Case Question - Aortic Stenosis

[smgilles]

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93 year-old lady who is still independent presents with a 8 mm common bile duct stone - she was unable to tolerate "conscious" sedation with the endoscope secondary to desaturations into the 80's. The GI doc wants to do this under general.

She has never had surgery before.
PMHx: HTN and known Severe AS - most recent ECHO showed AVA 0.4 cm2 with a gradient of 48 mmHg.

She has a very small mouth opening (she weighs 38 kg). She has large incisors with overbite, TMD is 2 fingerbreaths, and limited neck extension due to DJD.

Just curious how everyone would proceed or not proceed?

 

[sevoflurane]

93 year-old lady who is still independent presents with a 8 mm common bile duct stone - she was unable to tolerate "conscious" sedation with the endoscope secondary to desaturations into the 80's. The GI doc wants to do this under general.

She has never had surgery before.
PMHx: HTN and known Severe AS - most recent ECHO showed AVA 0.4 cm2 with a gradient of 48 mmHg.

She has a very small mouth opening (she weighs 38 kg). She has large incisors with overbite, TMD is 2 fingerbreaths, and limited neck extension due to DJD.

Just curious how everyone would proceed or not proceed?

Transfer to competing hospital. 😀

Symptomatic? Is she jaundiced, or have increased LFT's? I am assuming she does. What else does the Echo say? Short of breath? angina? syncope?

She has already had a stress test by the GI doc who likely gave some benzo's/narc and turned her into a smurf.

Explain the risk, makes sure she understands.

A-line upfront. Make sure the tank is full. Rescue drugs in the room. Awake fiberoptic may not be necessary as you will likely be able to ventilate a 38kg 94 y/o who I'm sure has compliant lungs. Slow induction with propofol (25 mg at a time) + phenylephrine in line. Don't hyperventilate or give big ***** TV as you wanna keep that venous return flowing. Sux. Mcgrath or glidescope + tube.

 

[seinfeld]

explain risks benefits to the pts loved ones, if even wishes to proceed, then proceed with GA. ALine, phenyleprine at the ready. Induce with whatever you want but be judicious with the dose and keep pressure wnl.

 

[Fastrach]

Regarding the airway, should be an easy mask; would do an asleep fiberoptic.
Preinduction a-line is a good idea.
Probably throw on the defib patches and have defibrillator in the room.
Gentle induction with etomidate or midaz/fent, with plenty of phenyl handy.
Risks/benefits clearly documented in chart.

 

[Planktonmd]

I would probably place an A line pre-induction, induce with a small dose of Propofol + Sux + some narcotic and some neo.
Then if I really felt that the airway is terrible I would take one look with a glidescope, if that does not work I would go for asleep FOB.
Most these elderly people with small mouth and big teeth can be intubated easilly with DL if you have a strong arm 😉

 

[nap$ter]

I would probably place an A line pre-induction, induce with a small dose of Propofol + Sux + some narcotic and some neo.
Then if I really felt that the airway is terrible I would take one look with a glidescope, if that does not work I would go for asleep FOB.
Most these elderly people with small mouth and big teeth can be intubated easilly with DL if you have a strong arm 😉

'

agreed. preinduction aline, full tank, gentle prop/sux/neo, maybe remi bolus c induction. glidescope or DL/bougie.

what do you guys think about offering another try at sedation c a dexmedetomidine gtt to the GI doc (and pt)?

if it doesn't work or hemodynamics become a problem - proceed with GA as above..

 

[smgilles]

Transfer to competing hospital. 😀

Symptomatic? Is she jaundiced, or have increased LFT's? I am assuming she does. What else does the Echo say? Short of breath? angina? syncope?

She has already had a stress test by the GI doc who likely gave some benzo's/narc and turned her into a smurf.

Explain the risk, makes sure she understands.

