ETT's and Emergency drugs ready for every case

[orangele]

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Something I learned in residency and then relearned in private practice is to have ETT's (I prefer pre-styletted) and Sux, and Atropine drawn and ready to use FOR EVERY CASE.

I have noticed that some of the CRNA's that I work with (I do not supervise them) do not do this (ETT's and sux and atropine in room but not styletted or drawn) In my opinion, to not have these basic life-saving tools IMMEDIATELY available can certainly be seen as negligent in the event of a bad outcome.

Do others in practice have a similar opinion.

 

[deleted126335]

Something I learned in residency and then relearned in private practice is to have ETT's (I prefer pre-styletted) and Sux, and Atropine drawn and ready to use FOR EVERY CASE.

I have noticed that some of the CRNA's that I work with (I do not supervise them) do not do this (ETT's and sux and atropine in room but not styletted or drawn) In my opinion, to not have these basic life-saving tools IMMEDIATELY available can certainly be seen as negligent in the event of a bad outcome.

Do others in practice have a similar opinion.

When I am sitting down for a case I also have atropine, sux, styletted tube, and a few cc of hypnotic (usually left over from induction) drawn up.

I have seen many practitioners both MD and CRNA who don't follow this practice. i think that this is unwise but not negligent.

 

[Noyac]

I can't remember the last time I gave atropine. It's been years. I also can't remember the last time I had to emergently intubate someone in the middle of a case. So due to "my" past experiences I don't have these items drawn up for every case with the exception of peds cases.

 

[bullard]

Agree with OP except on atropine -- I don't draw that up routinely outside of peds cases.

 

[GasEmDee]

Agree with OP except on atropine -- I don't draw that up routinely outside of peds cases.

I agree. I always sux drawn up. I have time to draw up everything else.

For very young kids, its sux and atropine.

 

[proman]

Our pharmacy has a robot that makes huge batches of multiple drugs with 1 month expiration dates. Makes it easy to have things out an available without wasting daily drugs.

I keep sux, atropine, phenylephrine/ephedrine and esmolol (vial) available. In the hospitals without the prefilled syringes, I just keep the vials of sux and atropine out but not drawn up plus either ephedrine or phenylephrine drawn up. No need for styletted tubes.

 

[GasEmDee]

They are definitely available. On our L&D, we have syringes of sux, phenylephrine, and ephedrine that are premanufactured (i.e., not pre-made by our pharmacy)

We have emergency syringes of sux and atropine, so it's not a big deal. My question though, is whether they have phenylephrine or not? I supervise, and for a select few, I have to delay induction because there is no phenyl ready. Even if I go slow with propofol or use etomidate, the one drug I like to have available is a pressor.

 

[Noyac]

They are definitely available. On our L&D, we have syringes of sux, phenylephrine, and ephedrine that are premanufactured (i.e., not pre-made by our pharmacy)

OB is different. I'll frequently have a tube and some sux along with the mandatory phenylephrine.

 

[doctor712]

Why (based upon the replies in this thread) atropine more so for Peds cases? Does it affect kids differently? Are kids predisposed to issues that require atropine more often than adults?
I did some reading about it, and it said that certain peds cases are pretreated with atropine, why is this? So, I understand it treats bradycardia, do kids get brady quick? Or is it that kids go south quicker and this drug needs to be at the ready because the seconds it would take do draw up might make a life and death difference?

Here's a case report of an MH-like illness that took place and atropine is mentioned. I'm curious,
if you asked the patient about his med history during pre-op, and he mentioned the muscle issues that took place when he was 5, but they didn't progress, with an inconclusive muscle biopsy for DMD or BMD and got an answer, "Turned out to be nothing, negative for DMD", would you STILL avoid an inhalation induction and sux at all costs in this 18 year old? Curious...

http://journals.lww.com/anesthesiol...t_Hyperthermia_like_Episode_in_Becker.30.aspx

Thanks! And happy memorial day all, I'm pool and BBq'd out for the weekend!

d712

 

[dhb]

It might be useful if you're supervising multiple rooms but when it's 1/1 i cqn't think of a situation that would require med's to be pre-drawn.

 

[Jay K]

Something I learned in residency and then relearned in private practice is to have ETT's (I prefer pre-styletted) and Sux, and Atropine drawn and ready to use FOR EVERY CASE.

Do others in practice have a similar opinion.

No.

It takes a second to open an ETT if I need one (otherwise it creates medical waste). I cannot recall ever having to emergently intubate/re-intubate anyone in the midst of a case. In the past year, only on two occasions I've done a DL and then decided to stylet my ETT, otherwise it's rare that I require a stylet (again generation of more medical waste). However, if I've examined the patient and decided to Glidescope intubate, I will use the re-usable J-stylet which comes with the Glidescope.

