How would you incubate this patient?

[europeman]

---

Members don't see this ad.

How would you go about Intubating the following patient if you were called to SICU.

56 yo hx of htn and esrd (thats all you know) 60kg not previously a difficult intubation done with a mac 3 but they did note he was anterior per anesthesia record from two days before; pod 2 from strangulated bowel now in unit acting septic (likely needs to go back to OR... Surgery hasn't decided yet)... Afebrile now, volume repleted clinically (lets just assume you believe he is clinically tanked up fluid wise) but now up to 10mcg/min levophed with bps hovering 80-100 / 40-50 with HR in 130s in and out of afib. Previous Icu person started on digoxin 12 hours before. Pulse ox 100% on 4L cannula

ECG half hour before you arrive and icu decides to call you to tube him shows new t wave changes and a troponin comes back at 40! Cards just saw him and bedside echo showed No wall motion abnormalities and EF is around 40% (again this in while on 10 of levo).

He is arousable, but not totally obtunded.

Also the hospital ran out of etomidate.

What drugs/doses would you use and what would you have immediately available?




European

 

[G-Man82]

I love airway scenarios, seeing as now that I'm a CA-2, my program will let me go to these alone.

Lots of restrictions, but not unlike stuff I've seen at my hospital already. First things first, are we intubating this patient because of septic shock and the need for a controlled protected airway? I assume we already have a central line in place since he has levo running. So, make sure suction is set up, an ambu hooked up to O2, the bed out, and a free-flowing IV is hooked up. He's satting 100% on nasal cannula, so I think we have time. Get him set up and positioned appropriately in his bed, which may help with the possible anterior view. I'd have a glidescope and bougie handy just in case, but would probably try to DL with a miller 2 first. I'd ask my assistant to push about 50 mg of propofol since we don't have etomidate. Seeing as he's already somewhat sleepy a "stun" dose of propofol in my experience usually works pretty well without the need for more induction agents. No need for paralytic unless he proves to be difficult; here, at a major trauma center in the ghetto, we never paralyze for floor/icu intubations anyway unless we run into problems. After the propofol is pushed and flushed in, go in with a miller blade, and pass the tube. Secure it, and watch the patient for a little, with some supplemental pressors handy. If needed, go up on the levo for a few mins if you encounter hypotension from propofol.

 

[Frank Rizzo]

I would incubate this pt with a larger version of this:

 

[europeman]

I love airway scenarios, seeing as now that I'm a CA-2, my program will let me go to these alone.

Lots of restrictions, but not unlike stuff I've seen at my hospital already. First things first, are we intubating this patient because of septic shock and the need for a controlled protected airway? I assume we already have a central line in place since he has levo running. So, make sure suction is set up, an ambu hooked up to O2, the bed out, and a free-flowing IV is hooked up. He's satting 100% on nasal cannula, so I think we have time. Get him set up and positioned appropriately in his bed, which may help with the possible anterior view. I'd have a glidescope and bougie handy just in case, but would probably try to DL with a miller 2 first. I'd ask my assistant to push about 50 mg of propofol since we don't have etomidate. Seeing as he's already somewhat sleepy a "stun" dose of propofol in my experience usually works pretty well without the need for more induction agents. No need for paralytic unless he proves to be difficult; here, at a major trauma center in the ghetto, we never paralyze for floor/icu intubations anyway unless we run into problems. After the propofol is pushed and flushed in, go in with a miller blade, and pass the tube. Secure it, and watch the patient for a little, with some supplemental pressors handy. If needed, go up on the levo for a few mins if you encounter hypotension from propofol.

Thanks for your enthusiasm!

Your response is ironic though.... In this scenario which really happened last week....the Icu opted to incubate him without asking for an anesthesia consult. In my opinion they were well over their heads.... As would you have been as a bright eyed ca-2 by yourself.

It's ironic because the Icu did EXACTLY what you said you would do. 50mg propofol and waited a little then intubated. got it on the second attempt. Shortly there after his bp tanked to 60s systolic (yes he had central and arterial line).... Levo drip increased to 30mcg/min but his pressure didn't bump and then he went into vtach arrest and died.

The impetus of my question is sorta geared to those more experienced anesthiologists who probably would have gone about this another way?


European

 

[OB1🤙]

Depending on how gorked and frail he looked, 2-4 of midaz, lots of roc, and tube.

