Fentanyl before RSI

[Sonny Crocket]

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How many of you guys make this a common practice? I typically do not. Especially with healthy patients.. The place I work at is really into it and when I say not to give fentanyl, they look at me like I'm crazy. I really dont give a %&&%% what they think. I also do not wait for my propofol to work before I give sux like everyone else at my hospital does.

 

[Jay K]

How many of you guys make this a common practice? I typically do not. Especially with healthy patients.. The place I work at is really into it and when I say not to give fentanyl, they look at me like I'm crazy. I really dont give a %&&%% what they think. I also do not wait for my propofol to work before I give sux like everyone else at my hospital does.

+1

 

[chmd]

In residency it was always propofol followed immediately by succ. Now I don't have heart to change the practice of my crnas who all give a little fentanyl. I say this mostly because >90% of my RSIs are the cya sort (only RSI because of minor ortho trauma or a little nausea but npo).

 

[Dejavu]

How many of you guys make this a common practice? I typically do not. Especially with healthy patients.. The place I work at is really into it and when I say not to give fentanyl, they look at me like I'm crazy. I really dont give a %&&%% what they think. I also do not wait for my propofol to work before I give sux like everyone else at my hospital does.

I do give the Fent. It probably blunts some sympathetic response to the intubation.

I have been giving the succs right away to everyone for well over two years now and it hasn't been a problem, at all.

 

[pgg]

I've always felt the most important part of a RSI is the R, so I flush the induction agent in with the relaxant. I won't go so far as to say waiting is wrong, but I think it makes no sense.


I don't always give fentanyl before the RSI, but usually I do. Depends on the reason for the RSI, the patient, and the case.

I sometimes prefer esmolol for sympathetic blunting, but fentanyl is just as good and I don't see anything wrong with it.

The few attendings I had in residency who insisted on pure RSIs with no narcs up front generally argued that if they needed to wake the patient then fentanyl would be a problem, or that the fentanyl could sedate the patient early and increase risk for aspiration before induction/relaxant. I don't agree with either argument, and the "pure" RSIs they made me do were often inelegant hypertensive tachycardic events so now I typically don't do them that way.

 

[dhb]

I have been giving the succs right away to everyone for well over two years now and it hasn't been a problem, at all.

Why would you give sux to everyone??

 

[Sonny Crocket]

Unless there is a clear contraindication, I happen to like sux. Nothing gives better intubating conditions.

 

[jwk]

How many of you guys make this a common practice? I typically do not. Especially with healthy patients.. The place I work at is really into it and when I say not to give fentanyl, they look at me like I'm crazy. I really dont give a %&&%% what they think. I also do not wait for my propofol to work before I give sux like everyone else at my hospital does.

There is no specific contra-indication to giving fentanyl prior to RSI. Why do you think this is a problem? Just because you don't do it doesn't mean that it's bad practice. PGG gives sound rationale.

 

[CodeBlu]

Unless there is a clear contraindication, I happen to like sux. Nothing gives better intubating conditions.

Sux has saved me on more than one occasion. And I don't even have THAT much experience doing anesthesia. But, I rarely see it used for induction. Most often, it's roc.

One of my attendings was trying to teach me the value of using low doses of everything on induction. Patient was elderly female in her mid 80s... 50 of fentanyl followed by some lido, 50 of propofol, and 20 of roc. I go to intubate, full view of cords and then boom laryngospasm. As I was pulling the blade out, she started to freaking wake up. I was micturating all over myself. Attending drops 100 of propofol and he pushed it REAL fast. Grabbed some sux and then intubated her.

Ever since then, I've been much more liberal on induction, but within reason. Unless it's a party animal college student. I've used 400 of propofol on those big boys.

 

[Dejavu]

Why would you give sux to everyone??

Actually, what I meant was that, in the people I use Succs for, I don't wait for proof of ventilation ability; haven't for the last couple of years.

If the pt is a little hard to ventilate most of us give the succs anyway, to help "loosen them up" for mask ventilation. So why, after spending three minutes preoxygenating, would you want to spend precious seconds trying to ventilate and losing time on the desaturating clock. I know people will say that checking first will prevent getting into the "canna ventilate/canna intubate" scenario, but I am just saying that giving the sux right away routinely hasn't seemed to be a problem in well over 2 years. I cannot remember ever saying, "I wish I hadn't done that", regarding the immediate sux. I have said that about a couple of things, but not that.

