient. I told them to call in-house anaesthesia if they needed the patient intubated in cath lab. Patient did well but I’m not sure if it’s because of what I did or despite what I did.

So 2 questions:
1. Would you have intubated the patient in the cath lab if you were running sedation?

2. If the patient were in respiratory distress forcing the issue, how would you have gone about intubating keeping in mind the pressing need to get the patient to the cath lab

Why did a Cath nurse tell you to Intubate???? Just do the Cath with local anesthesia .. patient is awake and alert.

And if Intubate then RSI.

 

[Mehd School]

Not the nurses call. I think you made the right decision in my limited experience, given the patient was A/A. Caths are done with local all the time safely.

 

[deleted59964]

welcome to the board.

it sounds like he did fine and it’s hard to argue with success. without being there it’s hard to know whether i’d have intubated him, as lots of factors are at play.

how likely is he to need intubating in cath lab due to cvs instability, hypoxia, or not tolerating the procedure under local and sedation? mostly procedures in cath lab get done fine under local.

how much of a problem is it to tube him in cath lab vs ED? assistance/equipment/positioning ... would he be anticipated to be difficult to intubate?

what’s his expected course - cath lab and a balloon and he gets better, or is he likely to end up intubated in ICU because of comorbidity, degree of shock, or institutional factors.

weighing all that it’s still unlikely i’d intubate him.

as for how i’d intubate a patient in cardiogenic shock if i had to - the sicker he is, the less he gets.

i would get an art line first if possible - have pressors / inotropes ready and then induce slowly.

this guys CO is low and it will take time for him to get the drugs to his brain. the risk is not appreciating that, upping the dose and causing cvs collapse.

with regard to switching to ppv - that is definitely an issue - you can minimise it by giving a bit of preload first and by ventilating gently ... it doesn’t matter if his co2 drifts up a bit, infact it probably helps tissue O2 delivery

as for which agent - it’s more how you do it than what you do - slow and steady wins the race cvs risk >> aspiration risk here.

you could use ketamine and sux, but the tachycardia will increase his myocardial o2 consumption. we don’t have etomidate in australia so i can’t comment on that.

i’d use a little midaz (1) and then a little propofol (maybe 0.3 per kg) and wait ... when he closes his eyes give sux and maybe some alfentanil ... but there are many ways to skin the cat.

 

[Wiscoblue]

Just call the anesthesiologist and let him accompany the patient to the catch lab. If the patient deteriorates, they can tube him in the hallway or in the cathlab. But it is definitely not the nurses call to tell you to intubate. Just the intubating drugs and positive pressure ventilation could send him into cardiac arrest. Less is more.


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[Hoya11]

I’m an Emergency Physician that ran into this situation a few months back and that luckily had a good outcome but would like an anesthesiologist’s take on the matter. I had a STEMI patient come in in late one night in massive cardiogenic shock from presumed LV pump failure. SBP in the 60’s. Luckily the patient was awake (impressively enoug) and alert with no airway issues and with Interventional Cardiology maybe 5 minutes out. I was giving a careful fluid bolus and had levophed ready and just starting. I didn’t want to delay cath so patients ready to go. However cath team nurse was insistent we intubate patient before going. I honestly didn’t believe RSI would be safe in this patient let alone a sudden switch to positive pressure, nor did I think I could optimize the patient without an IABP. I refused to intubate and sent the patient. I told them to call in-house anaesthesia if they needed the patient intubated in cath lab. Patient did well but I’m not sure if it’s because of what I did or despite what I did.

So 2 questions:
1. Would you have intubated the patient in the cath lab if you were running sedation?

2. If the patient were in respiratory distress forcing the issue, how would you have gone about intubating keeping in mind the pressing need to get the patient to the cath lab

1. This guys is at deaths door. Being intubated and and paralyzed adds an element of control to the situation. Doing this from the getgo (as opposed to me following him around and waiting for him to crump) may be the best thing to do. So I can understand the side of the nurse. Lets intubate now, paralyze now, get under control now, then transport, move him to the table, do the procedure all in a controlled fashion. I do understand the other side of letting him be spontaneous and trying to get away with the cath awake, but then I feel like I have to follow him around, waiting for him to crump in a hallway, on the cath table, during move from stretcher to table, in some uncontrolled setting. In the end, I would prefer to just go ahead and intubate up front IF i knew the cath process was going to take forever, and I was going to have to be standing by this guy forever, Id just go ahead and do it. But if I knew that a cath was minutes away and could be done safely awake from the cardiologist standpoint (including IABP in this pt). Then I would rather stand by a few minutes. But again if its gonna be a 2hr ordeal of me being on stanby, forget it im tubing him uprfront.

