Etomidate should go the route of The Extinct

[periopdoc]

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Thank goodness I don't work at a JCAHO hospital anymore.

It was in the airway bag, checked out just like every other medication in that airway bag, to "anesthesia emergency patient." After the intubation I grabbed a patient sticker and checked out replacement stock under that patient's name for everything that I used. At the end of the shift I returned all unused meds to the anesthesia emergency patient, problem solved.

I never had a nurse turn down the offer. In our situation it wasn't so much a problem of obtaining an order from the ICU intern as it was a problem of getting pharmacy to release the meds in a timely fashion after the order was faxed.

- pod

 

[Idiopathic]

really no reason for etomidate. Its been shown in many studies to increase mortality especially in ICU/sepsis situations. Floor: depending on how sick, hypercarbia is a great sedative. but Fent/versed works as well for sick hearts. prop plus neo for vasculopaths. The only time I would use it for ECT when brevital wasn't available.

RR not that large and nonexistent when adjusted for non-septic patients...newer studies showing no change in mortality with septic patients. its certainly not a slam dunk and if you have the right patient, it can be a very valuable drug.

 

[deleted162650]

Called to trauma bay today for intubation. 30-something dude found down wreaks of Etoh. No major trauma. Negative FAST. Guys somewhat combative and GCS hovering around 8. Vitals = HR 110, BP 140/90, O2 100%. I draw up a stick of Prop and a stick of Sux. Ready to to induce and trauma nurse stops me.

Nurse: "Not allowed to give propofol in here"

Me: "What"

Nurse: "No propofol in trauma bay right Dr. Trauma Surgeon"

Trauma Surgeon: "Right never propofol in trauma bay"

Me: "WFT, fine"

Etomidate, Sux, Tube . . . vitals = HR 120, BP 160/110

Me:

 

[pgg]

called to trauma bay today for intubation. 30-something dude found down wreaks of etoh. No major trauma. Negative fast. Guys somewhat combative and gcs hovering around 8. Vitals = hr 110, bp 140/90, o2 100%. I draw up a stick of prop and a stick of sux. Ready to to induce and trauma nurse stops me.

Nurse: "not allowed to give propofol in here"

me: "what"

nurse: "no propofol in trauma bay right dr. Trauma surgeon"

trauma surgeon: "right never propofol in trauma bay"

me: "WFT, fine" "if you'd like to intubate him yourself that's ok, but i'm going to use propofol."

ftfy 😀

 

[ssmallz]

Called to trauma bay today for intubation. 30-something dude found down wreaks of Etoh. No major trauma. Negative FAST. Guys somewhat combative and GCS hovering around 8. Vitals = HR 110, BP 140/90, O2 100%. I draw up a stick of Prop and a stick of Sux. Ready to to induce and trauma nurse stops me.

Nurse: "Not allowed to give propofol in here"

Me: "What"

Nurse: "No propofol in trauma bay right Dr. Trauma Surgeon"

Trauma Surgeon: "Right never propofol in trauma bay"

Me: "WFT, fine"

Etomidate, Sux, Tube . . . vitals = HR 120, BP 160/110

Me:

This is why I can't wait to be an attending

 

[ejs064]

Been awhile since I even looked on SDN, but this is an intriguing thread. It's funny how - despite very different training practices and times when we all trained - people have the same ideas, pretty much. Etomidate is bad (but we all still use it sometimes), ketamine is good (but none of us use it enough), and measured propofol is the best.

I was on last night and teaching a surgery intern that despite the mere 6mg of etomidate that I was about to give an obtunded, recently-dialysed ESRD patient, that he was going to become hypotensive after induction, no matter how I induced him (or IF I induced him). After intubation, I had the phenylephrine in line when his next SBP was 75. I told the the RT turn off his PEEP and he no longer needed the phenylephrine.

I've learned many-a-time that starting PPV in hypovolemic patients determines their crappy hemodynamics after intubation than what induction drugs I use. I remember 2 patients in a row that I gave <10mg of etomidate to, then I emptied 50mg of ephedrine and 1mg of phenylephrine into them in the next 10 minutes.