Outside of residency, I no longer draw up drugs I don't plan on giving (generates medical waste and expense). "Emergency" drugs take a second to draw because our hospital provides empty syringes preloaded with needles. Like others, the exception is in peds cases particularly at the ENT clinic, I will walk around with a syringe of sux and atropine in my pocket, particular to cover any kids in recovery should the need arises. I draw them only because there are no drug boxes in recovery, where my patient or one that my partners dropped off may potentially have a problem. And like Noyac, I cannot recall the last time I had an indication to give atropine.

This is also just my experience. I don't think there's a right or wrong. It would only be negligence should you anticipate problems and not prepare for them. Some of this is just my personal "war against medical waste" - I don't have a need for these items, can obtain them in seconds, my patient care is not compromised and I like not having produced more medical waste. Since you asked...

 

[bostonblaz]

I do none of the above. It is a huge waste. I highly doubt that one can't get any of the above stated things ready in the time they would need it. Think about how much waste we create on any given day that we have to use, why add extra.

 

[jwk]

I do none of the above. It is a huge waste. I highly doubt that one can't get any of the above stated things ready in the time they would need it. Think about how much waste we create on any given day that we have to use, why add extra.

At least there is a little common sense on this thread here and there.

This is the totally classic academia vs private practice/real world BS.

Our pharmacy pre-fills: sux, lido, neostigmin, and phenylephrine. That's it. I like having the lidocaine, since I use it on most GA's, and the sux is handy just in case. The others I'm fine without having them pre-drawn.

Our tubes are pre-styletted from the manufacturer, which I HATE!!! (and it's more expensive for those of us who DON'T always use/need a stylet)

It just isn't that difficult to quickly lay your hands on what you need. Aren't your carts/machines organized with airway stuff and drugs in the very top drawers? I drum this into my students, many of whom use the full academia setup with 3 ETT's, at least two laryngoscopes with blades, a suction catheter AND a yankauer taped to the absorber arm with one of them connected, tape pre-torn for eyes and ETT (stupid IMHO, but that's another thread), and if they've set up the room before I get there, about 3x as many drugs as I could possibly use on a single case.

This is not at all about being negligent (or not). What it IS about is being more than just a little insecure and lacking confidence in what you do, and wasting a TREMENDOUS amount of supplies and drugs. Do y'all not remember the nationwide shortage of ephedrine a few months back, or the various shortages/backorders of propofol and many other anesthesia drugs just in the past year? How many of you blindly drew them up JUST IN CASE, particularly "emergency drugs", and then tossed them, and then bitched about them being hard to get?

There's another side issue with this, and that's confusing drugs. Anectine/Roc/Vec - same color labels, almost always drawn up in 5cc syringes. Pressors like neo and ephedrine? Same thing. I don't want multiple drugs that have similar labels/sizes all lying together in the drawer. It takes a few seconds to get something extra and draw it up and LOOK at the label.

What's my setup for EVERY case? The appropriate-sized airway device that I'm 99% sure I will use is on top of my anesthesia machine. Everything else (different sizes of LMA's or ETT's, different blades, etc.) is all in the next drawer, immediately available. My propofol, lidocaine, narcotic, and muscle relaxant of choice (if I plan on using one) is sitting on top of my cart. Everything else is in the drawer, immediately available. A yankauer suction hooked up (and turned on). That's it. If I have a special case (neuro, vascular, trauma) then I may have a couple other things, but for most of my cases, that's all I set up, and it's all I need.

 

[lord_jeebus]

All of the hospitals my residency sends me to has code cart syringes (this sort of thing) of atropine, epinephrine, lidocaine, and bicarb in the anesthesia carts. I think they have longer shelf life than drugs drawn up by pharmacy, and they hardly get used so it shouldn't be much of an expense. Is this that unusual?

 

[proteus2025]

Hurrah the most honest practical voice on this topic.

 

[Bertelman]

I quit drawing up sux by the mid-point of my CA-1 year. I've gotten enough slack, though, that I will just put the vial on the cart, with a syringe + needle right next to it. If you can't reach over and draw up the sux in 5 sec or less, you may be in the wrong business.

I make sure I have a stick of phenylephrine, and if I'm doing an LMA or natural airway case, I'll lay out an ETT on the cart, but I damn sure won't open it or throw in the stylet. Funny thing is, the airway drawer in our carts is full of opened, pre-styletted tubes from every prior case, so I usually just grab one of those.

When I walk into a room with everything under the sun laid out on the cart, I think that person has problems with stress or unanticipated situations. I don't place oral airways out for every case. When I need one, which is like twice a month, it's really no hassle to just reach into the drawer and grab it. Shit. If you're reaching for the oral airway, it's because you can't ventilate sufficiently. If your mask airway isn't good enough, why can't you just let go of the mask and the bag and find what you need? Same goes for the stupid tongue depressor and a wad of gauze to grab the tongue. Worthless.

