Direct Laryngoscopy using a sux gtt

[Gasnoob]

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Do any of you run a sux drip for a direct laryngoscopy for biopsies? I was thinking of IV induction and masking with sevo and 100% O2 and running a sux drip. Is the sux drip overkill? The case should not be more than 5-10 minutes so not too worried about a phase II block with the sux drip. I was going to put 200mg in 100ml bag of saline and infuse wide open. Does anyone else use a different mixture of sux?

 

[imfrankie]

Do any of you run a sux drip for a direct laryngoscopy for biopsies? I was thinking of IV induction and masking with sevo and 100% O2 and running a sux drip. Is the sux drip overkill? The case should not be more than 5-10 minutes so not too worried about a phase II block with the sux drip. I was going to put 200mg in 100ml bag of saline and infuse wide open. Does anyone else use a different mixture of sux?

Use to do it that way all the time. Used the powder but your idea sounds fine.
Minidrippers work well for this. Make sure to tape a big THIS SUCKS on the bag.

 

[Gasnoob]

Did you cut your induction dose of sux down at all or just utilize the drip instead of any induction dose of sux?

Use to do it that way all the time. Used the powder but your idea sounds fine.
Minidrippers work well for this. Make sure to tape a big THIS SUCKS on the bag.

 

[IlDestriero]

I do a lot of flex and rigid bronchs and reconstructions. I usually only paralyze if they're doing some kind of reconstruction that's going to take >30 minutes. I think it's generally easier if they're very deep and spontaneously ventilating.
I used to do a TIVA with prop/remi, but most are only 5 minutes, so it's overkill.
I do like the old school appeal of a Sux drip though! Nice.

 

[proman]

I like doing sux drips for things like rigid bronchs/tracheal stents etc. Intensely stimulating and vitally important to keep the patient still. I figure out what the maximum safe dose would be, around 4mg/kg. I take half that for induction and half in the bag. I've yet to run out. The ED95 of sux is ~0.25mg/kg so for most patients we significantly overdose them.

Just put 1/2 cc of methylene blue in the bag and you'll have everyone in the room looking at the pretty infusion. I think I learned that on here a few years ago.

 

[Monty Python]

I like doing sux drips ..... Just put 1/2 cc of methylene blue in the bag and you'll have everyone in the room looking at the pretty infusion. I think I learned that on here a few years ago.

Absolutely. You want the mainline IV to be clear of any blue tinge from the piggy-backed IV sux before concluding your care of the pt.



.

 

[jetproppilot]

I like doing sux drips for things like rigid bronchs/tracheal stents etc. Intensely stimulating and vitally important to keep the patient still. I figure out what the maximum safe dose would be, around 4mg/kg. I take half that for induction and half in the bag. I've yet to run out. The ED95 of sux is ~0.25mg/kg so for most patients we significantly overdose them.

Just put 1/2 cc of methylene blue in the bag and you'll have everyone in the room looking at the pretty infusion. I think I learned that on here a few years ago.

What a cool idea!

 

[proman]

Absolutely. You want the mainline IV to be clear of any blue tinge from the piggy-backed IV sux before concluding your care of the pt.

Giving credit where due, it was your post with indigo carmine in this thread:

If you want your older attending to smile, or the younger one to grimace, mix up a sux drip for your next 20 minute case where paralysis is preferred. Add a drop of indigo carmine or other dye to the bag, attach it to your mainline IV, and let 'er rip after the usual induction drugs and intubation. Turn it off about 5 minutes prior to waking up.

http://www.brooksidepress.org/Produ.../DATA/operationalmed/Meds/Succinylcholine.htm

Must keep in mind some of the peripheral consideration of sux, however: http://www.rxmed.com/b.main/b2.phar...hs/CPS- (General Monographs- A)/ANECTINE.html

For more fun, set up a modified Jackson-Rees nonrebreather:

http://www.harvardapparatus.com/web...1051_37415_-1_HAI_ProductDetail_N_37326_37345
.

Does that make me an old attending or a young one?

 

[jetproppilot]

Giving credit where due, it was your post with indigo carmine in this thread:



Does that make me an old attending or a young one?

That's great of you to give credit where credit is due. Says a lot about you.👍

Btw I worked with Trinity Alumnus for years.