2. Etomidate 6mg. Fentanyl 100. Sux 80. Cricoid pressure. Then give neo,ephedrine, epi boluses from syringes until cath lab.

 

[anbuitachi]

Just call the anesthesiologist and let him accompany the patient to the catch lab. If the patient deteriorates, they can tube him in the hallway or in the cathlab. But it is definitely not the nurses call to tell you to intubate. Just the intubating drugs and positive pressure ventilation could send him into cardiac arrest. Less is more.


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You have anesthesiologists available to just walk people like that?

 

[Southpaw]

Would’ve done exactly what you did. Started Levo and careful bolus, which will hopefully improve the situation. Your patient is alert and awake, and any sedation/PPV (certainly without fluids/pressers) will make the situation worse.

If it became necessary to intubate, I like the saying I read here recently ‘it’s not the wand but the wizard’. With whatever sedation you choose, go low and slow.

Thank you for posting on our forum. Welcome.

 

[Noyac]

Excellent post by Jobsfan. I especially liked the attention to the situation. This guy’s circulatory time is extended tremendously. You must not get anxious and start push more and more drugs. Time is key. Give a little and wait.
I also really liked the choice of drugs. Versed with a touch of propofol. But anything can work well if you are careful.

I personally would not have tubed him. Especially not in the ER. In my experience, it takes way too long to get the resuscitation meds to the pt in the ER. I wOuld have tried to get him through the case with some sedation alone.

 

[T-burglar]

It's 2018 and these situations are what point of care ultrasound is for. No excuse these days to just gamble, figure out the physiology. Positive pressure is safe for isolated LV failure. If the right heart is pumping ok with no significant TR, and there is no wide open MR, you could safely start some norepi and put him to sleep. The LV systolic function is almost irrelevant except to guage how much anesthetic he'll need to lose consciousness. Also good to rule out other "do not intubate" red flags like tamponade, massive PE, type A dissection. Remember STEMI can be a red herring.

 

[vector2]

It seems like there's a lot of misunderstanding here of the effects of PPV on LV shock. Most isolated LV shock presents with a dilated, failing ventricle that is on the far right side of the starling curve, and this kind of ventricle is usually begging for some positive pressure. If RV function and preload is at some reasonable normal baseline (as determined by your bedside FATE exam), PPV will decrease preload and shift the LV to a more favorable LVEDV where contractility is optimized. In addition, there is also possibly an effect where LV transmural pressure is decreased when intrathoracic pressure becomes positive (the LV doesn't have to overcome -5cm H2O plus systemic afterload to eject) which will improve myocardial oxygen demand and stroke volume.

That being said, I probably wouldn't immediately intubate this guy either, and Jobsfan nailed it in how I'd induce one of these guys if need be, but I would be very quick to initiate a norepi infusion and NIPPV like CPAP or BiPAP if echo findings confirmed my suspicion.

 

[hankbb02]

You did well not to wait to intubate. If it were me in the cardaic OR I would place an awake arterial line followed by an awake central line. This way I know my drugs will work as quickly as his physiology will allow. I'd also scan him with the US for fluid status, RV and LV function but presumably he is fluid overloaded. Starting levo prior to induction with any of the drugs listed is a good idea. I'd also have epi hanging and ready to bolus. Nice work!

 

[deleted171991]

If this patient had no signs of pulmonary edema (e.g. no problems lying flat, no oxygenation issues, no severe interstitial edema on lung POCUS) and the cath people are minutes away, why would one intubate? What is to be gained, except putting the patient at risk? The LV will benefit from PPV mainly if the preload is inappropriately high (which seems not to have been the case). If decreasing the preload would not improve EF and CO, then intubation may just make things worse.

Even if there was a degree of interstitial edema, one would argue that a well-titrated norepi infusion combined with careful preload reduction with NTG gtt (or NIPPV) can actually achieve more than exposing a sick heart to the stress of intubation. One could consider even CPAP/BiPAP with some calming sedation as a bridge, until the heart is fixed/CO is augmented in the cath lab.

I tend to belong to the school of thought where less is more, and the biggest problem with modern medicine is "iatrogenesis". First, do no harm. In this case, I am not so sure that the benefits of immediate intubation exceeded the risks. Maybe it's my CCM background, but I have seen enough people get f*cked up just from having been intubated, from peri-intubation crash to VAP to cardiac arrest from tracheal suctioning. Primum non nocere. Don't just reflexively/algorithmically treat numbers, treat the patient.

Kudos to @Rendar5.

 

[OB1🤙]

OP, you did the right thing IMO.

Inducing these patients generally involves a dink of this, chased by pressor, then maybe a whiff of that, chased by more pressor.