A-line upfront. Make sure the tank is full. Rescue drugs in the room. Awake fiberoptic may not be necessary as you will likely be able to ventilate a 38kg 94 y/o who I'm sure has compliant lungs. Slow induction with propofol (25 mg at a time) + phenylephrine in line. Don't hyperventilate or give big ***** TV as you wanna keep that venous return flowing. Sux. Mcgrath or glidescope + tube.

She is not jaundiced. LFT's are unknown. Has moderate MR. LVEF 63%.
Family and the patient understand she may die on the table.

 

[smgilles]

I would probably place an A line pre-induction, induce with a small dose of Propofol + Sux + some narcotic and some neo.
Then if I really felt that the airway is terrible I would take one look with a glidescope, if that does not work I would go for asleep FOB.
Most these elderly people with small mouth and big teeth can be intubated easilly with DL if you have a strong arm 😉

Her mouth opening is so small we and GI doc aren't sure there is going to be enough room for the endoscope and the ETT.

 

[Licoricestick]

She has already had a stress test by the GI doc who likely gave some benzo's/narc and turned her into a smurf.

 

[Planktonmd]

If that's the case then you probably should do a nasal fiberoptc intubation asleep.

Her mouth opening is so small we and GI doc aren't sure there is going to be enough room for the endoscope and the ETT.

 

[sevoflurane]

'

agreed. preinduction aline, full tank, gentle prop/sux/neo, maybe remi bolus c induction. glidescope or DL/bougie.

what do you guys think about offering another try at sedation c a dexmedetomidine gtt to the GI doc (and pt)?

if it doesn't work or hemodynamics become a problem - proceed with GA as above..

Would you consider an remi infusion rather than a bolus?

Hypotension and muscle regidity is real and does happen with a remi bolus. I've seen it. A difficult airway and critical AS may not be the right candidate for a remi bolus.

 

[Planktonmd]

Would you consider an remi infusion rather than a bolus?

Hypotension and muscle regidity is real and does happen with a remi bolus. I've seen it. A difficult airway and critical AS may not be the right candidate for a remi bolus.

Absolutely, and it can even happen without a bolus if you increase the rate too fast.

 

[Arch Guillotti]

I have not seen muscle rigidity with a remi bolus but I have senn some pretty significant hypotension.

Would you consider an remi infusion rather than a bolus?

Hypotension and muscle regidity is real and does happen with a remi bolus. I've seen it. A difficult airway and critical AS may not be the right candidate for a remi bolus.

 

[dhb]

I have not seen muscle rigidity with a remi bolus but I have senn some pretty significant hypotension.

same here

 

[sevoflurane]

It is rare, but it does happen. Especially with a bolus. Can cause great difficulty with ventilation. I know there are better articles out there, but here are a couple of recent articles.

http://www.springerlink.com/content/v812427706n76w16/

http://cat.inist.fr/?aModele=afficheN&cpsidt=21930839

 

[sevoflurane]

The first study states that ventilation was impossible with 2 of the patients.

 

[dhb]

Once again:
http://www.anesthesia-analgesia.org/cgi/content/abstract/83/3/629

Much more convincing that "muscle rigidity"

 

[sevoflurane]

http://www.anesthesia-analgesia.org...INDEX=0&sortspec=relevance&resourcetype=HWCIT

You quoted a sufenta article from 1996 which is the same year remi was introduced. This one deals with remi specifically, also a bit interesting. "rigidity of abdominal wall"

2007.

The point is... In critical AS and possible difficult airway... I would be cautious giving a remi bolus because of difficulty ventilating and hypotension. My 2 cents.

 

[smgilles]

If that's the case then you probably should do a nasal fiberoptc intubation asleep.

My plan was awake a-line, Etomidate + phenylephrine. She definitely looked like an easy mask. I wanted to induce nice and gently and keep her deep with some volalite and then asleep nasal vs oral fiberoptic.

Attending likes to use the bullard... He also wanted defib pads.