High quality dude who's great at what he does.👍👍

 

[Arch Guillotti]

Just put 1/2 cc of methylene blue in the bag and you'll have everyone in the room looking at the pretty infusion. I think I learned that on here a few years ago.

Second this. Cool little trick.👍

 

[sevoflurane]

Love, love, loooooove it...

SDN is not selfish and continues to give.

I had the opportunity to do a sux gtt once or twice during residency but never got around to it (only one old timer still showing us young bucks how to do it old school style).

Now... if I remember correctly you use a sux drip with a peripheral nerve stimulator to control your drip rate. Right? 😕

You just want to keep an equal twitch response down 70-80% from baseline... since it's a depolarizer.

If you start to get fade you are risking a Phase 2 block and delayed recovery. How easy is it to titrate your drip without risking phase 2 block?

Also, any of you guys get the heeebeee-jeeebeee's with sux drips and peds?

COOL THREAD! I will show my excitement by dancing:

 

[sevoflurane]

So 2mg/kg in the bag + MB... OK. How quick or slow does the drip rate usually run...?

drip, pause and wait, drip, pause and wait, drip, pause and wait

or

drip, drip, drip, drip,

or

drip, dri, dr, d, d... (I'm guessing not)

PNS is your friend here I'm sure, but just wondering what types of rates are typically encountered to keep the twitch response down without risking fade.

Oh, yeah... and do you put your sux into a 100cc bag or 250 cc bag? That will obviously affect the drip rate.

 

[Arch Guillotti]

Now... if I remember correctly you use a sux drip with a peripheral nerve stimulator to control your drip rate. Right? 😕

You just want to keep an equal twitch response down 70-80% from baseline... since it's a depolarizer.

If you start to get fade you are risking a Phase 2 block and delayed recovery. How easy is it to titrate your drip without risking phase 2 block?

Also, any of you guys get the heeebeee-jeeebeee's with sux drips and peds?

Yes I use a peripheral nerve stimulator and titrate to a faint twitch.

I have never seen a phase 2 block although my sample size is not great. Cases are usually quick enough that it isn't an issue.

I wouldn't do one in a kid. There are other ways to accomplish the same goal.

So 2mg/kg in the bag + MB... OK. How quick or slow does the drip rate usually run...?

drip, pause and wait, drip, pause and wait, drip, pause and wait

or

drip, drip, drip, drip,

or

drip, dri, dr, d, d... (I'm guessing not)

PNS is your friend here I'm sure, but just wondering what types of rates are typically encountered to keep the twitch response down without risking fade.

Oh, yeah... and do you put your sux into a 100cc bag or 250 cc bag? That will obviously affect the drip rate.

The drips run pretty fast and on a micro dripper its hard to tell exactly what the rate is since those sets seem to be notoriously inaccurate on the drip rate.

I suggest withdrawing some fluid from the bag and then adding the sux so that it comes out to 2 mg/ml.

 

[sevoflurane]

Yes I use a peripheral nerve stimulator and titrate to a faint twitch.

I have never seen a phase 2 block although my sample size is not great. Cases are usually quick enough that it isn't an issue.

I wouldn't do one in a kid. There are other ways to accomplish the same goal.



The drips run pretty fast and on a micro dripper its hard to tell exactly what the rate is since those sets seem to be notoriously inaccurate on the drip rate.

I suggest withdrawing some fluid from the bag and then adding the sux so that it comes out to 2 mg/ml.

👍

Vial of sux into 100 cc bag on a mini dripper.

Thanks Arch.

 

[Monty Python]

Giving credit where due, it was your post with indigo carmine in this thread:



Does that make me an old attending or a young one?

We'll say ......................... it makes you an open-minded one to taking the scientific approach to a new idea.

And I must also give credit where it's due. I learned the sux drip with indigo carmine from someone who trained in the 1960s. This gentleman did a lot of missionary work in third world countries where drugs, supplies, etc., were expensive and in short supply. Sux was dirt-cheap, didn't require reversal with another drug which cost money, so they utilized a sux drip frequently. Back in the day when I was in training we still had sux flo-packs, powdered sux which you spiked into a piggyback and reconstituted. I think it was 250 mg in 500 ml crystalloid. Don't know if economics or the pharmacy association caused flo-packs to disappear. (we weren't pharmacists, heaven forbid that we ad-mix our IVs. Only RPhs can do that, so they say.)

