"Hemodynamically Benign" RSI

[Noyac]

---

Members don't see this ad.

Anything wrong with giving a skoosh of norepi? Take too long to draw up?

Nope. No issue but I've never done it.
To continue on witht eh discussion Blade and I had going, here is a recent study:
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2587563

It confirms that vasopressin is acceptable. It does not confirm any superiority and actually was slightly less effective in treating vasoplegic events than norepinephrine. Also, this is a different pt population. But the ideal is still there and the use of vasopressin remains acceptable.

 

[drmwvr]

Anything wrong with giving a skoosh of norepi? Take too long to draw up?

I use it instead of phenylephrine (the pharmacy provided syringes) if I have a bag hanging for a case. But it comes in a 5 ml amp and the trouble of preparing one syringe defeats the purpose, IMO/E...I do cut the concentration by half, give a cc and see what happens.

 

[psychbender]

Anything wrong with giving a skoosh of norepi? Take too long to draw up?

If your pharmacy does not provide premade syringes, then diluting a 4mg vial of norepi into a 250 or 500mL bag and drawing off a syringe takes the same amount of time as diluting a 10mg vial of phenylephrine into a 100mL bag and drawing off a syringe. It's totally fine to give small boluses of norepi in lieu of phenylephrine or ephedrine. I tend to side with Blade, though, and go to vaso as my next line agent if phenylephrine or ephedrine aren't cutting it.

 

[BLADEMDA]

Nope. No issue but I've never done it.
To continue on witht eh discussion Blade and I had going, here is a recent study:
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2587563

It confirms that vasopressin is acceptable. It does not confirm any superiority and actually was slightly less effective in treating vasoplegic events than norepinephrine. Also, this is a different pt population. But the ideal is still there and the use of vasopressin remains acceptable.

I still prefer Vasopressin when SHTF in a tough situation. I also know many of these patients (like the OP's) are catecholamine depleted and tachycardic to begin with.

Here is a brief point from the study you just referenced:

Another interesting property of vasopressin in patients undergoing cardiac surgery is its neutral effects on myocardial oxygen consumption. In our study, vasopressin did not increase the heart rate and was not associated with a higher incidence of myocardial ischemia. Similar observations were reported in the VASST study.23
24 It is likely that norepinephrine, but not vasopressin, can increase adrenergic stimuli through the B1 receptors, resulting in increased atrial ectopic activity and, consequently, in a higher incidence of atrial fibrillation.

 

[Noyac]

I still prefer Vasopressin when SHTF in a tough situation. I also know many of these patients (like the OP's) are catecholamine depleted and tachycardic to begin with.

Here is a brief point from the study you just referenced:

Another interesting property of vasopressin in patients undergoing cardiac surgery is its neutral effects on myocardial oxygen consumption. In our study, vasopressin did not increase the heart rate and was not associated with a higher incidence of myocardial ischemia. Similar observations were reported in the VASST study.23
24 It is likely that norepinephrine, but not vasopressin, can increase adrenergic stimuli through the B1 receptors, resulting in increased atrial ectopic activity and, consequently, in a higher incidence of atrial fibrillation.

"Likely" isn't enough for me to change my practice. I'll stick with my experience.
But to be clear here, I am not saying your approach is wrong or even poor.
Blade, you are a smart guy. I trust what you say. But you are not going to convince me that vasopressin is the better choice in the pt the OP described. And you don't need to make it a mission to prove to me that I'm wrong. It most likely won't happen barring some damn convincing study.
In the end both you and I know how to manage this case with minimal fanfare. That's the goal.

 

[Shimmy8]

Unless I'm reading it wrong, seemed like from that study a significant decrease in "reaching the endpoint" (30 day mortality, significant morbidity) in vaso vs NE, thus making vaso superior.

Am I just not reading the conclusion correctly? 😵

 

[Hamhock]

Unless I'm reading it wrong, seemed like from that study a significant decrease in "reaching the endpoint" (30 day mortality, significant morbidity) in vaso vs NE, thus making vaso superior.