 

[Planktonmd]

The debate whether it is glottic closure versus muscle rigidity is not easy to resolve, but regardless of the mechanism, when you are using Remi on a non intubated patient, you need to anticipate a rather rapid transition from spontaneous ventilation to apnea.
This ability to produce apnea suddenly with minimal changes of the dose could be a disaster if the reason why you are using Remi is to manage a difficult airway.

 

[dhb]

http://www.anesthesia-analgesia.org...INDEX=0&sortspec=relevance&resourcetype=HWCIT

You quoted a sufenta article from 1996 which is the same year remi was introduced. This one deals with remi specifically, also a bit interesting. "rigidity of abdominal wall"

2007.

The point is... In critical AS and possible difficult airway... I would be cautious giving a remi bolus because of difficulty ventilating and hypotension. My 2 cents.

No offense but your case reports are pretty soft compared to the p=0.00001 of the article i quoted. What was true in 1996 can still be true in 2010.
If you want to believe in muscle rigidity fine but there's not much to back it up.

 

[nap$ter]

Would you consider an remi infusion rather than a bolus?

Hypotension and muscle regidity is real and does happen with a remi bolus. I've seen it. A difficult airway and critical AS may not be the right candidate for a remi bolus.

when i was a ca2 i spent a month giving a lot of patients remi bolusses with propofol, sans relaxant (with the attendings who let me ie weren't afraid of bradycardia) for induction. never saw rigidity (doesn't mean it doesn't happen), and i did not think that the post-induction hypotension was greater than in patients that i gave propofol/fentanyl to.

so no, i would still just go with a bolus. the purpose being a short acting (this sounds like it's gonna be just a quick scope) method to prevent tachycardia during laryngoscopy. this 93yo lady isn't gonna tolerate much propofol, and i don't want her to get tachy with laryngoscopy. you could use alfentanil with induction instead, i suppose. or you could just induce and stick a blade in while watching her heart rate, and pull out and give remi if she does get tachy.

it sounds like she would be an easy mask, even if her tube has potential for difficulty, so you will have some time and an aline tracing to adapt to whatever hemodynamic behavior she exhibits.

the more i think about it, the more i think she deserves another chance at conscious sedation. it doesn't surprise me that the GI folks turned a 93 yo lady into a smurf - but i like to think that we could be a bit more elegant with her airway management during a conscious sedation.

again, i would place an aline, prepare for GA as above, and then give her a try with a dexmed gtt.

 

[sevoflurane]

No offense but your case reports are pretty soft compared to the p=0.00001 of the article i quoted. What was true in 1996 can still be true in 2010.
If you want to believe in muscle rigidity fine but there's not much to back it up.

No offense taken. We are all trying to learn here. That's all.

Big Barash. Page 372. 2nd to last paragraph:

"Remifentanil can produce muscle rigidity, especially with boluses."

Agree to disagree. 🙂

 

[Planktonmd]

when i was a ca2 i spent a month giving a lot of patients remi bolusses with propofol, sans relaxant....

Correct me if I am wrong but you are here referring to giving Remi for induction of GA not as a part of a sedation protocol.
I think that muscle rigidity or glottic closure causing apnea is a problem when Remi is used for sedation but this problem does not exist if your plan is to intubate the patient as soon as they become unconscious, and even if there is some degree of muscle tegidity it won't matter that much since the next thing you do after intubation is usually giving inhaled agents that will terminate that problem.

 

[nap$ter]

Correct me if I am wrong but you are here referring to giving Remi for induction of GA not as a part of a sedation protocol.
I think that muscle rigidity or glottic closure causing apnea is a problem when Remi is used for sedation but this problem does not exist if your plan is to intubate the patient as soon as they become unconscious, and even if there is some degree of muscle tegidity it won't matter that much since the next thing you do after intubation is usually giving inhaled agents that will terminate that problem.