I'll be honest, I can't wait for the day when I don't have to please other people. My setup will be exactly what I need for the case, and nothing more. One handle, one blade, one ETT, two pieces of eye tape, two gloves, suction and 3 or 4 syringes.

 

[BLADEMDA]

No.

It takes a second to open an ETT if I need one (otherwise it creates medical waste). I cannot recall ever having to emergently intubate/re-intubate anyone in the midst of a case. In the past year, only on two occasions I've done a DL and then decided to stylet my ETT, otherwise it's rare that I require a stylet (again generation of more medical waste). However, if I've examined the patient and decided to Glidescope intubate, I will use the re-usable J-stylet which comes with the Glidescope.

Outside of residency, I no longer draw up drugs I don't plan on giving (generates medical waste and expense). "Emergency" drugs take a second to draw because our hospital provides empty syringes preloaded with needles. Like others, the exception is in peds cases particularly at the ENT clinic, I will walk around with a syringe of sux and atropine in my pocket, particular to cover any kids in recovery should the need arises. I draw them only because there are no drug boxes in recovery, where my patient or one that my partners dropped off may potentially have a problem. And like Noyac, I cannot recall the last time I had an indication to give atropine.

This is also just my experience. I don't think there's a right or wrong. It would only be negligence should you anticipate problems and not prepare for them. Some of this is just my personal "war against medical waste" - I don't have a need for these items, can obtain them in seconds, my patient care is not compromised and I like not having produced more medical waste. Since you asked...

I agree. No need for extra waste. I can anticipate what I need and get it in less than 30 seconds.

 

[Laryngophed]

Why (based upon the replies in this thread) atropine more so for Peds cases?

I'm wondering the same thing. Anyone want to teach a soon to be M1 a lesson or direct me to some relavent reading?

 

[DreamLover]

I'm wondering the same thing. Anyone want to teach a soon to be M1 a lesson or direct me to some relavent reading?

As far as having atropine for peds cases...little babies can often get bradycardic on induction etc...often times people pretreat with atropine (less common though these days) or keep it drawn up just in case

 

[hoyden]

I usually have prestyletted tube and the cuff checked, but I do not have 3 sizes of the tubes as we were required in residency. I have a laryngoscope checked and ready and the eye pads - I put them on after induction. Soft bite block, oral airway and tongue blade as well.
Drugs - anesthetic drug, paralytic, fentanyl. No rescue drugs drawn but on top of the cart and with syringes set aside.
If it is a prone neuro case, I will also have BIS monitor and eye protector, flexible tube connector, esophageal temperature probe - everything sitting and ready to go, since it makes the time from intubation to cutting faster.

However, even if I haven't been in a room for an add-on case and they are asking are you ready - I am ready - I can check and draw everything while the nurses are positioning the patient. I do not especially like it that way, though )))

 

[hoyden]

Why (based upon the replies in this thread) atropine more so for Peds cases? Does it affect kids differently? Are kids predisposed to issues that require atropine more often than adults?
I did some reading about it, and it said that certain peds cases are pretreated with atropine, why is this? So, I understand it treats bradycardia, do kids get brady quick? Or is it that kids go south quicker and this drug needs to be at the ready because the seconds it would take do draw up might make a life and death difference?

Here's a case report of an MH-like illness that took place and atropine is mentioned. I'm curious,
if you asked the patient about his med history during pre-op, and he mentioned the muscle issues that took place when he was 5, but they didn't progress, with an inconclusive muscle biopsy for DMD or BMD and got an answer, "Turned out to be nothing, negative for DMD", would you STILL avoid an inhalation induction and sux at all costs in this 18 year old? Curious...

http://journals.lww.com/anesthesiol...t_Hyperthermia_like_Episode_in_Becker.30.aspx

Thanks! And happy memorial day all, I'm pool and BBq'd out for the weekend!

d712

It is sux AND atropine in one syringe - 4 cc of sux and 1 cc of atropine for and IM injection for a 20 kg kid when you do not have an IV yet ( mask induction) and you can not brake the laryngospasm by PPV. Sux alone may cause significant bradycardia in smll kids.

 

[IlDestriero]

I'm wondering the same thing. Anyone want to teach a soon to be M1 a lesson or direct me to some relavent reading?