The crucial skill here is being facile with what EM folks call "push-dose" pressors in syringes.

We do this all the time in anesthesia, but it isn't a common thing in the EM world, not that I've witnessed anyway. And it's a function of our different environments.

The way to do it otherwise is to *start* a levophed drip before doing anything else, and once you see the pressure start to climb, you go about your gentle induction of choice.

If I was consulted from the ER with the patient you describe, I would ask the EM doc to hold off on intubation, would get a bunch of equipment to the cath lab, and conducted a sedation strategy based on verbal coaching and figurative hand holding. Assuming stable respiratory status that is. Maybe some low dose anxiolytic but not much else.

If the **** truly hits the fan during the cath, then you do what you gotta do. Keeping in mind that cerebral hyoperfusion is pretty amnestic...

 

[dchz]

-Nurse was out of line for instructing you to intubate, she's putting the pt's life at risk for some minor convinience in the cath lab.
-I wouldnot intubate if he's stable
-Probably go pretty opioid heavy on the intubation if I had to, pre induction a line is a good luxury but i've seen them struggle with a lines in the ED for hours at times....

 

[deleted697535]

Just call the anesthesiologist and let him accompany the patient to the catch lab. If the patient deteriorates, they can tube him in the hallway or in the cathlab. But it is definitely not the nurses call to tell you to intubate. Just the intubating drugs and positive pressure ventilation could send him into cardiac arrest. Less is more.


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Ah this is an anesthesiologists board!?!

Intubating drugs? What be they now?
Good job we have them

Anyway 'A' problems are sometimes to usually fixed by a tube.
A tube rarely fixes anything else like bleeds, or clogged arteries etc. It might enable surgeons to fix things but it sounds like that wasn't a problem. So good call on not tubing him.

If I had to tube him and I'd resist it to the hilt it'd be with an art line, ketamine fent midaz and about 30 of propofol tops. Once the eyes close or even before I'd slide in a guedel. If he tolerates that then slide in the glidescope, spray 4% lido and pop your tube in breathing

I'd have epi 10mcg per cc drawn up in a bag and 10cc syringe and dobutamine ready too. 20 mcgs of epi fixes a lot little hypotensive blips Peri intubation **** shows. Just make sure you have good access and your bolus port is really close to the vein. You want instant response from your inotropes. Flush everything thoroughly

Just get him on psv and run ketofol sedation
And get rid of him

That's the way I like to approach these guys. It worked really well for me many times. I've actually never had any issues with it

 

[Wiscoblue]

You have anesthesiologists available to just walk people like that?

Once an anesthesiologist gets called for an unstable patient going to the cath lab with a stemi, he’s yours until his procedure is done and the artery is open. I don’t think we can just tube this guy in the ER and walk away. I think that is what you would want if this was your Dad with an MI. You would want an anesthesiologist to be there for sedation/intubation if this guy deteriorates while going to the cath lab or in the time leading up to stenting the coronary.

Opening that artery is the only thing that will save this guy right now. Any extra time spent in the ED, doing lines and waiting for pharmacy to bring a norepinephrine drip, is only killing more myocardium that is holding its head under water.


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[anbuitachi]

Once an anesthesiologist gets called for an unstable patient going to the cath lab with a stemi, he’s yours until his procedure is done and the artery is open. I don’t think we can just tube this guy in the ER and walk away. I think that is what you would want if this was your Dad with an MI. You would want an anesthesiologist to be there for sedation/intubation if this guy deteriorates while going to the cath lab or in the time leading up to stenting the coronary.

Opening that artery is the only thing that will save this guy right now. Any extra time spent in the ED, doing lines and waiting for pharmacy to bring a norepinephrine drip, is only killing more myocardium that is holding its head under water.


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I think it works a bit differently here. When we get called to the ICU or floor for unstable patient for intubation, we intubate and leave. They aren't our patient. We can't just stay with every unstable patient we are called to. In fact i think we have pretty strict policies since we dont even have access to controlled drugs (benzo/opioid/ketamine) for patients unless they are in the OR/hybrid OR. If they called us down to the ED, then it's for intubation. There are 2 different teams for intubation and anesthesia for procedures. Here we don't just do anesthesia whereever we want. If they want us for the cath, then we'll tell them which cath room to go to, and we have to set up the cath room for anesthesia. Otherwise if they call you to ED and then down there you find out they want you to stay and accompany patient to cath, until procedure is done, they literally just pushed all the liability on you, while you did nothing to set up for success for yourself.