Originally Posted by slavin
'

agreed. preinduction aline, full tank, gentle prop/sux/neo, maybe remi bolus c induction. glidescope or DL/bougie.

what do you guys think about offering another try at sedation c a dexmedetomidine gtt to the GI doc (and pt)?

if it doesn't work or hemodynamics become a problem - proceed with GA as above..

correct. i would never give a remi bolus as part of sedation. in addition, i have never given remi for sedation even as an infusion, and probably never will, because, as arch mentioned, the therapeutic window is too narrow... too much potential for apnea. there are better alternatives ie fentanyl and alfentanil.

 

[Mista Suprane]

Attending likes to use the bullard...

we have one of those attendings as well; in his 70s, has probably done 1000+ bullard intubations, would put money on him intubating with a bullard over anyone with any other device on a difficult airway. actually seems like a good option for this case if you are deft with it (i am not); you barely need a mouth opening at all. that being said if you are gonna have to rock a nasal tube because you are concerned that there is not room for the ETT and the endoscope, then i guess it would be useless.

 

[proman]

we have one of those attendings as well; in his 70s, has probably done 4000+ bullard intubations, would put money on him intubating with a bullard over anyone with any other device on a difficult airway. actually seems like a good option for this case if you are deft with it (i am not); you barely need a mouth opening at all. that being said if you are gonna have to rock a nasal tube because you are concerned that there is not room for the ETT and the endoscope, then i guess it would be useless.

Fixed it for you.

 

[Noyac]

I have not seen muscle rigidity with a remi bolus but I have senn some pretty significant hypotension.

At the ASA this year there was a discussion about using a Remi infusion and just giving a small bolus during a case that caused dramatic chest rigidity to the point that they could not ventilate without giving muscle relaxants.

 

[dhb]

At the ASA this year there was a discussion about using a Remi infusion and just giving a small bolus during a case that caused dramatic chest rigidity to the point that they could not ventilate without giving muscle relaxants.

Let me guess the case was with an LMA the patient was light and he was given a bump for a stimulating part of the procedure. The provider mistimed the bolus leading to laryngospasm die to a light plain am I right?

 

[Fastrach]

I've only been in this game for 3 1/2 years but I have never seen narcotic chest wall rigidity. I've used remi and sufent a bunch too. I'm still a skeptic.

One of my staff told me they've seen extreme chest wall rigidity with 25 mcg of fentanyl... not sufent, not remi, just garden variety fent. I'll believe it when I see it myself.

 

[Noyac]

Let me guess the case was with an LMA the patient was light and he was given a bump for a stimulating part of the procedure. The provider mistimed the bolus leading to laryngospasm die to a light plain am I right?

Well there were a few of them that I heard of during the ASA but that wasn't one of them. The one I was talking about was a prone lumbar spine case.

Did you hear of this one with the LMA while at the ASA?

 

[Noyac]

I've only been in this game for 3 1/2 years but I have never seen narcotic chest wall rigidity. I've used remi and sufent a bunch too. I'm still a skeptic.

Since you have only been at this for 3 1/2 years I don't suspect you are aware of the fentanyl shortage we saw about 7 yrs ago. I personally witnessed a partner of mine give 100 mcg of sufenta (on accident thinking it was fentanyl) and then instantly not be able to ventilate the pt. It was like trying to mask a rock. Very scary at the time.

 

[Licoricestick]

Since you have only been at this for 3 1/2 years I don't suspect you are aware of the fentanyl shortage we saw about 7 yrs ago. I personally witnessed a partner of mine give 100 mcg of sufenta (on accident thinking it was fentanyl) and then instantly not be able to ventilate the pt. It was like trying to mask a rock. Very scary at the time.

I've had a similar experience with a large remi bolus at induction - completely unable to ventilate despite the fact that there was no reason to suspect he would be a difficult facemask ventilation and I was generating decent pressures with the bag. We were sure it was the remi so the consultant gave vec and things started to improve, once paralysed he was one of the easiest facemask ventilations I've ever done.

 

[doctor712]

Since you have only been at this for 3 1/2 years I don't suspect you are aware of the fentanyl shortage we saw about 7 yrs ago. I personally witnessed a partner of mine give 100 mcg of sufenta (on accident thinking it was fentanyl) and then instantly not be able to ventilate the pt. It was like trying to mask a rock. Very scary at the time.