The little guys tend to develop a bradycardic response to many different things (volatile anesthetics on induction, stimuli, hypoxia, etc) Their BP is also often heart rate dependent. When your older patient drops his/her HR from 85 to 50, his BP is often fine, when little Johnny drops his HR from 125 to 75 you might be in real trouble. Atropine to the rescue.👍

 

[NYRN]

The little guys tend to develop a bradycardic response to many different things (volatile anesthetics on induction, stimuli, hypoxia, etc) Their BP is also often heart rate dependent. When your older patient drops his/her HR from 85 to 50, his BP is often fine, when little Johnny drops his HR from 125 to 75 you might be in real trouble. Atropine to the rescue.👍

Please correct me if I'm wrong, but if my memory serves me right, when kids get ketamine it increases secretions, and the atropine helps to dry them up? Some of our docs use atropine before sedation and some don't, and I could swear that this was one of the reasons given to me in addition to the HR/BP thing.

To the pre-meds/M1, low HR in a child is a BAD sign. At the very least, learn the normal v/s for children of different ages, this is very important!

 

[IlDestriero]

Here's a case report of an MH-like illness that took place and atropine is mentioned. I'm curious,
if you asked the patient about his med history during pre-op, and he mentioned the muscle issues that took place when he was 5, but they didn't progress, with an inconclusive muscle biopsy for DMD or BMD and got an answer, "Turned out to be nothing, negative for DMD", would you STILL avoid an inhalation induction and sux at all costs in this 18 year old? Curious...

http://journals.lww.com/anesthesiol...t_Hyperthermia_like_Episode_in_Becker.30.aspx
d712

Based on that history, I would have given him a non triggering anesthetic, no question. He's clearly got something abnormal going on (documented) and a non triggering TIVA is safe and easy. It takes less than 5 minutes to set up. (if you have prepped the machine). Our techs use some new system that is very fast now. I should probably know exactly what they do, but I don't. If it were an emergency we have an MH machine available at all times. The odds are that a random myopathy is not going to trigger MH or rhabdo and hyperkalemia, however playing the odds to save a few minutes or some $$ when the consequences can be lethal is poor medicine, if not malpractice.
His response to the volatiles was not MH BTW.

Copied from the MH website for y'all. (bolding and typo correction by me😉)

ARE THERE LINKS BETWEEN MH AND OTHER DISORDERS?The following disorders have been shown to predispose a patient to MH:
· Central Core Disease and Multiminicore Disease These patients should not receive MH triggers.
· Duchenne Muscular Dystrophy and Becker's Muscular Dystrophy patients may develop life-threatening hyperkalemia with succinylcholine and/or potent volatile anesthetic agents, although this is not MH per se.
· The vast majority of muscle and neuromuscular disorders do not predispose to MH.
· However, succinylcholine may precipitate muscle breakdown and/or rigidity (especially the myotonias). In general, succinylcholine should be avoided in all patients with clinical muscle or neuromuscular disorders. Mitochondrial myopathies do not predispose to MH.

 

[IlDestriero]

Please correct me if I'm wrong, but if my memory serves me right, when kids get ketamine it increases secretions, and the atropine helps to dry them up? Some of our docs use atropine before sedation and some don't, and I could swear that this was one of the reasons given to me in addition to the HR/BP thing.

To the pre-meds/M1, low HR in a child is a BAD sign. At the very least, learn the normal v/s for children of different ages, this is very important!

I invite you to review the pharmacology of ketamine, atropine, and any other drug that you plan to administer, preferably before you administer it.

 

[NYRN]

I invite you to review the pharmacology of ketamine, atropine, and any other drug that you plan to administer, preferably before you administer it.

I'm not giving any of these drugs. We are allowed to administer them during conscious sedation IF the attending is literally within arms reach. Haven't done that in several years though. I am only talking about when I used to assist with procedures and I have asked the MD who I was working with why some docs gave atropine and some don't. Several attending have told me that was ONE of the reasons.

 

[Licoricestick]

I'm still training, so I am dependent on what the bosses want, to a certain extent. Current emerg drugs I draw up: sux, atropine, metaraminol, ephedrine. The only predrawn synringes we have are the minijets, and everything else is still separate. Probably won't continue to routinely draw up ephedrine when I work on my own, but think I will continue to draw up the other three.

Have used my emergency atropine several times in adults. Laparoscopic procedures with profound bradycardia (including 15-20sec of asystole once) most commonly. Most recently I was very glad to have it drawn up when I did a gas induction in an extremely needle phobic adult, without the consultant present. Had a nurse who could put the IV in which was fantastic, but with the HR in 40s shortly after it went in (and given that the surgery was going to be repair of a retinal detachment), it was quite nice just to be able to tell the nurse to give half a mL from the syringe with the green atropine label on it, without having to let go of the airway.

As for ETTs - I only have one ready to go if I'm planning on intubating. I don't normally stylet, so that's not an issue. The only time I have needed a different sized tube (outside of paeds, and even then the tubes are just available, not opened) was needing a smaller laser tube on an airway tumour.