Otherwise if you can just call an anesthesiologist to accompany unstable patients, we'll just be a transport service with all the liability

 

[Mman]

I think it works a bit differently here. When we get called to the ICU or floor for unstable patient for intubation, we intubate and leave. They aren't our patient. We can't just stay with every unstable patient we are called to. In fact i think we have pretty strict policies since we dont even have access to controlled drugs (benzo/opioid/ketamine) for patients unless they are in the OR/hybrid OR. If they called us down to the ED, then it's for intubation. There are 2 different teams for intubation and anesthesia for procedures. Here we don't just do anesthesia whereever we want. If they want us for the cath, then we'll tell them which cath room to go to, and we have to set up the cath room for anesthesia. Otherwise if they call you to ED and then down there you find out they want you to stay and accompany patient to cath, until procedure is done, they literally just pushed all the liability on you, while you did nothing to set up for success for yourself.

Otherwise if you can just call an anesthesiologist to accompany unstable patients, we'll just be a transport service. Got an unstable patient in the CT scanner? We only do that if they are our patient.

similar. If we get called to intubate an unstable cath lab patient, we get the tube in and turn the vent over to RT while the RN gives fent/versed sedation and the cardiologist manages the hemodynamics.

 

[Psai]

Once an anesthesiologist gets called for an unstable patient going to the cath lab with a stemi, he’s yours until his procedure is done and the artery is open. I don’t think we can just tube this guy in the ER and walk away. I think that is what you would want if this was your Dad with an MI. You would want an anesthesiologist to be there for sedation/intubation if this guy deteriorates while going to the cath lab or in the time leading up to stenting the coronary.

Opening that artery is the only thing that will save this guy right now. Any extra time spent in the ED, doing lines and waiting for pharmacy to bring a norepinephrine drip, is only killing more myocardium that is holding its head under water.


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Sorry but we're not just sitting around waiting for unstable patients to show up to the ED. When we're getting called for airways, we're also in the OR, getting called for preops, etc. There's no time to babysit someone else's patients unless they end up in our room.

 

[deleted162650]

-Probably go pretty opioid heavy on the intubation if I had to, pre induction a line is a good luxury but i've seen them struggle with a lines in the ED for hours at times....

I don’t think I’d go heavy on anything on the intubation for this guy.

 

[dchz]

I don’t think I’d go heavy on anything on the intubation for this guy.

That's really interesting you say that, because my first post stated i was gonna go 2 midaz and 100 sux and go... But then i realized the resultant tachycardia is very bad for his specific pathology....

What would be the optimal intubating drug for this person?

Ofc if he deteriorates to the crumping zone with no BP and heart stopping, we just drop the tube. but for argument's sake we are going to intubate him before he crumps, given his assumed acute MI/cardiogenic shock 2/2 to oxygen delivery mismatch... what would be your intubation drugs?

 

[deleted162650]

That's really interesting you say that, because my first post stated i was gonna go 2 midaz and 100 sux and go... But then i realized the resultant tachycardia is very bad for his specific pathology....

What would be the optimal intubating drug for this person?

Ofc if he deteriorates to the crumping zone with no BP and heart stopping, we just drop the tube. but for argument's sake we are going to intubate him before he crumps, given his assumed acute MI/cardiogenic shock 2/2 to oxygen delivery mismatch... what would be your intubation drugs?

I know what you're getting at with wanting to avoid tachycardia, but this guy is in extremis. He needs every bit of juice his adrenals can squeeze out, and then some. Take that away with a "heavy" dose of narcs, and he's gonna crump - hard (even though the opioids aren't cardiac depressants themselves). The OP didn't give us a complete set of vitals, but my guess is he's already tachy. I don't think putting some PVC through his cords is gonna change his HR much. My first choice would be to not intubate him. If it's really necessary, them I'm gonna try to get away with as little possible. I think your original instincts were spot on. A coupe of midaz - give it a minute - maybe a little more midaz (if needed) - give it a minute - paralytic - tube. Lot's of purple drugs on standby - not opposed to giving some preemptively either.

 

[jwk]

Ah this is an anesthesiologists board!?!

Intubating drugs? What be they now?
Good job we have them

Anyway 'A' problems are sometimes to usually fixed by a tube.
A tube rarely fixes anything else like bleeds, or clogged arteries etc. It might enable surgeons to fix things but it sounds like that wasn't a problem. So good call on not tubing him.