Am I just not reading the conclusion correctly? 😵

1. As mentioned by Noyac above, this is a completely different population than the patient in the original post.

2. As is almost always the case, composite endpoints are misleading here. Table 2 should be very carefully reviewed before drawing conclusions. That said, I think the importance of AKI and Afib in this population should not be minimized and I am a fan of more evidence supporting the use of vasopressin in "hearts" vs. the automatic concern about the SVR.

3. Personally, I think vaso IVP, very careful adrenaline IVP (ie no more than 10 mcgs to start), noradrenaline, or even phenylephrine would work OK in the original case. However, I shy away from recommending any IVP pressors except for phenylephrine to the 'average' physician who is not trained in EM or anesthesiology...or has extensive experience with mixing and pushing alternatives, in which case they probably won't be asking my opinion outside of discussions like this.

HH

 

[Arch Guillotti]

Just give 10 mcgs epi for god's sake. It's always available, easy to mix up and works great.

 

[Noyac]

Just give 10 mcgs epi for god's sake. It's always available, easy to mix up and works great.

and is the best option

 

[BLADEMDA]

When all else fails or you need that extra BP push in a super sick patient reach for the vasopressin. I don't care whether you believe me or not but I've saved quite a few lives with IV vasopressin when typically many would try Epi with minimal results.

Phenyephrine isn't enough in some of these situations and Epi 10 ug may not be sufficient to bump the BP. Seconds can be critical in these types of patients and the hypotension may lead to full blown cardiac arrest.

I'm finished discussing the subject. I've been there so many times it simply isn't worth arguing over.

 

[GravelRider]

I remember reading an article (too tired to look for it) suggesting that vasopressin should be used early in code situations because it improves coronary perfusion pressure better than epinephrine. I would think that any myocardial depression that one sees in a septic patient on induction is a result of poor coronary perfusion rather than any direct myocardial effects from the induction meds. I know that the meds can have direct myocardial effects, but I think they would be less pronounced than the perfusion effects.

In the end, I like having a stick of vasopressin around when I have a disaster from the ICU on the table or a trauma screaming up from the ER. I like epi boluses for certain situations, but vasopressin has bailed me out of many tough spots, so it holds a special place in my heart.

 

[Robotic Wis-Hipple]

It cracks me up that this is still going, meanwhile we say IM guys mentally masturbate in excess....

I think the take home is you can argue vaso vs epi vs norepi all day and have proponents for each, each with small studies saying reasons to use their drug backing them up.

In most clinical situations like the one described in this thread originally I'd think epi is going to be most likely to be around as every code bag/crash cart will have it. And it will work. I still think arguing that vaso is the best using vasoplegia/sepsis rationale as the basis is a bit odd, but again, vaso will work. And of course epi will increase your MvO2 etc, but we aren't talking about using epi to maintain a MAP in a hypovolemic patient long term, this thread was about inducing without crashing. Anyone here would use their drug of choice and then resuscitate with volume as the primary methodology of BP maintenance post induction.

 

[Arch Guillotti]

When all else fails or you need that extra BP push in a super sick patient reach for the epi.

I fixed that for you slim.

 

[BLADEMDA]

It cracks me up that this is still going, meanwhile we say IM guys mentally masturbate in excess....

I think the take home is you can argue vaso vs epi vs norepi all day and have proponents for each, each with small studies saying reasons to use their drug backing them up.

In most clinical situations like the one described in this thread originally I'd think epi is going to be most likely to be around as every code bag/crash cart will have it. And it will work. I still think arguing that vaso is the best using vasoplegia/sepsis rationale as the basis is a bit odd, but again, vaso will work. And of course epi will increase your MvO2 etc, but we aren't talking about using epi to maintain a MAP in a hypovolemic patient long term, this thread was about inducing without crashing. Anyone here would use their drug of choice and then resuscitate with volume as the primary methodology of BP maintenance post induction.

How many near dead patients or codes have you brought back in your career? How many times have you used Epi vs Vasopressin in a near death situation? In what situations did one work better than the other? I'm talking IV push here. One final thought to consider is the risk of pulmonary edema/CHF/Ischemia with each medication via IV push. If your "N" is over 20 in answering these questions then by all means continue with Epi over Vasopressin.

The reason I responded to your post is because I have seen lives saved with the use of vasopressin when EPi failed to work. I want Residents and young attendings to know my anecdotal experiences so they are well informed if/when they need to deal with the situation.