Noy,
The instance you describe with your partner giving 100mcg of sufentanil, assuming he/she ended up ventilating and continuing the case, is this something that gets disclosed to the family should everything have gone well in the end anyway? Just curious from a disclosure standpoint. If the end result was good, do these situations come up with the family?
Thanks
D712

 

[Planktonmd]

I am not sure that there is an answer to this question that can be both honest and good to be published on the internet.

Noy,
The instance you describe with your partner giving 100mcg of sufentanil, assuming he/she ended up ventilating and continuing the case, is this something that gets disclosed to the family should everything have gone well in the end anyway? Just curious from a disclosure standpoint. If the end result was good, do these situations come up with the family?
Thanks
D712

 

[dhb]

Did you hear of this one with the LMA while at the ASA?

No

I've witnessed difficulty ventilating after opiates and yes you feel like the patient turned into a rock but if you think about it it's the same feeling on the bag when a patient goes into laryngospasm. As i've said there's nothing to back this muscle rigidity theory, on the other hand the study i've shown provides a physio-pathological explanation.
Check out this other study by the same groupe:
Difficult or Impossible Ventilation after Sufentanil-induced Anesthesia Is Caused Primarily by Vocal Cord Closure
Bennett, Joel A. DDS, MD; Abrams, Jonathan T. MD; Van Riper, Daniel F. MD; Horrow, Jan C. MD
(Anesthesiology: November 1997 - Volume 87 - Issue 5 - pp 1070-1074)"

If you look at the literature vocal cord closure can happens with basically all induction agents: pent, prop, fent, sufenta etc..
I think we experience it less nowadays is because we are using faster acting muscle relaxant so you get vocal cord opening much sooner. Why do you see it more with fentanyl compared to sufenta? again fent delay of action is shorter than sufenta so the vocal cord close earlier. Think about it a fent/panc induction is a lot different that a sufenta/roc induction in terms of pharmacokinetics.

The "muscle rigidity" is just too much voodoo and unsubstantiated IMHO.

 

[pgg]

I am not sure that there is an answer to this question that can be both honest and good to be published on the internet.

I look at it like this:

If there is something to be gained by informing the patient's future caregivers about an unexpected problem or non-obvious complication, then it's worth telling the patient and even writing a letter or copying the anesthetic record for the patient to give to future anesthesiologists. Example - unexpected difficult airway, atypical pseudocholinesterase, MH.

If there was a complication that produced injury or required unplanned nonzero risk interventions (needed a transfusion, needed a central line, needed an overnight admission) then the patient deserves an appropriately complete explanation.


But for this topic - transient upper airway obstruction secondary to a narcotic bolus - I wouldn't mention it. What is there to gain? There's no future risk to mitigate or avoid. Just like I wouldn't say anything if I needed to give 100 mcg of phenylephrine to treat a momentary BP of 80/40, or if I gave some extra neostigmine or a bit of Narcan because the patient was too weak or got too much fentanyl.

I don't think it's unethical or dishonest to not formally explain every instance in which we nudge a patient's physiologic state back to normal.

 

[doctor712]

I don't think it's unethical or dishonest to not formally explain every instance in which we nudge a patient's physiologic state back to normal.

Thanks for the replies pgg and DM (and plank). is there a typical threshold or do you just use your judgement (and cover your butt). if same 100mcg case of sufent instead of fent caused a resuscitation, then it goes to family? or, from what im hearing, when it NEEDS to go to family for future reference, or because the patient isn't waking up so soon after OR, and family will know anyway, then it's up for discussion?

when do you get into an ethical grey area? and if you guys dont wanna talk ethics in public, cool, i get it.

D712

 

[Planktonmd]

In the example being discussed here the WRONG medication was administered and as a result a complication (although transient) happened.
The complication could have been more serious and could have caused real injury.
The question was: would you or wouldn't you tell the patient about the medication error.