 

[Planktonmd]

Rapid sequence = Induction agent followed by succinylcholine followed by tube
No waiting, no masturbation and nothing else!
All that crap about rapid sequence with rocuronium or about adding opiates is silly and meaningless.

 

[ssmallz]

Why wouldn't you give fent before an RSI? Are you worried about obtundation and regugitation prior to getting the tube in? My standard protocol is fent, preoxygenate, prop, sux tube, never had a problem b/c of the fent

 

[Planktonmd]

Why wouldn't you give fent before an RSI? Are you worried about obtundation and regugitation prior to getting the tube in? My standard protocol is fent, preoxygenate, prop, sux tube, never had a problem b/c of the fent

By definition... you are doing RSI because you want to intubate quickly and avoid any cause of vomiting before intubation... Opiates are not needed to achieve that goal and they might induce vomiting.
Also if you encounter a difficult intubation and you want the quickest return to spontaneous breathing, opiates are going to delay that return and make you lose precious time.

 

[pgg]

By definition... you are doing RSI because you want to intubate quickly and avoid any cause of vomiting before intubation... Opiates are not needed to achieve that goal and they might induce vomiting.
Also if you encounter a difficult intubation and you want the quickest return to spontaneous breathing, opiates are going to delay that return and make you lose precious time.

I have never once in my life caused a patient to vomit with a judiciously small pre-induction dose of fentanyl. Just because an RSI maybe doesn't NEED any fentanyl doesn't mean it can't be done more smoothly with it. You could push a dose of alfentanil immediately before your induction agent, and it'll probably peak about the time the fasiculations stop.

As for the delay of return to spontaneous ventilation, I don't agree with that as an argument to avoid opiates with or pre induction. Naloxone exists and works really fast. Faster than the induction agent or succ are going to wear off, anyway. If you're really worried about a dodgy airway (why are you RSI'ing then?), remifentanil.

 

[Planktonmd]

I have never once in my life caused a patient to vomit with a judiciously small pre-induction dose of fentanyl. Just because an RSI maybe doesn't NEED any fentanyl doesn't mean it can't be done more smoothly with it. You could push a dose of alfentanil immediately before your induction agent, and it'll probably peak about the time the fasiculations stop.

As for the delay of return to spontaneous ventilation, I don't agree with that as an argument to avoid opiates with or pre induction. Naloxone exists and works really fast. Faster than the induction agent or succ are going to wear off, anyway. If you're really worried about a dodgy airway (why are you RSI'ing then?), remifentanil.

I didn't say you can't do it... I said it's not needed to achieve your goal of quick intubation. I mean if you ask me to define RSI I wouldn't include opiates in that definition.

 

[Sonny Crocket]

I actually have had a patient be completely obtunded and start vomiting after 50 mcqs of fentanyl.

 

[deleted9493]

I'll use fentanyl in the few minutes prior to RSI if I'm particularly not interested in seeing a big sympathetic response. That usually comes in the context of having a more fragile patient with whom I am giving more thought to a balanced induction, as opposed to a wallop of induction agent and paralytic.

 

[Arch Guillotti]

How many of you guys make this a common practice? I typically do not. Especially with healthy patients.. The place I work at is really into it and when I say not to give fentanyl, they look at me like I'm crazy. I really dont give a %&&%% what they think. I also do not wait for my propofol to work before I give sux like everyone else at my hospital does.

I don't think this is a battle worth fighting.

If I am doing a "true" RSI, I push the sux directly after the induction agent (not ketamine though). I don't wait for them to fall asleep from the propofol, check the lash or whatever. Wham, bam.

 

[fakin' the funk]

There is a drug called alfentanil, you should try it

 

[pgg]

There is a drug called alfentanil, you should try it

Alfentanil is great, but most places I work don't stock it.

 

[Arch Guillotti]

Alfentanil is great, but most places I work don't stock it.

Agree. We don't have it where I work. Great drug for intubating without muscle relaxant although it can cause some significant hypotension if not used properly.