That said, it sounds like you guys don't have anaesthetic nurses/anaesthetic techs to assist you - is that right? We always have a dedicated assistant available for induction/emergence (College requirement for any anaesthesia) so getting additional airway gear is very easy. They don't, however, normally have anything to do with the drug side of things.

 

[fakin' the funk]

Please correct me if I'm wrong, but if my memory serves me right, when kids get ketamine it increases secretions, and the atropine helps to dry them up? Some of our docs use atropine before sedation and some don't, and I could swear that this was one of the reasons given to me in addition to the HR/BP thing.

To the pre-meds/M1, low HR in a child is a BAD sign. At the very least, learn the normal v/s for children of different ages, this is very important!

???

 

[jwk]

I'm still training, so I am dependent on what the bosses want, to a certain extent. Current emerg drugs I draw up: sux, atropine, metaraminol, ephedrine. The only predrawn synringes we have are the minijets, and everything else is still separate. Probably won't continue to routinely draw up ephedrine when I work on my own, but think I will continue to draw up the other three.

Metaraminol? Wow - hadn't seen or heard that in more than 30 years.

 

[orangele]

I don't think my practice of drawing Sux and atropine and having styletted ETT's ready to go reflects any lack of confidence but my personal experience. Indeed I believe over-confidence is more of a risk as an anesthesiologist than lack of confidence.

Regarding having atropine; I have personally seen bradycardia going to periods of asystole (up to 5 secs) during colonoscopy on multiple occassions. Yes, this still happened despite notifying the surgeon doing the scope of the bradycardia, and him stopping advancing the scope. I was outside of a room on two separate occassions during a scope (CRNA doing case) when the patient had bradycardia progressing to asystole requiring CPR (both patients recovered completely). Perhaps the cases I did where there was a period of aystole, did not require CPR because I had atropine drawn, and I administered it quickly? I can't say for sure, but I was sure glad I had it drawn and ready to use.

Regarding having sux drawn; as anesthesiologists I believe most have had cases where we have considered intubating someone (or reintubating) where that was not the anticipated plan. Having sux drawn is just one step less I have to worry about. I have personally needed drugs emergently, and had the pyxis lock up. I am personally aware of a case at my facility during a stat c-section where the CRNA had the pyxis lock up and he was unable to get sux. I have read about multiple cases with bad patient outcomes, and subsequent lawsuits where it was mentioned that there was a delay in getting sux. Perhaps this was not a determining factor in the bad outcome, but it certainly did not help the defense of the CRNA (both cases I recall involved CRNA's).

Regarding having styletted ETT's; Unless you do a routine inventory of these supplies, you are assuming that those supplies are in your cart. Personally, I do not want to assume this; especially in my small hospital with no dedicated anesthesia tech.

I am not saying I am right and those who do not practice as I do are wrong. I am saying that in the event of a bad outcome involving a patient that requires intubation or asystole, I would rather not have to explain that it was only a short delay in getting these supplies.

 

[IlDestriero]

I don't think my practice of drawing Sux and atropine and having styletted ETT's ready to go reflects any lack of confidence but my personal experience. Indeed I believe over-confidence is more of a risk as an anesthesiologist than lack of confidence.

Regarding having atropine; I have personally seen bradycardia going to periods of asystole (up to 5 secs) during colonoscopy on multiple occassions. Yes, this still happened despite notifying the surgeon doing the scope of the bradycardia, and him stopping advancing the scope. I was outside of a room on two separate occassions during a scope (CRNA doing case) when the patient had bradycardia progressing to asystole requiring CPR (both patients recovered completely). Perhaps the cases I did where there was a period of aystole, did not require CPR because I had atropine drawn, and I administered it quickly? I can't say for sure, but I was sure glad I had it drawn and ready to use.

Regarding having sux drawn; as anesthesiologists I believe most have had cases where we have considered intubating someone (or reintubating) where that was not the anticipated plan. Having sux drawn is just one step less I have to worry about. I have personally needed drugs emergently, and had the pyxis lock up. I am personally aware of a case at my facility during a stat c-section where the CRNA had the pyxis lock up and he was unable to get sux. I have read about multiple cases with bad patient outcomes, and subsequent lawsuits where it was mentioned that there was a delay in getting sux. Perhaps this was not a determining factor in the bad outcome, but it certainly did not help the defense of the CRNA (both cases I recall involved CRNA's).

Regarding having styletted ETT's; Unless you do a routine inventory of these supplies, you are assuming that those supplies are in your cart. Personally, I do not want to assume this; especially in my small hospital with no dedicated anesthesia tech.

I am not saying I am right and those who do not practice as I do are wrong. I am saying that in the event of a bad outcome involving a patient that requires intubation or asystole, I would rather not have to explain that it was only a short delay in getting these supplies.