I look at it like this:

If there is something to be gained by informing the patient's future caregivers about an unexpected problem or non-obvious complication, then it's worth telling the patient and even writing a letter or copying the anesthetic record for the patient to give to future anesthesiologists. Example - unexpected difficult airway, atypical pseudocholinesterase, MH.

If there was a complication that produced injury or required unplanned nonzero risk interventions (needed a transfusion, needed a central line, needed an overnight admission) then the patient deserves an appropriately complete explanation.


But for this topic - transient upper airway obstruction secondary to a narcotic bolus - I wouldn't mention it. What is there to gain? There's no future risk to mitigate or avoid. Just like I wouldn't say anything if I needed to give 100 mcg of phenylephrine to treat a momentary BP of 80/40, or if I gave some extra neostigmine or a bit of Narcan because the patient was too weak or got too much fentanyl.

I don't think it's unethical or dishonest to not formally explain every instance in which we nudge a patient's physiologic state back to normal.

 

[doctor712]

Right Plank, sorry, I meant to imply that by saying sufent instead of fent...
as it was given by error...

D712

 

[Noyac]

I've never given that large a bolus that I can remember. Usually 50 mcg tops.

Are you talking about fentanyl or sufenta? Like I said, it was an accident b/c he thought it was fentanyl. I don't think people go around giving 100mcg sufenta boluses hell, 50 mcg is a more than I would give.

 

[Noyac]

Noy,
The instance you describe with your partner giving 100mcg of sufentanil, assuming he/she ended up ventilating and continuing the case, is this something that gets disclosed to the family should everything have gone well in the end anyway? Just curious from a disclosure standpoint. If the end result was good, do these situations come up with the family?
Thanks
D712

No

 

[Noyac]

No

I've witnessed difficulty ventilating after opiates and yes you feel like the patient turned into a rock but if you think about it it's the same feeling on the bag when a patient goes into laryngospasm. As i've said there's nothing to back this muscle rigidity theory, on the other hand the study i've shown provides a physio-pathological explanation.
Check out this other study by the same groupe:
Difficult or Impossible Ventilation after Sufentanil-induced Anesthesia Is Caused Primarily by Vocal Cord Closure
Bennett, Joel A. DDS, MD; Abrams, Jonathan T. MD; Van Riper, Daniel F. MD; Horrow, Jan C. MD
(Anesthesiology: November 1997 - Volume 87 - Issue 5 - pp 1070-1074)"

If you look at the literature vocal cord closure can happens with basically all induction agents: pent, prop, fent, sufenta etc..
I think we experience it less nowadays is because we are using faster acting muscle relaxant so you get vocal cord opening much sooner. Why do you see it more with fentanyl compared to sufenta? again fent delay of action is shorter than sufenta so the vocal cord close earlier. Think about it a fent/panc induction is a lot different that a sufenta/roc induction in terms of pharmacokinetics.

The "muscle rigidity" is just too much voodoo and unsubstantiated IMHO.

I think the "chest rigidity" problem is different than a simple laryngospasm. Here's how I see it. Chest rigidity post narcotic bolus does not improve until muscle relaxants are given (someone correct me if i'm wrong). Even when the pt becomes hypoxic into the 30's the rigidity is still there, I suspect. I haven't been there. But laryngospasm can improve without relaxants. Pressure points behind the ear, positive pressure, and hypoxia are ways in which laryngospasm can resolve. These don't work in narc induced chest rigidity. So something is different. It may still be that the cords are shut but I doubt it. Also, this happens with an endotracheal tube in place therefore, the cords are out of the picture. I think these people are looking at two different things. The ASA case was a prone man with an ETT.

The faster relaxant theory may be valid but I also doubt it has anything to do with it. We use much less sux these days and nothing is faster than sux.