If I had to tube him and I'd resist it to the hilt it'd be with an art line, ketamine fent midaz and about 30 of propofol tops. Once the eyes close or even before I'd slide in a guedel. If he tolerates that then slide in the glidescope, spray 4% lido and pop your tube in breathing

I'd have epi 10mcg per cc drawn up in a bag and 10cc syringe and dobutamine ready too. 20 mcgs of epi fixes a lot little hypotensive blips Peri intubation **** shows. Just make sure you have good access and your bolus port is really close to the vein. You want instant response from your inotropes. Flush everything thoroughly

Just get him on psv and run ketofol sedation
And get rid of him

That's the way I like to approach these guys. It worked really well for me many times. I've actually never had any issues with it

Maybe it's different in academia - but this is NOT an anesthesia case in our institutions. I'm with MMan. We would not routinely have staff available to drop everything for an emergent cardiac cath. It's not within our usual area of responsibility. We have been involved with one cardiac cath case out of the thousands of caths that have been done at our hospital in the last 5-6 years - and it was a cluster because the cath lab staff totally decompensated with anesthesia staff being around.

FWIW - it would NEVER be the cath lab nurse's call about intubating ANY patient. Cardiologist request? Then we'd have a chat about what was appropriate and go from there.

 

[deleted59964]

umm guys ... i’m pretty sure our emergency physician colleague knows intubation is not the cath lab nurses call.

 

[deleted59964]

It's 2018 and these situations are what point of care ultrasound is for. No excuse these days to just gamble, figure out the physiology. Positive pressure is safe for isolated LV failure. If the right heart is pumping ok with no significant TR, and there is no wide open MR, you could safely start some norepi and put him to sleep. The LV systolic function is almost irrelevant except to guage how much anesthetic he'll need to lose consciousness. Also good to rule out other "do not intubate" red flags like tamponade, massive PE, type A dissection. Remember STEMI can be a red herring.

good point about utility of a quick TTE.
other thing that’s helpful is a quick look at the 12 lead ... will tell you location of i nfarct

 

[nimbus]

Another great blog

Cardiac Transthoracic Echocardiography (TTE) - Summary And Labeled Views | RK.md

 

[Planktonmd]

So... from the original post it sounds like the patient was hypotensive but suprisingly was not in pulmonary edema and not in respieratory distress. If that was the case I agree that intubating him and adding positive pressure ventilation would have likely abolished whatever cardiac output he had left.
On the other hand if he was in fully blown pulmonary edema, hypoxic and dyspneic then you have no choice but intubating him.
Start an inotrope upfront, use Etomidate + Sux to intubate then ventilate with low tidal volumes.

 

[calel-S]

I’m an Emergency Physician that ran into this situation a few months back and that luckily had a good outcome but would like an anesthesiologist’s take on the matter. I had a STEMI patient come in in late one night in massive cardiogenic shock from presumed LV pump failure. SBP in the 60’s. Luckily the patient was awake (impressively enoug) and alert with no airway issues and with Interventional Cardiology maybe 5 minutes out. I was giving a careful fluid bolus and had levophed ready and just starting. I didn’t want to delay cath so patients ready to go. However cath team nurse was insistent we intubate patient before going. I honestly didn’t believe RSI would be safe in this patient let alone a sudden switch to positive pressure, nor did I think I could optimize the patient without an IABP. I refused to intubate and sent the patient. I told them to call in-house anaesthesia if they needed the patient intubated in cath lab. Patient did well but I’m not sure if it’s because of what I did or despite what I did.

So 2 questions:
1. Would you have intubated the patient in the cath lab if you were running sedation?

2. If the patient were in respiratory distress forcing the issue, how would you have gone about intubating keeping in mind the pressing need to get the patient to the cath lab

Just my 2 cents. Im not sure, but it sounds like the SBP you are referring to may be by Non-invasive cuff. These are difficult situations. A good baseline clinical assessment can never hurt. Following this adequate access- large bore IV followed by advanced monitoring. First after establishing large bore IV access I would then place an arterial line. Most patients are not conscious with a SBP of 60. The cerebral auto regulation stops around 50 and your patient was awake and interactive thereby indicating a better picture of overall perfusion, but you don't know how good. The arterial line will sort that out. Once you figure out whether your are dealing with shock or not. Central venous access and pressure measurement. In this case a swan would be helpful. Once having these you can definitely titrate medications as well as anesthetics.

As far as intubation is concerned I would not intubate an awake patient who can protect their airway. Once sedation is prescribed then that is up to the team. Personally he doesn't sound like a good candidate for mod-deep sedation which is how most cardiology practices. They need intubation and inotropic support. However, if your cardiologist is not cavalier and can do it under straight local that would be best for the patient. Be prepared however to rapidly secure the airway. This I would do with high dose narcotic (if in heart failure) with low dose propofol 0.3-0.5 mg/kg and sux 1.2 mg/kg followed by 10mcg of epi and have difficult airway equipment available. If EF is >30% I would do propofol 0.5-1 mg/kg and sux 1.2mg/kg. Hope this helps. More information is always better. CVP, PAP, wedge, CI....etc also a quick bedside echo rule out flail mitral leaflet with wide open MR vs over systolic failure would also help. Vasodilators vs inotropic support. Goodluck.