Would still anticipate hypotension and be ready with the requisite sticks of uppers.

You don't need propofol here, you just want amnesia.

 

[pgg]

It's ironic because the Icu did EXACTLY what you said you would do. 50mg propofol and waited a little then intubated. got it on the second attempt. Shortly there after his bp tanked to 60s systolic (yes he had central and arterial line).... Levo drip increased to 30mcg/min but his pressure didn't bump and then he went into vtach arrest and died.

Predictable. I bet even a gentle induction dose of etomidate would've done the same. 20 or 30 of propofol might've been OK if they'd chased it with some extra levo or phenylephrine, but once you knock these guys down you're behind the curve.

Second, their response to the hypotension was wrong (increasing the levo drip). Futzing with drips in response to a sudden crash in BP is the ICU nurse / pulmonologist-CC method but it's too little too late here. That patient needed a pressor bolus with or immediately after the propofol.

I've never once in my life seen a non-anesthesiologist intensivist push any pressor. Probably better if they didn't use propofol at all for these intubations, since they seem to be universally missing that tool.


+1 on the midaz/roc combo Hawaiin Bruin mentioned, most of these deaths-door ICU patients don't need induction agents.

 

[rsgillmd]

Depending on how gorked and frail he looked, 2-4 of midaz, lots of roc, and tube.

Would still anticipate hypotension and be ready with the requisite sticks of uppers.

You don't need propofol here, you just want amnesia.

I'm with Hawaiian. Midaz. Roc if needed. I've found most of the "anterior" airways are usually due to poor positioning, but I would still be cautious. This guy is probably more volume positive than he was a few days ago. Can't really assess edema over the internet.

Midaz will provide amnesia + additional sedation so he is not fighting you. I would probably go with DL after positioning properly, but have backup in the room.

Of course vasopressors on hand as already stated.

 

[ASA6]

This patient is post op day number 2. Assuming he was in normal sinus rhythm before surgery, this is a new onset arrhythmia in a patient with ECG changes and a troponin of 40. This is clearly indicative of a post operative MI, possibly a right sided MI manifesting as a new onset arrythmia. I would also expect on levophed his heart to to hyperdynamic, especially with sepsis on the differential. He probably as no wall motion abnormalities but is globally depressed given his EF of 40%. Since normal sinus rhythm is the most electrically efficent rhythm, what are peoples thoughts on sedating with midazolam, and then cardioverting/giving rate controlling agents? Or possibly going to cath lab/placing an aortic balloon pump?

 

[BobBarker]

My standard incubation set up is a cardboard box and a 100 watt bulb. Works great for my prize winning hens.

 

[pgg]

My standard incubation set up is a cardboard box and a 100 watt bulb. Works great for my prize winning hens.

Do you have this bumper sticker?

My brother's girlfriend does ... don't know what kind of incubator wattage she prefers though.

 

[Oggg]

Attempt awake DL if he's out of it. PPF 20, maybe sux if he fights. PPF 10 maybe. I like the chaser of pressor idea.

 

[tennisballs]

Sounds like the ICU was not prepared to keep this patient hemodynamically stable on induction. How long did it take to secure the airway? Did the patient ever de-sat?

Here's what I would do: stick pacer pads on, optimal sniffing position, 3 minutes of pre-O2, 100 mcg phenylephrine, 50 mg propofol (or less), 50 mg roc, quickly secure airway; then phenylephrine boluses PRN until the propofol wears off (heart rate in the 130s, so less concern for bradycardic response)

Also, an appropriately staffed anesthesia team should have been present to intubate this patient. This scenario would not be appropriate for any anesthesia resident to do alone.

Alternatively, the versed for amnesia sounds like a great option. If there is concern for recall, you could strap on a BIS monitor on and wait until his BIS drops < 60.

 

[europeman]

Phenylephrine really appropriate to chase your tail when he is already on 10mcg/min Levo barely maping 60?

How about levo or even Epi pushes?


European

 

[OB1🤙]

A few points:

Phenylephrine probably isn't gonna cut it for this player on 10 of norepi. I'd make a 10mcg/ml syringe of norepi for bolus purposes and be liberal with it. I'd also probably make a stick of vaso. And prior to "induction," I'd do a little dose-finding experiment with these to see if they worked or not. An ABG wasn't presented but if there is a significant acidosis afoot, the vaso may work better than the levo.