I like the way you think DHB.👍

 

[sevoflurane]

I think the "chest rigidity" problem is different than a simple laryngospasm. Here's how I see it. Chest rigidity post narcotic bolus does not improve until muscle relaxants are given (someone correct me if i'm wrong). Even when the pt becomes hypoxic into the 30's the rigidity is still there, I suspect. I haven't been there. But laryngospasm can improve without relaxants. Pressure points behind the ear, positive pressure, and hypoxia are ways in which laryngospasm can resolve. These don't work in narc induced chest rigidity. So something is different. It may still be that the cords are shut but I doubt it. Also, this happens with an endotracheal tube in place therefore, the cords are out of the picture. I think these people are looking at two different things. The ASA case was a prone man with an ETT.

The faster relaxant theory may be valid but I also doubt it has anything to do with it. We use much less sux these days and nothing is faster than sux.

I like the way you think DHB.👍

Yep. Muscle relaxants completely fix the problem.

 

[pgg]

In the example being discussed here the WRONG medication was administered and as a result a complication (although transient) happened.
The complication could have been more serious and could have caused real injury.
The question was: would you or wouldn't you tell the patient about the medication error.

Oh, my mistake, misunderstood the scenario.

I'd still not say anything to the patient. Although this particular medication error carried (small) potential to harm the patient, no harm did occur and the patient is not at any future risk. As a medication error it should be documented and internally tracked, perhaps even subject to M&M discussion if there were systemic or engineering factors in the error.

But I don't see the point in upsetting or freaking out a patient who wasn't injured.

 

[pgg]

More ...

Something else that guides how much I tell patients: I ask myself if I'm giving them the information for their benefit, or just to make myself feel better about the error. It's not about me, so I need a reason to give potentially scary information to them after the fact.

With all respect to patient autonomy, and without trying to be too paternalistic, I really believe patients do NOT need to know about every little bullet they dodge in the OR, whether it's the surgeon mumbling 'oops' and extending the surgery 10 minutes to tie off that vessel he just whacked, or my student playing xylophone on the teeth and tubing the goose before I took over the airway, or any of 1000 other small risky events. If patients knew how many low-% bullets were out there, they'd be terrified ... and for no purpose.

We shouldn't order tests that won't affect managment, and we shouldn't volunteer scary information to patients if it won't affect their future care or decision making process. JMHO.

 

[Planktonmd]

I really think that this subject should not be discussed openly on an internet public forum because believe it or not everything you post here is subject to misinterpretation and could be subpoenaed to be used against you or against a colleague.

 

[sevoflurane]

I think the "chest rigidity" problem is different than a simple laryngospasm. Here's how I see it. Chest rigidity post narcotic bolus does not improve until muscle relaxants are given (someone correct me if i'm wrong). Even when the pt becomes hypoxic into the 30's the rigidity is still there, I suspect. I haven't been there. But laryngospasm can improve without relaxants. Pressure points behind the ear, positive pressure, and hypoxia are ways in which laryngospasm can resolve. These don't work in narc induced chest rigidity. So something is different. It may still be that the cords are shut but I doubt it. Also, this happens with an endotracheal tube in place therefore, the cords are out of the picture. I think these people are looking at two different things. The ASA case was a prone man with an ETT.

The faster relaxant theory may be valid but I also doubt it has anything to do with it. We use much less sux these days and nothing is faster than sux.

I like the way you think DHB.👍

Sufentanil. I use sufentanil on all the hearts I've been doing lately. I often give 30-50 mcgs prior to intubation, with my induction. I haven't seen chest rigidity with these doses. I check to see if I can ventilate before giving a long acting muscle-relaxant. I have never noticed a problem. If it occurs, it must be rare.

How about hypotension? Just curious.

 

[Planktonmd]

How about hypotension? Just curious.

I was not aware that a Sufentanil induction causes hypotension!
Did you mean Remi?

 

[sevoflurane]

I was not aware that a Sufentanil induction causes hypotension!
Did you mean Remi?

Nope. Sufentanil. I don't induce with remi.