I agree with what you are saying 100%. However, my opinions are biased as I do 100% peds where things like laryngospasm on induction, symptomatic bradycardai, wrong size tube, etc happen all the time.

 

[Bertelman]

Regarding having sux drawn; as anesthesiologists I believe most have had cases where we have considered intubating someone (or reintubating) where that was not the anticipated plan. Having sux drawn is just one step less I have to worry about. I have personally needed drugs emergently, and had the pyxis lock up. I am personally aware of a case at my facility during a stat c-section where the CRNA had the pyxis lock up and he was unable to get sux. I have read about multiple cases with bad patient outcomes, and subsequent lawsuits where it was mentioned that there was a delay in getting sux. Perhaps this was not a determining factor in the bad outcome, but it certainly did not help the defense of the CRNA (both cases I recall involved CRNA's).

I actually still draw up atropine, because I do see bradycardia often enough for it to be worth my while.

As for the sux, I guess it depends on your practice. We only get narcs from the Pyxis. Nearly every other drug is located in the top drawer of my cart, and can be had in a few seconds.

 

[Intensivist]

Someone said that maybe some asystole didn't required CPR b/c right after begining of flat line they gave atropine. Well, if you only think for a sec there, if there's no electricity, there's no heart mechanics, therefore no blood flow, therefore no way for a atropine to work. Unless, you gave it prior to actual asystole.

People keep mentioning lido as emerg drug? why? Never seen it being prefilled, and on rarely used all together. Bicarbs also.
l would set, if it was up to me, basic CPR drugs, including atropine, most likely phenylephrine, not always. No stylett in ETTs.

 

[Mman]

Our hospital purchases prefilled syringes of almost everything that we routinely (or not so routinely) use other than controlled substances/induction drugs.

Sux
Vec
Phenylephrine
Ephedrine
Epi
Lidocaine
Atropine

I'm probably forgetting a few. The only drugs that need drawing up to start almost any case are the induction drug and some fentanyl. The rest is already ready to go.

 

[Jay K]

People keep mentioning lido as emerg drug? why? Never seen it being prefilled, and on rarely used all together. Bicarbs also. l would set, if it was up to me, basic CPR drugs, including atropine, most likely phenylephrine, not always. No stylett in ETTs.

Currently lidocaine has a place in the ACLS protocol, therefore it is used in emergencies. In code situations, the crash carts often have lidocaine in pre-filled syringes from the manufacturer and bicarb.

Lidocaine drawn as part of the induction anesthetic is used to "ease" the discomfort of propofol in the IV line. The previous posters only mention what they have drawn up at the start of case or have available pre-drawn by their hospitals; They don't specify that it's drawn as an emergency drug.

 

[Laryngophed]

As far as having atropine for peds cases...little babies can often get bradycardic on induction etc...often times people pretreat with atropine (less common though these days) or keep it drawn up just in case

The little guys tend to develop a bradycardic response to many different things (volatile anesthetics on induction, stimuli, hypoxia, etc) Their BP is also often heart rate dependent. When your older patient drops his/her HR from 85 to 50, his BP is often fine, when little Johnny drops his HR from 125 to 75 you might be in real trouble. Atropine to the rescue.👍

Thank you, thank you.

Any particular identified reason or just one of those things that we know happens and have to plan accordingly?

 

[Intensivist]

l am aware of ACLS protocol, which gives priority to amiodaron over lidocain, and yet no one has mention it.
in my short anesthesia experience never saw lido being given to ease propofol bolus, and know many anesthesiologists that never use it, but here l see it's quite common.

 

[lushmd]

Whether or not administration of lidocaine decreases the burning sensation associated with propofol injection is debatable (in my experience, rate of injection is more important in this regard). Having said that, its often given on induction to decrease the sympathetic response to laryngoscopy.

 

[proman]

Whether or not administration of lidocaine decreases the burning sensation associated with propofol injection is debatable (in my experience, rate of injection is more important in this regard).

Agree

Having said that, its often given on induction to decrease the sympathetic response to laryngoscopy.

Esmolol is better.

Effects of esmolol, lidocaine and fentanyl on haemodynamic responses to endotracheal intubation: a comparative study.