Point 2 is that if you're gonna give roc in this scenario, frigging give it. This isn't a lap appy, this dude is gonna be breathing through pvc for a good long time. At minimum give your 4ED95 dose (1.2/kg), I'd probably give even more because why not. 100mg, here ya go. The more you give, the faster it'll work, which is the point here.

 

[periopdoc]

Midaz 2 at a time until I believe that more likely than not he will not remember the intubation. Doubt it will take more than 2-4 mg. Big dose of Roc. Intubate and be ready to resuscitate with epi boluses. He may not crump on induction, but he certainly will within a few minutes of taking over breathing for him. With the amount of norepi that he is requiring, you aren't going to get by with the usual peri-induction drugs (neo/ephedrine). If you are in a place that a balloon pump is an option, you might want to be ready to go at the time of induction.

- pod

 

[Idiopathic]

this patient probably was hurt more from PPV than from the actual intubation, unless he developed hypercarbia/hypoxia and acute right heart failure which could have taken a short while to manifest as death.

 

[periopdoc]

Absolutely agree which is why I said he will crump in the few minutes after taking over breathing for him.

- pod

 

[somedumbDO]

I love airway scenarios, seeing as now that I'm a CA-2, my program will let me go to these alone.

Lots of restrictions, but not unlike stuff I've seen at my hospital already. First things first, are we intubating this patient because of septic shock and the need for a controlled protected airway? I assume we already have a central line in place since he has levo running. So, make sure suction is set up, an ambu hooked up to O2, the bed out, and a free-flowing IV is hooked up. He's satting 100% on nasal cannula, so I think we have time. Get him set up and positioned appropriately in his bed, which may help with the possible anterior view. I'd have a glidescope and bougie handy just in case, but would probably try to DL with a miller 2 first. I'd ask my assistant to push about 50 mg of propofol since we don't have etomidate. Seeing as he's already somewhat sleepy a "stun" dose of propofol in my experience usually works pretty well without the need for more induction agents. No need for paralytic unless he proves to be difficult; here, at a major trauma center in the ghetto, we never paralyze for floor/icu intubations anyway unless we run into problems. After the propofol is pushed and flushed in, go in with a miller blade, and pass the tube. Secure it, and watch the patient for a little, with some supplemental pressors handy. If needed, go up on the levo for a few mins if you encounter hypotension from propofol.

you just killed the patient...

 

[Pooh & Annie]

you just killed the patient...

If he's reading the thread he already knows it. Replies like this just make people not want to post.

 

[tennisballs]

A few points:

Phenylephrine probably isn't gonna cut it for this player on 10 of norepi. I'd make a 10mcg/ml syringe of norepi for bolus purposes and be liberal with it. I'd also probably make a stick of vaso. And prior to "induction," I'd do a little dose-finding experiment with these to see if they worked or not. An ABG wasn't presented but if there is a significant acidosis afoot, the vaso may work better than the levo.

Point 2 is that if you're gonna give roc in this scenario, frigging give it. This isn't a lap appy, this dude is gonna be breathing through pvc for a good long time. At minimum give your 4ED95 dose (1.2/kg), I'd probably give even more because why not. 100mg, here ya go. The more you give, the faster it'll work, which is the point here.

Good points. Any concern that bolusing with norepi will increase myocardial demand in a patient with a heart rate of 130 and troponin level at 40?

 

[RxBoy]

56 yo hx of htn and esrd (thats all you know) 60kg not previously a difficult intubation done with a mac 3 but they did note he was anterior per anesthesia record from two days before; pod 2 from strangulated bowel now in unit acting septic (likely needs to go back to OR... Surgery hasn't decided yet)... Afebrile now, volume repleted clinically (lets just assume you believe he is clinically tanked up fluid wise) but now up to 10mcg/min levophed with bps hovering 80-100 / 40-50 with HR in 130s in and out of afib. Previous Icu person started on digoxin 12 hours before. Pulse ox 100% on 4L cannula

What drugs/doses would you use and what would you have immediately available?

Was he RSI'ed? I guess it wouldn't matter if it took the ICU team 2 attempts. Not sure the progression of vital sign events but nasty aspiration leading to hypoxia/hypercarbia is another possibility for hd collapse.