 

[deleted59964]

Just my 2 cents. Im not sure, but it sounds like the SBP you are referring to may be by Non-invasive cuff. These are difficult situations. A good baseline clinical assessment can never hurt. Following this adequate access- large bore IV followed by advanced monitoring. First after establishing large bore IV access I would then place an arterial line. Most patients are not conscious with a SBP of 60. The cerebral auto regulation stops around 50 and your patient was awake and interactive thereby indicating a better picture of overall perfusion, but you don't know how good. The arterial line will sort that out. Once you figure out whether your are dealing with shock or not. Central venous access and pressure measurement. In this case a swan would be helpful. Once having these you can definitely titrate medications as well as anesthetics.

As far as intubation is concerned I would not intubate an awake patient who can protect their airway. Once sedation is prescribed then that is up to the team. Personally he doesn't sound like a good candidate for mod-deep sedation which is how most cardiology practices. They need intubation and inotropic support. However, if your cardiologist is not cavalier and can do it under straight local that would be best for the patient. Be prepared however to rapidly secure the airway. This I would do with high dose narcotic (if in heart failure) with low dose propofol 0.3-0.5 mg/kg and sux 1.2 mg/kg followed by 10mcg of epi and have difficult airway equipment available. If EF is >30% I would do propofol 0.5-1 mg/kg and sux 1.2mg/kg. Hope this helps. More information is always better. CVP, PAP, wedge, CI....etc also a quick bedside echo rule out flail mitral leaflet with wide open MR vs over systolic failure would also help. Vasodilators vs inotropic support. Goodluck.

Really? A swan?

 

[vector2]

Can we also please get away from the 30 year old notion that high dose narcotics are required for cardiac induction? Time and time again I see ppl push 500mcg of fentanyl for induction, intubation goes fine, and then they're fighting hypotension throughout the entire vein harvest until sternotomy (or in the case of a minimally stimulating CEA, the entire case). Here's Hawaiian Bruin's excellent post from the old etomidate thread:

To answer that I first have to say that I have always found the idea of a "cardiac induction" involving high dose midaz/versed to be a vestige of an era that existed prior to short-acting cardioactive drugs.

Yes, you want to avoid tachycardia in CAD. There are other, better ways of accomplishing rate control than massive narcotic doses IMO. For example, esmolol.

I use benzos/opiates as I would in any other major case. Most of my hearts get 1-2.5 mg midaz for the a-line, and 500mcg fentanyl total for the case.

To induce a sick patient- I don't have a standard induction, I try to tailor each induction to the patient's particular ideal hemodynamic state. But some combination of 100-150mcg fent, .25-1 mg/kg ketamine, .5-2 mg/kg propofol usually does the trick. If I'm giving narcotic, I'll give that a few minutes up front. As we get going, ketamine goes in first, followed by NMBD (I don't test for maskability, but that's another thread), then judicious propofol to effect.

I don't use fentanyl if I want a higher heart rate (i.e. regurgitant valvular disease). I don't use ketamine if tachycardia poses a particularly bad threat, though doses around .5mg/kg don't cause much tachycardia. For most AS patients, ketamine + propofol does just fine.

For the truly, truly sick? They get a dash of midaz and then breathe sevo. And they go down nice and stable. Nothing more stable than an inhaled induction.

There are many ways to skin the cardiac cat without etomidate.

 

[deleted59964]

Can we also please get away from the 30 year old notion that high dose narcotics are required for cardiac induction? Time and time again I see ppl push 500mcg of fentanyl for induction, intubation goes fine, and then they're fighting hypotension throughout the entire vein harvest until sternotomy (or in the case of a minimally stimulating CEA, the entire case). Here's Hawaiian Bruin's excellent post from the old etomidate thread:

Agreed
High dose opioids are good at abolishing sympathetic drive, good if you want to avoid tachycardia or hypertension on laryngoscopy ... eg pre eclampsia - but very bad when you’ve got a patient who needs all the sympathetic tone they can muster

 

[anbuitachi]

Can we also please get away from the 30 year old notion that high dose narcotics are required for cardiac induction? Time and time again I see ppl push 500mcg of fentanyl for induction, intubation goes fine, and then they're fighting hypotension throughout the entire vein harvest until sternotomy (or in the case of a minimally stimulating CEA, the entire case). Here's Hawaiian Bruin's excellent post from the old etomidate thread:

Yea i wouldn't use a high dose narc for this patient. Dont care if laryngoscopy causes hypertension in this case. Also not sure why people are so obsessed with propofol. Sure you can use propofol for anything, but the risk in these patients is still higher than drugs like etomidate. Why take the chance? You are just adding another variable for failure. And if something does happen on induction, i imagine propofol would be harder to defend against too even if given with inotrope/pressor in low dose