 

[proman]

👍

Vial of sux into 100 cc bag on a mini dripper.

Thanks Arch.

I put mine on a pump, starting at 0.01mg/kg/min. Titrate it to PNS. The dose comes out to about 0.5-1mg/min done that way. I think by only exposing the patient to a maximum of 4mg/kg total combined dose (induction + infusion) you aren't in too much danger of a Phase II block, by infusion. What I've found is that I have left over infusion at the end of the case and the patient has seen much less than 4mg/kg.

 

[sevoflurane]

I put mine on a pump, starting at 0.01mg/kg/min. Titrate it to PNS. The dose comes out to about 0.5-1mg/min done that way. I think by only exposing the patient to a maximum of 4mg/kg total combined dose (induction + infusion) you aren't in too much danger of a Phase II block, by infusion. What I've found is that I have left over infusion at the end of the case and the patient has seen much less than 4mg/kg.

Nice. 👍

 

[diceksox]

Was running sux drips in an ENT room one day. Another resident came in to get me out for a break. I had been putting methylene blue in the bags so while I was gone she decided to make up another one and squirted a 10cc syringe of air into the methylene blue to draw it up quicker. It exploded all over her, the anesthesia machine ,anesthesia record, surgeons shoes, floor, and ceiling. When I came back it looked like someone shot the smurfs.

 

[TrustMe]

Not trying to hijack but that made me think of a funny CA-1 moment of mine with methylene blue. I was in the bariatric room for the first time doing a lap. gastric bypass. The surgeons have us pass a 30 Fr. OG tube which they use to form the gastric pouch. One of the guys has us put some dilute methylene blue down the OG to check suture lines. I had never done this so I diluted 10cc of MB in a 60 cc syringe and squirted it in. When I took out the OG I filled this fat lady's mouth and covered her lips with methylene blue. In he PACU it looked like she just ate a pack of Smurfs. Found out later that the RN in the OR usually puts 1-2cc of MB in 100cc of saline for us to squirt in (very dilute). Oops. Sorry fat lady for having everyone stare at your blue face.

 

[sevoflurane]

A MB moment is a right of passage. 😉

It only takes one experience to respect the blue.

 

[dhb]

The sux gtt is probably a nice ol' timers trick but these cases are perfect for remifentanil (and i'm not a big remi fan).
Apart from the price i don't see any upside to the sux gtt.

 

[proman]

The sux gtt is probably a nice ol' timers trick but these cases are perfect for remifentanil (and i'm not a big remi fan).
Apart from the price i don't see any upside to the sux gtt.

For one, you get immobility without the nasty hemodynamic effects of remi.

 

[dhb]

For one, you get immobility without the nasty hemodynamic effects of remi.

I was thinking the opposite: with just sux and a metal blade down your throat you're going to get tachy and hypertensive both of which responses you can control with remi.

 

[Arch Guillotti]

I was thinking the opposite: with just sux and a metal blade down your throat you're going to get tachy and hypertensive both of which responses you can control with remi.

I wouldn't want to rely solely on remi.

When I have done a sux drip in the past it was normally in conjunction with a propofol and remi gtt.

 

[Gern Blansten]

I learned the methylene blue trick 15 years ago in residency when I was told the story of the sux drip in the OB suite that was left in line with the main IV when the patient was transported to the PACU after a c-section. The roller clamps looked the same and the nurse opened up the roller clamp and unwittingly restarted the sux drip in the PACU. No real harm since it was recognized, but caused quite a scare. I never really knew if that story was urban legend or true. Either way, it made a believer out of me.

 

[proman]

I was thinking the opposite: with just sux and a metal blade down your throat you're going to get tachy and hypertensive both of which responses you can control with remi.

An induction agent helps too

 

[Monty Python]

The sux gtt is probably a nice ol' timers trick but these cases are perfect for remifentanil (and i'm not a big remi fan).
Apart from the price i don't see any upside to the sux gtt.

Unless, like me, you work somewhere without remi or precedex. 😡

I'm glad we at least got smart pumps recently. Makes those hour-long colonoscopies soooooo much smoother.