Any case
4 versed, 100 sux, glidescope because I'm not talking chances. Intubating LMA, bougie, and DL on standby. 10 mcg epi sticks in pocket.


As for propofol...
As a
CA1 - Nectar
CA2 - Satisfactory
CA3 - Poison

I honestly don't remember the last time I pushed 200 of the good stuff. Then again I can't remember the last time I did a standard surgery on a 30 yo ASA 1.

 

[BobBarker]

Do you have this bumper sticker?

My brother's girlfriend does ... don't know what kind of incubator wattage she prefers though.

Yes, on my scooter.

 

[cincincyreds]

How would you go about Intubating the following patient if you were called to SICU.

56 yo hx of htn and esrd (thats all you know) 60kg not previously a difficult intubation done with a mac 3 but they did note he was anterior per anesthesia record from two days before; pod 2 from strangulated bowel now in unit acting septic (likely needs to go back to OR... Surgery hasn't decided yet)... Afebrile now, volume repleted clinically (lets just assume you believe he is clinically tanked up fluid wise) but now up to 10mcg/min levophed with bps hovering 80-100 / 40-50 with HR in 130s in and out of afib. Previous Icu person started on digoxin 12 hours before. Pulse ox 100% on 4L cannula

ECG half hour before you arrive and icu decides to call you to tube him shows new t wave changes and a troponin comes back at 40! Cards just saw him and bedside echo showed No wall motion abnormalities and EF is around 40% (again this in while on 10 of levo).

He is arousable, but not totally obtunded.

Also the hospital ran out of etomidate.

What drugs/doses would you use and what would you have immediately available?




European

1. Preoxygenate with 100% O2
2. Priest at HOB which should be elevated[kind of like an exorcism]
3. R2 pads + whatever pressors are needed for BP maintenace
4. IV scop if conscious, otherwise nothing; even etomidate will tank the pressure[I don't think the 5 cc's of propofol is a very good idea, only 3cc's did MJ in]
5. DL with Mac 3 versus glidescope...
6. put tube thru cords
7. hope for the best
7. get ready with stick of levo or epi when bp crashes from PPV

In this situation, there really is no anesthesia like no anesthesia

 

[periopdoc]

Good points. Any concern that bolusing with norepi will increase myocardial demand in a patient with a heart rate of 130 and troponin level at 40?

Nope.

One way or another you are going to have some temporary increase in ischemia. If you don't use pressors, supply is going to go down when the pressure tanks (probably terminally). If you use them, demand is going to go up. Try to use just enough to keep the patient alive through induction/ initiation of PPV.

- pod

 

[OB1🤙]

In this scenario (low DBP and tachycardia which means less time for coronary perfusion in diastole), increasing the CPP (and if you get lucky, decreasing the HR) with levophed will buy you more supply than it'll cost you in demand.

 

[doctor712]

Why does PPV tank BP?

D712

 

[sevoflurane]

Why does PPV tank BP?

D712

Decrease preload via loss of negative intrathoracic pressure. Especially important with aggresive bagging/big TV's/autopeep situations. If you get a chance... look at the CVP variation during PPV.

 

[Idiopathic]

In this scenario (low DBP and tachycardia which means less time for coronary perfusion in diastole), increasing the CPP (and if you get lucky, decreasing the HR) with levophed will buy you more supply than it'll cost you in demand.

better balance of coronary supply and demand with norepi than with neo, for sure. no problem bolusing 4-20 mcg of norepi at a time, titrating drips during induction of this patient is worthless.

im still not convinced that this patient wouldnt have had this outcome regardless of the sedative given. i think its highly likely that a prolonged intubation contributed to the demise. however sturdier management of peri-induction hemodynamics could possibly have stabilized him (i.e. i think its okay to use a small dose of propofol or whatever sedative, if you know what your are doing.)

 

[Idiopathic]

I love airway scenarios, seeing as now that I'm a CA-2, my program will let me go to these alone.