BACKGROUND AND OBJECTIVE: Predicting the haemodynamic changes that may result in myocardial ischaemia for patients undergoing laryngoscopy and tracheal intubation will help to avoid events that trigger ischaemia and allow immediate treatment. The objective of this study was to compare the effects of esmolol with those of lidocaine (lignocaine) and fentanyl on prevention of tachycardia and hypertension caused by endotracheal intubation. METHODS: This was a prospective, randomised, double-blind study. The study was conducted at the Adnan Menderes University Hospital in Aydin, Turkey and involved 120 patients of American Society of Anesthesiologists physical status I or II aged 20-50 years. The patients were randomised into four equal groups. The control group (group C) received dextrose 5% 5 mL, the esmolol group (group E) received esmolol 1.5 mg/kg, the fentanyl group (group F) received fentanyl 1 microg/kg and the lidocaine group (group L) received lidocaine 1.5 mg/kg 2 minutes before endotracheal intubation. Heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were recorded before and after induction of anaesthesia, immediately after intubation, and 1, 3, 5, 7 and 10 minutes after intubation. RESULTS: Compared with control, HR decreased significantly in group E after induction, immediately after intubation and 1 minute after intubation (p < 0.0083). In group F there was an increase in MAP immediately after intubation, but the increase was less than in other groups. Compared with control, RPP decreased significantly in groups E and F after induction, immediately after intubation and 1 minute after intubation (p < 0.0083). RPP was significantly lower in group E than in controls and group L 3 minutes after intubation (p < 0.0083), and it was significantly lower in group F than in controls 10 minutes after intubation (p < 0.0083). CONCLUSION: It can be concluded that administration of esmolol 1.5 mg/kg 2 minutes before intubation prevents tachycardia and an increase in RPP caused by laryngoscopy and tracheal intubation, and can be beneficial when administered before laryngoscopy and tracheal intubation in patients with tachycardia.

 

[Bertelman]

Someone said that maybe some asystole didn't required CPR b/c right after begining of flat line they gave atropine. Well, if you only think for a sec there, if there's no electricity, there's no heart mechanics, therefore no blood flow, therefore no way for a atropine to work. Unless, you gave it prior to actual asystole.

People keep mentioning lido as emerg drug? why? Never seen it being prefilled, and on rarely used all together. Bicarbs also.
l would set, if it was up to me, basic CPR drugs, including atropine, most likely phenylephrine, not always. No stylett in ETTs.

It was Licorice that mentioned the stretch of asystole. For the purposes of this thread, and anesthesia in general, separate what we do from the ACLS protocol that seems so familiar to you. Yes, most of us have seen an entire screen with maybe one QRS. That doesn't mean I'm pulling out my ACLS card working through the bradycardia algorithm. It means I'm standing up and asking the surgeon to please stop whatever it is they are doing, because the heart isn't real happy right now. Bingo. I usually get a HR back.

So when licorice talks about a stretch of asystole, it is with the assumption that once the parasympathetic stimulus is withdrawn, the HR will increase (or return for that mater), and the atropine will be circulated.

l am aware of ACLS protocol, which gives priority to amiodaron over lidocain, and yet no one has mention it.
in my short anesthesia experience never saw lido being given to ease propofol bolus, and know many anesthesiologists that never use it, but here l see it's quite common.

Again, when we draw up "emergency" or "resuscitative" drugs, we're not worried about cardiac arrest or CPR. We're more commonly worried about bradycardia from surgical stimulation (or airway manipulation in kiddos), or we're worried about vasodilation from our anesthetics causing profound hypotension.

If you're interested in CPR in the OR, you should peruse the ASA website. They've got a nice summary of ACLS scenarios unique to the OR. It's a different beast.

Here's a summary:
Common Situations Associated with Peri-op Circulatory Crisis are listed below:

Anesthetic
o Intravenous anesthetic overdose
o Inhalation anesthetic overdose
o Neuraxial block with high level sympathectomy
o Local anesthetic systemic toxicity
o Malignant hyperthermia
o Drug administration errors

Respiratory
o Hypoxemia
o Auto PEEP
o Acute Bronchospasm

Cardiovascular
o Vasovagal reflex
o Hypovolemic and/or hemorrhagic shock
o Tension Pneumothorax
o Anaphylactic Reaction
o Transfusion Reaction
o Acute Electrolyte Imbalance (high K)
o Severe Pulmonary Hypertension
o Increased intraabdominal pressure
o Pacemaker failure
o Prolonged Q-T syndrome
o Acute Coronary Syndrome
o Pulmonary Embolism
o Gas embolism
o Oculocardiac reflexes
o Electroconvulsive therapy

 

[Jay K]

Whether or not administration of lidocaine decreases the burning sensation associated with propofol injection is debatable (in my experience, rate of injection is more important in this regard).