 

[ejs064]

Called to trauma bay today for intubation. 30-something dude found down wreaks of Etoh. No major trauma. Negative FAST. Guys somewhat combative and GCS hovering around 8. Vitals = HR 110, BP 140/90, O2 100%. I draw up a stick of Prop and a stick of Sux. Ready to to induce and trauma nurse stops me.

Nurse: "Not allowed to give propofol in here"

Me: "What"

Nurse: "No propofol in trauma bay right Dr. Trauma Surgeon"

Trauma Surgeon: "Right never propofol in trauma bay"

Me: "WFT, fine"

Etomidate, Sux, Tube . . . vitals = HR 120, BP 160/110

Me:

Sounds all too familiar. Someday I'd like to see a TICU/SICU team round with a surgery attending (any surgery attending) where everyone of his vented patients have been put on propofol and BiPAP. Just to see his/her face.

 

[nap$ter]

Sounds all too familiar. Someday I'd like to see a TICU/SICU team round with a surgery attending (any surgery attending) where everyone of his vented patients have been put on propofol and BiPAP. Just to see his/her face.

huh?

 

[stimmed]

...midaz 2mg....

watch the patient....sleepy? No? Thirty seconds later

....midaz 2mg...sleepy? Probably.

If not, give the other milligram, which you have left, since you had/asked for the 5mg/mL midaz....then

40-60 mg succinylcholine.

Midazolam in increments.

Sux every time (almost).

IMHO.

fentanyl too or no?

and how do you redose if you need to reattempt?

 

[ejs064]

huh?

Surgeons seem to patently hate propofol and BiPAP, even when they might be indicated. That's all I meant. I understand what SaltyDog's situation.

 

[nap$ter]

Surgeons seem to patently hate propofol and BiPAP, even when they might be indicated. That's all I meant. I understand what SaltyDog's situation.

gotta say, propofol and bipap seems like a bad idea to me too.

 

[Idiopathic]

gotta say, propofol and bipap seems like a bad idea to me too.

well, when the alternative is intubation, its not the worst thing in the world. plenty of people need BIPAP but wont tolerate it because of anxiety. assuming they are appropriate candidates, I think its fine to give a little sedation in that setting.

 

[ejs064]

gotta say, propofol and bipap seems like a bad idea to me too.

My BB communication is way off -- I clearly haven't done this for awhile. 😕

Surgeons don't seem to like either propfol or BiPAP. I didn't really mean together. I'd like to see surgeons faces rounding in a SICU when every patient is on EITHER propfol or BiPAP.

...but now my comment has lost all its moxie. Yup, moxie. 😉

 

[nap$ter]

well, when the alternative is intubation, its not the worst thing in the world. plenty of people need BIPAP but wont tolerate it because of anxiety. assuming they are appropriate candidates, I think its fine to give a little sedation in that setting.

a little sedation, yes. propofol, no, not with bipap. at least not in our icu - our nurses are only accustomed to using it with intubated patients, and it would be dangerous to give them sedation reins with the propofol pony. a little too much, lose airway reflexes, pukage, blow chunks to and fro, not good.

dexmed and bipap - that's a winner.

all that being said, don't bipap if the pt needs a tube - it's a rickety bridge.

 

[Mman]

Called to trauma bay today for intubation. 30-something dude found down wreaks of Etoh. No major trauma. Negative FAST. Guys somewhat combative and GCS hovering around 8. Vitals = HR 110, BP 140/90, O2 100%. I draw up a stick of Prop and a stick of Sux. Ready to to induce and trauma nurse stops me.

Nurse: "Not allowed to give propofol in here"

Me: "What"

Nurse: "No propofol in trauma bay right Dr. Trauma Surgeon"

Trauma Surgeon: "Right never propofol in trauma bay"

Me: "WFT, fine"

Etomidate, Sux, Tube . . . vitals = HR 120, BP 160/110

Me:

as the attending, I'd tell them that I'm giving the drugs and I'm putting the tube in and if they don't like it they can find someone else.