Lots of restrictions, but not unlike stuff I've seen at my hospital already. First things first, are we intubating this patient because of septic shock and the need for a controlled protected airway? I assume we already have a central line in place since he has levo running. So, make sure suction is set up, an ambu hooked up to O2, the bed out, and a free-flowing IV is hooked up. He's satting 100% on nasal cannula, so I think we have time. Get him set up and positioned appropriately in his bed, which may help with the possible anterior view. I'd have a glidescope and bougie handy just in case, but would probably try to DL with a miller 2 first. I'd ask my assistant to push about 50 mg of propofol since we don't have etomidate. Seeing as he's already somewhat sleepy a "stun" dose of propofol in my experience usually works pretty well without the need for more induction agents. No need for paralytic unless he proves to be difficult; here, at a major trauma center in the ghetto, we never paralyze for floor/icu intubations anyway unless we run into problems. After the propofol is pushed and flushed in, go in with a miller blade, and pass the tube. Secure it, and watch the patient for a little, with some supplemental pressors handy. If needed, go up on the levo for a few mins if you encounter hypotension from propofol.

i would get away from this mentality. i used to suffer from the condition of being afraid to give paralytics on the floor, but the providers around here coupled with my own experiences helped convert me.

1. there is no chance like the first chance. give yourself the best option for success. i can guarantee you that in a known moderately difficult airway, you will increase your chances for first time success with muscle relaxation.

2. once you induce these patients, either you will kill them or save them, there will be no "waking up" and likely by the time they have return of spontaneous respiration, their hemodynamics will be compromised to the point of no return. also, if you find them to be difficult, they will very likely be past the point of no return.

3. there is no compelling reason NOT to paralyze for floor intubations, unless you are committing to an awake procedure/awake look or they are already being coded.

4. paralytic allows you to use less sedation, and you can avoid coughing, bucking, or anything else that the stimulated person in extremis is likely to do.

 

[Stillwater45]

70mg Roc, 1-2mg Versed, Tube.

 

[pgg]

A few points:

Phenylephrine probably isn't gonna cut it for this player on 10 of norepi. I'd make a 10mcg/ml syringe of norepi for bolus purposes and be liberal with it. I'd also probably make a stick of vaso. And prior to "induction," I'd do a little dose-finding experiment with these to see if they worked or not. An ABG wasn't presented but if there is a significant acidosis afoot, the vaso may work better than the levo.

Point 2 is that if you're gonna give roc in this scenario, frigging give it. This isn't a lap appy, this dude is gonna be breathing through pvc for a good long time. At minimum give your 4ED95 dose (1.2/kg), I'd probably give even more because why not. 100mg, here ya go. The more you give, the faster it'll work, which is the point here.

Good points; I think I was the first one to mention phenylephrine in this thread, my bad. 🙂 I like the dose-finding experiment idea.

 

[DrBeaker]

No one has mentioned this yet. What about some ketamine for induction? I know the book says it is a big myocardial depressant even though it increases sympathetic tone.

 

[OB1🤙]

Agree 100% on all points.

i would get away from this mentality. i used to suffer from the condition of being afraid to give paralytics on the floor, but the providers around here coupled with my own experiences helped convert me.

1. there is no chance like the first chance. give yourself the best option for success. i can guarantee you that in a known moderately difficult airway, you will increase your chances for first time success with muscle relaxation.

2. once you induce these patients, either you will kill them or save them, there will be no "waking up" and likely by the time they have return of spontaneous respiration, their hemodynamics will be compromised to the point of no return. also, if you find them to be difficult, they will very likely be past the point of no return.

3. there is no compelling reason NOT to paralyze for floor intubations, unless you are committing to an awake procedure/awake look or they are already being coded.

4. paralytic allows you to use less sedation, and you can avoid coughing, bucking, or anything else that the stimulated person in extremis is likely to do.

 

[G-Man82]

Thanks for all the pointers, folks.

Where I did med school and internship, the anesthesiologists always paralyzed on the floors, usually with succinylcholine. It just seems to be the mentality of the institution that I'm at for residency to avoid NMBs. While as a CA-1, on call we'd go with a senior resident or CRNA to airways and basically intubate under their supervision. Now, after I get back from my 8 weeks of peds, I'll be thrown to airways at any time, most of the time alone, with an attending who only shows up or knows about the airway if I call him when I'm in trouble.

The OPs scenario is one that's highly likely here at my hospital, so it was a cool opportunity for me to "practice," so to speak before the real thing. I've always thought about midazolam or ketamine in these situations, but usually the senior or CRNA went with etomidate or "stun dose" propofol, and I can recall only one instance so far in which we used a paralytic here.