Your experience re: rate of injection is indeed correct, however in my experience the lidocaine works, and I am impatient when it comes to injecting my induction dose of propofol. 😉

 

[Licoricestick]

Metaraminol? Wow - hadn't seen or heard that in more than 30 years.

put that one down to regional differences then 🙂
I use phenylephrine mostly for sections. Although I never knew it by the brand name until I started reading this forum - took me weeks to work out that "neo" wasn't neostigmine 😀

Mostly metaraminol is what I'm used to (and lets be honest, that's a major determining part of how anyone chooses to practice), but it is also easier, and thus I think safer, to draw up. Remember, no prefilled syringes. Metaraminol is 1 x 10mg vial into 20mL; whereas phenylephrine comes as a 10mg vial as well, so you have to either draw off 0.1 of a ml and dilute that up or do a serial dilution (from 10mg/ml to 1mg/ml to 100mcg/ml). That's more dilution than is required for any other routine drug I use.

 

[Licoricestick]

It was Licorice that mentioned the stretch of asystole. For the purposes of this thread, and anesthesia in general, separate what we do from the ACLS protocol that seems so familiar to you. Yes, most of us have seen an entire screen with maybe one QRS. That doesn't mean I'm pulling out my ACLS card working through the bradycardia algorithm. It means I'm standing up and asking the surgeon to please stop whatever it is they are doing, because the heart isn't real happy right now. Bingo. I usually get a HR back.

So when licorice talks about a stretch of asystole, it is with the assumption that once the parasympathetic is withdrawn, the HR will increase (or return for that mater), and the atropine will be circulated.

Definitely agree on theatre being a whole different ball game for arrests etc.

As for the asystole with PSNS stimulus, by the time I'd told the surgeon to let the abdomen down, we had a HR of about 25, so I gave the atropine (but boy does that circulation time take an eternity!). Would probably have done a precordial thump if still asystolic after abdomen being let down, but also still given the atropine, knowing that as soon as it could get circulating (however I achieved that), it would work. Atropine mainly given not to treat the initial problem, cause removal of the stimulus and time is usually enough, but to enable to stimulus to be repeated, so the surgeons can get on with the operation.

 

[doctor712]

Thanks for all the answers and explanations guys! And gals!

D712

 

[hoyden]

That said, it sounds like you guys don't have anaesthetic nurses/anaesthetic techs to assist you - is that right? We always have a dedicated assistant available for induction/emergence (College requirement for any anaesthesia) so getting additional airway gear is very easy. They don't, however, normally have anything to do with the drug side of things.

Of course, not. It is the US, not a cushy world outside.

I always had a nurse-anesthetist in a room assisting me in my home country. And yes, there is no problem with them opting out - they are just regular nurses, trained in helping anesthesiologist. they chart, they administer drugs ( whatever you say, they set up the machine, IV and everything else).

 

[hoyden]

l am aware of ACLS protocol, which gives priority to amiodaron over lidocain, and yet no one has mention it.
in my short anesthesia experience never saw lido being given to ease propofol bolus, and know many anesthesiologists that never use it, but here l see it's quite common.

maybe, those are the key words here? It is one thing to observe others doing something and totally different to do it yourself and be responsible for your decisions?

 

[hoyden]

put that one down to regional differences then 🙂
I use phenylephrine mostly for sections. Although I never knew it by the brand name until I started reading this forum - took me weeks to work out that "neo" wasn't neostigmine 😀

Mostly metaraminol is what I'm used to (and lets be honest, that's a major determining part of how anyone chooses to practice), but it is also easier, and thus I think safer, to draw up. Remember, no prefilled syringes. Metaraminol is 1 x 10mg vial into 20mL; whereas phenylephrine comes as a 10mg vial as well, so you have to either draw off 0.1 of a ml and dilute that up or do a serial dilution (from 10mg/ml to 1mg/ml to 100mcg/ml). That's more dilution than is required for any other routine drug I use.

Definitely a lot of regional differences here )))) Why won't you just dilute 1ml/10 mg vial in a 100ml bag of NS to get a concentration of a 100mcg/ml or in a 250ml bag to get a 40 mcg/ml ?

 

[IlDestriero]

Definitely a lot of regional differences here )))) Why won't you just dilute 1ml/10 mg vial in a 100ml bag of NS to get a concentration of a 100mcg/ml or in a 250ml bag to get a 40 mcg/ml ?

The last 2 places I worked didn't stock 100 or 250 cc bags routinely. So I, or my resident/fellow has to double dilute.

 

[proman]

The last 2 places I worked didn't stock 100 or 250 cc bags routinely. So I, or my resident/fellow has to double dilute.

How did you make drips like norepi (16mg in 116cc), epi (2mg in 100cc), remi(2-4 mg in 100cc)? Preference was to have the pharmacy make it, but insulin was the only drip I would never make myself.

 

[IlDestriero]

How did you make drips like norepi (16mg in 116cc), epi (2mg in 100cc), remi(2-4 mg in 100cc)? Preference was to have the pharmacy make it, but insulin was the only drip I would never make myself.

Pharmacy, by policy. Remi is mixed as needed. Usually in 60 cc syringe of NS.