Best of Luck to all for 2017.

 

[Robotic Wis-Hipple]

How many near dead patients or codes have you brought back in your career? How many times have you used Epi vs Vasopressin in a near death situation? In what situations did one work better than the other? I'm talking IV push here. One final thought to consider is the risk of pulmonary edema/CHF/Ischemia with each medication via IV push. If your "N" is over 20 in answering these questions then by all means continue with Epi over Vasopressin.

The reason I responded to your post is because I have seen lives saved with the use of vasopressin when EPi failed to work. I want Residents and young attendings to know my anecdotal experiences so they are well informed if/when they need to deal with the situation.

Best of Luck to all for 2017.

Certainly my "n" is nowhere near yours, but it's def >20. Look, I'm no stranger to using epi or vaso IVP, and I'd agree, if you're resorting to 3-4u pushes of vaso your patient is certainly on the brink, and vaso is more than likely the drug of choice vs 20-100mcg pushes of epi (but in these scenarios it's usually vasoplegia and/or profound acidosis that puts you there).

With that said, I'm just going to have to agree to disagree that in the induction of a GI bleed vaso is the obvious drug of choice in all scenarios and locations. I never said it wouldn't work, in fact I said it would. Hell, I even pontificated that it may actually benefit you from a splanchnic bleeding standpoint.

There is more than one way to skin the proverbial cat.

And likewise; Happy Holidays.

 

[deleted162650]

Why was vasopressin removed from ACLS in the most recent revision? Was it based on any data or just another attemp to simplify the algorithm?

 

[pgg]

Why was vasopressin removed from ACLS in the most recent revision? Was it based on any data or just another attemp to simplify the algorithm?

I assumed it was simplification, though I didn't look closely. ACLS ain't what it used to be; efficacy and evidence went out the window in favor of simplicity for nurses and EMTs quite a while ago.

Although whatever their reason, I don't think we should give a ton of weight to ACLS guidelines .... based on data from out-of-hospital cardiac arrests (many unwitnessed) from ACS-induced dysrhythmmias with delayed care from first responders. At least when it comes to dealing with issues in the OR.

 

[sigrhoillusion]

I assumed it was simplification, though I didn't look closely. ACLS ain't what it used to be; efficacy and evidence went out the window in favor of simplicity for nurses and EMTs quite a while ago.

Although whatever their reason, I don't think we should give a ton of weight to ACLS guidelines .... based on data from out-of-hospital cardiac arrests (many unwitnessed) from ACS-induced dysrhythmmias with delayed care from first responders. At least when it comes to dealing with issues in the OR.

I was waiting for someone to bring up the new ACLS guidelines and the omission of vasopressin. I thought the removal of Vaso was due to lack of benefit, which is what I thought I was initially told. But also may be due to simplicity. Of course this is somewhat seperate from the original case scenario...

And after looking it up, it looks like it was removed solely for simplicity as no evidence that adding it to epinephrine had any benefit. That being said, not sure if they did any studies showing Vaso alone. But I feel like IRBs aren't about to let that study get started...

 

[Ronin2258]

I was waiting for someone to bring up the new ACLS guidelines and the omission of vasopressin. I thought the removal of Vaso was due to lack of benefit, which is what I thought I was initially told. But also may be due to simplicity. Of course this is somewhat seperate from the original case scenario...

And after looking it up, it looks like it was removed solely for simplicity as no evidence that adding it to epinephrine had any benefit. That being said, not sure if they did any studies showing Vaso alone. But I feel like IRBs aren't about to let that study get started...

I was talking about this with my ICU colleagues. The simplicity for outside of hospital use is key for first responders, but the cynical consensus is that it was so the AHA could publish more books.

Like most of us don't buy the new version every two years to make sure we didn't miss anything.

 

[sigrhoillusion]

I was talking about this with my ICU colleagues. The simplicity for outside of hospital use is key for first responders, but the cynical consensus is that it was so the AHA could publish more books.

Like most of us don't buy the new version every two years to make sure we didn't miss anything.

I posted a few months ago while i was credentialing for my new job what a scam the acls recert exam is.