I might try midazolam (esp in volume repleted patients) or maybe even ketamine in the hypotensive patient that we're consulted for in the future. The major problem that I can think of with ketamine in the critically ill is if they're catecholamine-depleted, because then I think the resulting effects of ketamine may be the opposite of what's intended.

 

[NotAMD]

500 fent, 50 roc, 200 neo, 4 midaz, 10 prop

 

[BobBarker]

Good luck obtaining ketamine anywhere out on the floor, ICU.

 

[imfrankie]

How would you go about Intubating the following patient if you were called to SICU.

56 yo hx of htn and esrd (thats all you know) 60kg not previously a difficult intubation done with a mac 3 but they did note he was anterior per anesthesia record from two days before; pod 2 from strangulated bowel now in unit acting septic (likely needs to go back to OR... Surgery hasn't decided yet)... Afebrile now, volume repleted clinically (lets just assume you believe he is clinically tanked up fluid wise) but now up to 10mcg/min levophed with bps hovering 80-100 / 40-50 with HR in 130s in and out of afib. Previous Icu person started on digoxin 12 hours before. Pulse ox 100% on 4L cannula

ECG half hour before you arrive and icu decides to call you to tube him shows new t wave changes and a troponin comes back at 40! Cards just saw him and bedside echo showed No wall motion abnormalities and EF is around 40% (again this in while on 10 of levo).

He is arousable, but not totally obtunded.

Also the hospital ran out of etomidate.

What drugs/doses would you use and what would you have immediately available?




European

I'm talking to the family first.

 

[RxBoy]

500 fent, 50 roc, 200 neo, 4 midaz, 10 prop

500 mcg Fentanyl??? Are you preparing him for a sternal saw?

 

[pgg]

500 fent, 50 roc, 200 neo, 4 midaz, 10 prop

That's more complicated than it needs to be, and 500 of fentanyl isn't as benign as you might think.

 

[Arch Guillotti]

500 fent, 50 roc, 200 neo, 4 midaz, 10 prop

WHOA! Who carries around all that midaz and fentanyl anyway?

 

[G-Man82]

We actually have ketamine and versed available in the ICU pyxis. Unfortunately, Anesthesiology personnel don't have access to it; I'd have to ask the RN to pull it and write the order for it post-intubation.

500 mcg of fentanyl .... wow.

 

[jwk]

In this situation, there really is no anesthesia like no anesthesia

👍

KISS - keep it simple, stupid!

 

[fakin' the funk]

How would you go about Intubating the following patient if you were called to SICU.

56 yo hx of htn and esrd (thats all you know) 60kg not previously a difficult intubation done with a mac 3 but they did note he was anterior per anesthesia record from two days before; pod 2 from strangulated bowel now in unit acting septic (likely needs to go back to OR... Surgery hasn't decided yet)... Afebrile now, volume repleted clinically (lets just assume you believe he is clinically tanked up fluid wise) but now up to 10mcg/min levophed with bps hovering 80-100 / 40-50 with HR in 130s in and out of afib. Previous Icu person started on digoxin 12 hours before. Pulse ox 100% on 4L cannula

ECG half hour before you arrive and icu decides to call you to tube him shows new t wave changes and a troponin comes back at 40! Cards just saw him and bedside echo showed No wall motion abnormalities and EF is around 40% (again this in while on 10 of levo).

He is arousable, but not totally obtunded.

Also the hospital ran out of etomidate.

What drugs/doses would you use and what would you have immediately available?

European

What's the indication for "incubation" here?

 

[Idiopathic]

What's the indication for "incubation" here?

very good question.

 

[DrN2O]

What's the indication for "incubation" here?

Absolutely. 100% on 4L. He gains nothing by positive pressure. Look at a-line variation. CVP. Get an ABG, and a central venous gas. Float a PAC. Why assume anything about the fluid status in an ESRD guy post-laparotomy with sepsis? You may argue he will still need intubation when he shows up in the OR. But I would argue that rushing to surgery with an under-resuscitated septic patient is the wrong move. Done it, and regretted it.

Besides fluid, cardioversion in an unstable AFIB patient? LV is depressed, what about RV? Electrolytes, especially with K+ and digoxin (reduced dose in ESRD)? EKG would be useful. CBC? Good post, but need more information. As other have pointed out, intubation is the easy part. Harder to induce. Even harder to say NO.

