Floor Intubations, any advice?

[Intensivist]

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it does so only when given to rapidly, according to 3 pharmacology textbooks that l have studied...

 

[rsgillmd]

it does so only when given to rapidly, according to 3 pharmacology textbooks that l have studied...

Does what?

 

[rsgillmd]

Intensivist, in my opinion the other attendings on this group are right. Go back to the books and talk to your anesthesiologists.

I find 0.5 mg/kg of Propofol usually allowed me enough relaxation for my unstable patients without usually significantly affecting their hemodynamics, and it worked quickly. I've rarely gone above 1 mg/kg of Propofol on the floor. Thiopental is just too inconvenient to use on the floor for the various reasons mentioned.

I like to induce my preeclamptic patients getting GA with Propofol. I find it blunts the response to laryngoscopy better than Thiopental. The CRNAs here had been using Thiopental, and that is one of the few situations I have converted them on.

The other advantages/disadvantages of the two drugs have already been mentioned.

 

[Intensivist]

even it may not seem like that, l will discuss these opinions with anesthesiologists here and see if thio policy here will change, thanks you all for your input, even the lil inappropriate ones...
pharmacology part - was reffering to CPP change when inducing with thiopental.

 

[Licoricestick]

even it may not seem like that, l will discuss these opinions with anesthesiologists here and see if thio policy here will change, thanks you all for your input, even the lil inappropriate ones...
pharmacology part - was reffering to CPP change when inducing with thiopental.

A little basic physiology goes a long way... you might want to read up on CPP and the Monroe-Kellie doctrine as well as the pharm (and while you're there look at cerebral metabolic requirements for oxygen too).

But as CPP = MAP-(greater of ICP or JVP) ANYTHING that causes a reduction in MAP will reduce CPP.

And giving a vasodilating agent even when wanting to maintain CPP isn't wrong - you just need to anticipate and prevent/deal with the resultant hypotension. It may also be important (eg: post subarachnoid haemorrhage) to prevent hypertension in response to laryngoscopy, so giving agents that cause a transient reduction in BP may be preferred.

As always in anaesthesia there are many ways to do things. One way is almost never the only right way.

 

[Boujee]

According to the books, Thipental tends to be more hemodynamically stable versus propofol bc it does not blunt the baroreceptor reflex like propofol. this can be avoided by slow infusion of propofol. Clinically, however, I am just a CA-1 with virtually no exp with TP...

 

[coprolalia]

Brutane™

-copro

 

[coprolalia]

On a side note...

I can't count the number of times I've been emergently called to the bedside, even in my relatively short career, because someone couldn't get the tube in. By the time I arrive, the patient is essentially in extremis and that airway is all bloodied-up.

They tell me they've tried every which way to get the tube in, and I'll see all kinds of bloody equipment laying around. With rare exception, I usually start from scratch, take a look with a Mac 3, and almost without fail have such a good view that I can see the carina.

In the words of Ronald Reagan, "trust but verify" when it comes to someone other than an anesthesiologist or nurse anesthetist looking at the airway and telling you it's difficult. Chances are, they have made it difficult. Start over from square one and use your best skills and training to get the job done quickly and correctly.

-copro

 

[periopdoc]

In the words of Ronald Reagan, "trust but verify" when it comes to someone other than an anesthesiologist or nurse anesthetist looking at the airway and telling you it's difficult. Chances are, they have made it difficult. Start over from square one and use your best skills and training to get the job done quickly and correctly.

My first question when someone calls to ask me about a patient with a previously documented "difficult intubation" is, who documented it? You quickly learn which of these documenters you can ignore completely and which ones should make your sphincter tone tight.

- pod

 

[Coastie]

l never said that l thought thiopental is better then propofol, and after all, l'm just a med student with limited knowledge and experience. l just thought that thiopental was good choice for head trauma since it reduces ICP but not CPP, unlike propofol, please correct me if l'm mistaken. and l didn't say thiopental is more often used in Europe, just said that it is used, not only in rare occasions but on daily basis

With euro dorks like this, who wants socialized medicine in the U.S.? Anyone?

Another prime EU export, this one!

 

[dhb]

With euro dorks like this, who wants socialized medicine in the U.S.? Anyone?

Another prime EU export, this one!

Insightful 🙄

 

[MarioJar]

As a working anaesthesiologist in one of the Nordic countries I can assure that we do not use thiopenthal on a daily basis, only in cases of soy or nut allergies mainly. Personaly I would prefer propofol anytime due to faster effect, in addition, thiopental doses vary much more than those of propofol. If you are afraid of hypotension, use slower injection technique and add some vasopressors.

 

[Planktonmd]

As a working anaesthesiologist in one of the Nordic countries I can assure that we do not use thiopenthal on a daily basis, only in cases of soy or nut allergies mainly. Personaly I would prefer propofol anytime due to faster effect, in addition, thiopental doses vary much more than those of propofol. If you are afraid of hypotension, use slower injection technique and add some vasopressors.

I have not seen Thiopental in many years... I don't think it exists in US anymore

 

[dhb]

Ha major necro bump for a 9 year old thread with all the big hitters

 

[pgg]

I have not seen Thiopental in many years... I don't think it exists in US anymore

Yeah, the manufacturer got all huffy because we were executing people with it, so they quit making it.

 

[Planktonmd]

Yeah, the manufacturer got all huffy because we were executing people with it, so they quit making it.

So... if we start executing criminals using the firing squad do you think a manufacturer like Remington would stop producing bullets? 🙂

 

[Apollyon]

So... if we start executing criminals using the firing squad do you think a manufacturer like Remington would stop producing bullets? 🙂

Or if we go back to letting the guys "ride the lightning", is Con Ed going to pull the plug?

(Actually, some, although I do not know if all, of the places that use the chair have their own generator on site, so as to not rile up the other prisoners by the lights dimming.)

 

[pgg]

So... if we start executing criminals using the firing squad do you think a manufacturer like Remington would stop producing bullets? 🙂

Thiopental's sole manufacturing site was in Italy, so there were delicate European sensibilities being offended.

I wonder if we started using Beretta rifles for the firing squads if there'd be similar angst.

 

[BuzzPhreed]

I think this is one of those stories that partially gets lost in legend and lore. At least partially.

Hospira (a U.S. based company in Illinois) was initially going to make it in the U.S. but getting the starter chemicals and fact that it was generic meant it was a money loser to make here. So they planned to have it made in their Italian plant. The Italian government wanted a guarantee that it wouldn't be diverted for lethal injection. Hospira said they didn't want that level of responsibility. So Hospira basically chose not to pursue it anymore. California and Arizona got some from a British manufacturer and when people over there found out that it was going to be used for lethal injection they (the Brits) embargoed it too.

http://www.theguardian.com/world/2011/jan/23/lethal-injection-sodium-thiopental-hospira

http://phx.corporate-ir.net/phoenix.zhtml?c=175550&p=irol-newsArticle&ID=1518610&highlight

Mark Warner even pleaded with the FDA to try to secure additional supplies from other European manufacturers. To date it hasn't happened.

http://www.asahq.org/For-Members/Ad...ASA-Letter-to-FDA-on-Thiopental-Shortage.aspx

So while we can bust on the Italians (especially given the Amanda Knox b.s.) for the political problem it's not entirely them. We could very easily manufacture it here in the U.S. if someone was willing to step up and get in the game. It's a political third rail at this point. Imagine if someone started making it again. You can just see the headlines. "Drug manufacturer starts to make lethal injection drug again in the U.S."