 

[jwk]

Just my 2 cents. Im not sure, but it sounds like the SBP you are referring to may be by Non-invasive cuff. These are difficult situations. A good baseline clinical assessment can never hurt. Following this adequate access- large bore IV followed by advanced monitoring. First after establishing large bore IV access I would then place an arterial line. Most patients are not conscious with a SBP of 60. The cerebral auto regulation stops around 50 and your patient was awake and interactive thereby indicating a better picture of overall perfusion, but you don't know how good. The arterial line will sort that out. Once you figure out whether your are dealing with shock or not. Central venous access and pressure measurement. In this case a swan would be helpful. Once having these you can definitely titrate medications as well as anesthetics.

As far as intubation is concerned I would not intubate an awake patient who can protect their airway. Once sedation is prescribed then that is up to the team. Personally he doesn't sound like a good candidate for mod-deep sedation which is how most cardiology practices. They need intubation and inotropic support. However, if your cardiologist is not cavalier and can do it under straight local that would be best for the patient. Be prepared however to rapidly secure the airway. This I would do with high dose narcotic (if in heart failure) with low dose propofol 0.3-0.5 mg/kg and sux 1.2 mg/kg followed by 10mcg of epi and have difficult airway equipment available. If EF is >30% I would do propofol 0.5-1 mg/kg and sux 1.2mg/kg. Hope this helps. More information is always better. CVP, PAP, wedge, CI....etc also a quick bedside echo rule out flail mitral leaflet with wide open MR vs over systolic failure would also help. Vasodilators vs inotropic support. Goodluck.

Maybe I'm sheltered (happily). How many cardiac cath cases are y'all involved with (ours is essentially zero despite very busy cath labs with their share of STEMIs), and if you are, do you "line them up"?

 

[deleted162650]

We’re involved in all the EP ablation cases, but I can’t think of a single cath case we’ve been asked to help with.

 

[calel-S]

Maybe I'm sheltered (happily). How many cardiac cath cases are y'all involved with (ours is essentially zero despite very busy cath labs with their share of STEMIs), and if you are, do you "line them up"?

Just to be clear. I believe this was a case in the ER not cath lab yet? The question was should they intubate before going to cath lab? A systolic blood pressure of 60 will soon not be compatible with life, that would need to be sorted out in the ER, first. Curious would anyone just send this gentleman, with an IV only, to cath lab and no arterial line? Also I'm also not aware of etomidate being used much for RSI? I believe this person came in basically as a 4E full stomach. Risk benefit here is full stomach vs. awake lines with titrated inotropic support and choice of anesthetics to balance each of these. Rapid onset prop, slow onset etomidate. Rapid offset prop, slow offset etomidate-with possible adrenal suppression for up to 5-6days. Everything in anesthesia is a grey area. I think anyone not placing an arterial line with large bore access prior to transport might be questionable. Like I stated before a POC TTE would help differentiate a lot of things as well. Another pertinent question no one has asked is does he demonstrate qualities of difficult intubation. Early/controlled access would be preferred vs transferring to the cath lab where he could become unstable and that is not when you want to be dealing with a difficult airway.

 

[deleted171991]

Just to be clear. I believe this was a case in the ER not cath lab yet? The question was should they intubate before going to cath lab? A systolic blood pressure of 60 will soon not be compatible with life, that would need to be sorted out in the ER, first. Curious would anyone just send this gentleman, with an IV only, to cath lab and no arterial line? Also I'm also not aware of etomidate being used much for RSI? I believe this person came in basically as a 4E full stomach. Risk benefit here is full stomach vs. awake lines with titrated inotropic support and choice of anesthetics to balance each of these. Rapid onset prop, slow onset etomidate. Rapid offset prop, slow offset etomidate-with possible adrenal suppression for up to 5-6days. Everything in anesthesia is a grey area. I think anyone not placing an arterial line with large bore access prior to transport might be questionable. Like I stated before a POC TTE would help differentiate a lot of things as well. Another pertinent question no one has asked is does he demonstrate qualities of difficult intubation. Early/controlled access would be preferred vs transferring to the cath lab where he could become unstable and that is not when you want to be dealing with a difficult airway.