 

[europeman]

Indication for intubation was precarious trachejectory. Septic patient now up to 10 levo with increased work of breathing, and increasing respiratory rate. As far as volume status.... This was assessed by the Icu using bedside ultrasound which revealed no ivc variation and no obvious effacement of ventricles. Straight leg raises didn't increase his pressure. This unit doesn't believe in cvp. Anyway for the purpose of this discussion I appreciate the focus on the assumption that he was volume replete cuz it keeps this discussion on point. Obviously assessing volume status is, in real life, not easy.... And in real life if u r called to the patient u will make your own determination and possibly give more fluids.

So it seems the consensus is most people here would use minimal Induction agent and lots of paralyzing agent in order to maximize a quick first pass success and most would have readily available push does pressors of levo or epi available.

Also having glidescope and boogie readily available would be important.... Possibly glidescope as first choice.

Anyone against this overall concept?

Thanks everyone!

 

[dhb]

Accurate summary.
I think in septic patients you should always be prepared for hypotension when initiating PPV regardless or volume status: these patients are riding a catecholamine wave and will tank when you put them out.

 

[ASA6]

People arent really mentioning this patients cardiac condition. Why is he in afib with rvr? why is his troponin 40?! Why is his EF 40% on levo and in sepsis which should be a high output state? If I was in the ICU, i would talk to the cardiologist. What does he/she think about giving 2 of midazolam and cardioverting? This would clearly help is blood pressure. Heart rate is the most likely thing to increase myocardial oxygen demand (followed by afterload, then preload), so slowing it down would be great for the heart. So my ideal plan would be 1) syncronized cardioversion, then see what he looks like, then intubate him with 2mg more of midaz (if needed) and 1mg/kg of roc. Someone mentioned sux earlier, which I would avoid because of his ESRD and risk of hyperkalemia. After that, he might need a cath and possibly a IABP. I think a cardiac event is just as likely as sepsis here. A troponin of 40 is awfully high for just "demand ischemia"

 

[Idiopathic]

People arent really mentioning this patients cardiac condition. Why is he in afib with rvr? why is his troponin 40?! Why is his EF 40% on levo and in sepsis which should be a high output state? If I was in the ICU, i would talk to the cardiologist. What does he/she think about giving 2 of midazolam and cardioverting? This would clearly help is blood pressure. Heart rate is the most likely thing to increase myocardial oxygen demand (followed by afterload, then preload), so slowing it down would be great for the heart. So my ideal plan would be 1) syncronized cardioversion, then see what he looks like, then intubate him with 2mg more of midaz (if needed) and 1mg/kg of roc. Someone mentioned sux earlier, which I would avoid because of his ESRD and risk of hyperkalemia. After that, he might need a cath and possibly a IABP. I think a cardiac event is just as likely as sepsis here. A troponin of 40 is awfully high for just "demand ischemia"

Your point is excellent, this is very possibly not sepsis at all. I think we can agree there was a cardiac event, some points, though.

True clinical sepsis is often a mixed picture, one of "high output" vasodilatory/distributive shock, coupled with a component of cardiogenic shock. Its rare that I see true high output sepsis in these patients. the conditions are often linked.

Yes he would benefit from cardioversion. Do you think it will be successful? Often times patients with intraabdominal processes like ischemia or infection will develop afib that is refractory to conversion, so whatever you gain, I think you will very likely be back in fib shortly. Im also not sure of the risk/reward of cardioverting the acutely injured heart.

Succinylcholine in ESRD is not contraindicated. The rise is serum potassium is similar and it is quickly returned to the cell. You can make arguments against sux here, but one of them should not be ESRD.

 

[fakin' the funk]

Indication for intubation was precarious trachejectory.

Can we make this a new anesthesia term, please? "The patient with the enlarging supraglottic mass was an a straight trachejectory to a surgical airway."

Septic patient now up to 10 levo with increased work of breathing, and increasing respiratory rate.

There's your indication. The indication is mechanical ventilation, in that mech ventilation will decrease VO2 and improve DO2-VO2 matching. I like you.

As far as volume status.... This was assessed by the Icu using bedside ultrasound which revealed no ivc variation and no obvious effacement of ventricles. Straight leg raises didn't increase his pressure. This unit doesn't believe in cvp.

I like you a lot.