I realize as the resident you can't exactly step on those toes. Didn't you have an attending with you?

 

[lord_jeebus]

as the attending, I'd tell them that I'm giving the drugs and I'm putting the tube in and if they don't like it they can find someone else.

I realize as the resident you can't exactly step on those toes. Didn't you have an attending with you?

I'm at the same institution as that poster. Our attendings do not routinely come to these intubations, although residents will call them to come according to their own judgement (or if requested by the trauma service). A senior resident will usually accompany a junior.

Regardless, Trauma will not let attending anesthesiologists administer propofol either. In some cases, we have told them to "find someone else" and they have managed the airway on their own. In another case, the attending pushed propofol, told them "it comes in white now," and they believed it. But yet another time, this was attempted and the trauma nurse responded maturely by pulling out the patient's IV.

As you may have guessed, we don't have the greatest relationship with our Trauma service.

On rare occasions, there is one trauma surgeon on call who will allow us to exercise our own clinical judgement and select the appropriate medications for these patients.

 

[pgg]

the trauma nurse responded maturely by pulling out the patient's IV.

😱 Unreal.

I'm at a loss for how I'd respond to that kind of assault on the patient. I hope the patient had other access ...

 

[Idiopathic]

Absolutely ridiculous and should not be tolerated. You should make it your mission to change this behavior.

 

[sevoflurane]

😱 Unreal.

I'm at a loss for how I'd respond to that kind of assault on the patient. I hope the patient had other access ...

This.

 

[Ronin2258]

😱 Unreal.

I'm at a loss for how I'd respond to that kind of assault on the patient. I hope the patient had other access ...

What the hell is the big fear of propofol in a trauma situation!? That we mistake them for an android from the Aliens movies when we push enough to make them bleed white? What has freaked everyone in the ED out to the point a nurse considers this stupidity a viable option when SHTF (and I hope the riot act was read to them, appropriately)?

I have never gotten questioned on the choice from our trauma surgeons.

Sorry if I sound like a smart-aleck, but I am frustrated that a hospital policy would hamstring a standard like this.

 

[jetproppilot]

.

 

[jetproppilot]

.

 

[Idiopathic]

two of your finest posts, jet 😉

 

[sevoflurane]

He just calls it how he sees it. Nothing wrong with that. If someone told me how to run my anesthetic, I'd say the same and/or give them an option to dismiss me from the situation.

 

[Idiopathic]

i was referring to the post-edit posts 😉

 

[lord_jeebus]

It seems Jet also knows when not to step up to the mic

For the record, I wasn't there for the IV-pulling incident, but if I was, heads would roll. I can't do much about the trauma chief's policies, but putting nurses in their place is within my scope, and I have much practice.

I am more than comfortable to leave Trauma to their own devices if my plan and theirs do not coincide. There is a lot of political drama extending beyond the trauma bay between our services, and I have little to contribute to that battle.

 

[jetproppilot]

two of your finest posts, jet 😉

I actually didnt mean to erase both...erased one (inadvertent double post) and somehow erased the second while trying to add some stuff. Makes me sad. That s h it pissed me off! Such RIDICULOUSNESS.

 

[Hamhock]

There is a lot of political drama extending beyond the trauma bay between our services, and I have little to contribute to that battle.

Is there not an EM residency at your hospital (assuming you are still a resident/at a teaching hospital)?

Usually these political battles are between trauma and EM...something I am sadly quite familiar with...but I have never heard of anesthesiology fighting with trauma over something like this.

HH

 

[lord_jeebus]

Is there not an EM residency at your hospital (assuming you are still a resident/at a teaching hospital)?

Usually these political battles are between trauma and EM...something I am sadly quite familiar with...but I have never heard of anesthesiology fighting with trauma over something like this.

HH

There is an EM residency. I'm not sure what political battles they face. However, Trauma has a strong influence here; the trauma bay is not even on the same floor as the emergency department, but instead is connected to the SICU.