A few points:
1. At an SBP of 60, the pre-induction A-line is almost irrelevant, as in you need a slow induction (which allows for frequent NIBP measurements anyway); any carelessness on induction can lead to CPR way before you have time to correct it. This is the kind of patient that cannot be really RSI'd. The cardiac risk is huge when compared to the aspiration risk. This guy needs a slow, controlled induction (which can be done with frequent NIBP measurements, too). Of course, if time permits, I would go for the A-line, but what's of essence here is improving the SBP/CO significantly before even beginning to induce the patient. That and patience will go a long way.
2. The interventionalist was 5 minutes away, so actually the best thing for the patient was to get to the cath lab ASAP. Nothing will stabilize a heart as much as opening up an occluded vessel. Time was of essence here.
3. Many STEMI patients get better fast once their coronary is reopened. Hence we never even hear about them. We only hear about the few who code or go into pulmonary edema on the table.
4. Etomidate onset is about 30 seconds, with peak effect at 1 minute. I don't see why one can't be RSI'd with it. You could RSI somebody even just with midazolam and sux. And I am pretty sure its onset and duration of action are not much different than of propofol, as in the differences are not clinically significant.
5. I agree that a SBP "in the 60's" is nonreassuring. The right thing to do was what OP did: "a careful fluid bolus and had levophed ready and just starting". An intubation etc. could have turned into a 30-minute ****fest and delay in the door to balloon time, if the patient's heart would have survived it in the first place.

 

[deleted162650]

Just to be clear. I believe this was a case in the ER not cath lab yet? The question was should they intubate before going to cath lab? A systolic blood pressure of 60 will soon not be compatible with life, that would need to be sorted out in the ER, first. Curious would anyone just send this gentleman, with an IV only, to cath lab and no arterial line? Also I'm also not aware of etomidate being used much for RSI? I believe this person came in basically as a 4E full stomach. Risk benefit here is full stomach vs. awake lines with titrated inotropic support and choice of anesthetics to balance each of these. Rapid onset prop, slow onset etomidate. Rapid offset prop, slow offset etomidate-with possible adrenal suppression for up to 5-6days. Everything in anesthesia is a grey area. I think anyone not placing an arterial line with large bore access prior to transport might be questionable. Like I stated before a POC TTE would help differentiate a lot of things as well. Another pertinent question no one has asked is does he demonstrate qualities of difficult intubation. Early/controlled access would be preferred vs transferring to the cath lab where he could become unstable and that is not when you want to be dealing with a difficult airway.

Not sure why you’re so fixated on an art line before he gets to cath lab. Guess what’s the first thing this guy is gonna get once he hits the cath lab - an arterial sheath.

Look, this guy has an occluded coronary. The only thing that is gonna save this guy is to open it back up. Time is myocardium, and every minute you delay PCI, you are allowing more cardiac myocytes to die. If he is mentating then get him to cath lab. If he isn’t mentating and can’t protect his airway/effectively exchange gases then put a tube in and get him on the cath table ASAP. If you really feel the need to dick with lines then do it while the cardiologist is starting to work - but again guess what - they are putting in lines for their procedure anyways.

Your lack of understanding of etomidate is strange. It is used for RSI hundreds if not thousands of times for RSI everyday. Onset/offset is not significantly different than propofol.

Bottom line is this guy needs a stent - not an anesthetic.

 

[deleted162650]

Looks like @FFP beat me to it.

 

[OB1🤙]

In my shop, if we get asked to help intubate in the cath lab, we will sometimes stay and help manage hemodynamics. Doesn't happen often at all but it does happen, and we bill anesthesia time for it.

Usually the scenario involves a cardiologist who needs to stay focused on their critical task at hand with a crashing patient, and is better off not having to worry about managing drips and ACLS and such.

The other thing is that after the cath is done, the cardiologist generally disappears, and in those minutes between them scrubbing out and the patient showing up in the CCU, it's nice to have an MD who knows what they're doing in charge of the patient's care. Better than leaving the cath lab RN alone in charge of drips etc.

But every shop is different.

 

[deleted859535]

OP: I'll defer to our anesthesiologist colleagues here in their house, but as another EP, I also would have done exactly as you did (and similarly have not intubated people in perilous situations as yours for whatever the reason in the past).

And perhaps would have had a nice, candid discussion with the RN in question.

 

[nimbus]

In my shop, if we get asked to help intubate in the cath lab, we will sometimes stay and help manage hemodynamics. Doesn't happen often at all but it does happen, and we bill anesthesia time for it.

Usually the scenario involves a cardiologist who needs to stay focused on their critical task at hand with a crashing patient, and is better off not having to worry about managing drips and ACLS and such.

The other thing is that after the cath is done, the cardiologist generally disappears, and in those minutes between them scrubbing out and the patient showing up in the CCU, it's nice to have an MD who knows what they're doing in charge of the patient's care. Better than leaving the cath lab RN alone in charge of drips etc.

But every shop is different.

We do the same. We just call our board runner and tell them we’ll be tied up for awhile.