ICU intubation

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diceksox

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I'm not an etomidate fan and do my best to avoid using it especially in the unit. 60 year old guy, lung CA, ARF last k = 6.5, HIT, septic, diagnosed adrenal suppression maxxed out on levophed and vaso now in severe respiratory distress, sats dropping needs a tube. I walk in and he is wide awake, looking right at me and understands what I tell him. Sat 80% on NRB, RR 40, BP 58/20!!!! I'm not used to guys with MAPs in the 30's being this with it. Ended up using etomidate and phenylephrine and he survived. Post induction BP 78/40.

I can't help but feel that although he made it through the induction/ intubation I've made things worse for this gentleman in the long run (not that his prognosis was great to begin with). However in this guy I really can't think of a better way to approach it given I didn't have time to do this awake. Thoughts?
 
diceksox said:
I'm not an etomidate fan and do my best to avoid using it especially in the unit. 60 year old guy, lung CA, ARF last k = 6.5, HIT, septic, diagnosed adrenal suppression maxxed out on levophed and vaso now in severe respiratory distress, sats dropping needs a tube. I walk in and he is wide awake, looking right at me and understands what I tell him. Sat 80% on NRB, RR 40, BP 58/20!!!! I'm not used to guys with MAPs in the 30's being this with it. Ended up using etomidate and phenylephrine and he survived. Post induction BP 78/40.

I can't help but feel that although he made it through the induction/ intubation I've made things worse for this gentleman in the long run (not that his prognosis was great to begin with). However in this guy I really can't think of a better way to approach it given I didn't have time to do this awake. Thoughts?
Click to expand...

1) There is no max on Levophed. It's only "maxed out" according to nurses' parameters.

2) You can get away with minimal cardiovascular depression using ANY drug provided you give just a small amount. The mantra that "etomidate is more hemodynamically stable" assumes you push a traditional induction dose. Intubations for respiratory failure outside the OR rarely require a full induction dose of any agent, so if you are pushing more than just a couple mL's my guess is that you are pushing too much.

3) Don't forget ketamine.

4) A cc or two of Versed or Ativan probably would've worked just fine too.

5) Don't forget the hemodynamic benefits of 100mg of lidocaine in the patient who otherwise is totally obtunded but has a good BP.

6) Propofol is an acceptable induction agent for a floor intubation too, you just have to be selective of the appropriate patient (prolly not this one) and stingy with the dose.
 
I you are afraid of adrenal suppression or hypotension, an often overlooked amnestic is the tertiary amine scopolamine. 400mcg's. Doesn't produce tachycardia like atropine or glycopyrrolate.

Ketamine is another choice, but may cause myocardial depression if the patient is out of endogenous catecholamines.

Of note... remember that scopolamine will cause mydriasis and could render your neuro exam useless.
 
He is already adrenally suppressed so whats the problem. I doubt you made anything worse.

On the other hand, I would have used versed. Small dose and wait for it to work.
 
sevoflurane said:
I you are afraid of adrenal suppression or hypotension, an often overlooked amnestic is the tertiary amine scopolamine. 400mcg’s. Doesn’t produce tachycardia like atropine or glycopyrrolate.

Ketamine is another choice, but may cause myocardial depression if the patient is out of endogenous catecholamines.

Of note... remember that scopolamine will cause mydriasis and could render your neuro exam useless.
Click to expand...


A great choice. In a few months I'll run through a case where I used it.
 
jennyboo said:
1) There is no max on Levophed. It's only "maxed out" according to nurses' parameters.

2) You can get away with minimal cardiovascular depression using ANY drug provided you give just a small amount. The mantra that "etomidate is more hemodynamically stable" assumes you push a traditional induction dose. Intubations for respiratory failure outside the OR rarely require a full induction dose of any agent, so if you are pushing more than just a couple mL's my guess is that you are pushing too much.

3) Don't forget ketamine.

4) A cc or two of Versed or Ativan probably would've worked just fine too.

5) Don't forget the hemodynamic benefits of 100mg of lidocaine in the patient who otherwise is totally obtunded but has a good BP.

6) Propofol is an acceptable induction agent for a floor intubation too, you just have to be selective of the appropriate patient (prolly not this one) and stingy with the dose.
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Can someone explain this? I know it is a class 1B antiarrhythmic and preferentially affects ischemic tissue, but how does it benefit hemodynamics?
 
I believe what she is referring to is the tendency of IV lidocaine, notably when given as an adjunct to anesthetic induction, to stabilize the hemodynamic profile/SANS-PANS balance. Blunts the response to laryngoscopy/intubation and can help minimize excessive hypertension and tachycardia, but also will allow you to significantly decrease your dose of amnestic, allowing for less drop in BP.

As an aside, we give lidocaine almost universally with induction in the OR, and I actually run it as an infusion in many GETA cases, but one day I was questioning whether a labor epidural was in the right place (small heme, negative test dose) so rather than wait to see if the bupiv worked, I thought I would give 5cc of 2% lidocaine through it and the patient got tremulous, dysphoric, somnolent and spent the next three hours sleeping. She also cried and had a feeling of impending doom. I cannot say that she did not seize, either. It gave me a tremendous respect for lidocaine, which up until that point I just considered a tier above saline on the pharmcologic activity scale.
 
Other than theory, can anyone point to any good evidence that lidocaine is a hemodynamically stabilizing agent in this situation?

Lots of theory...lot of religious belief (of course - like the existence of a god - I can't disprove it either)...but very little evidence of any benefit (as far as I know --> I would love to be shown otherwise) and even the theories are weak and often contradictory.

I would suspect the addition of lidocaine for this RSI, like that in head trauma, would only result in delay and potentially confusion with supporting staff and clinicians.

The case presented is a guy that even the choice of etomidate or not is highly unlikely to matter (outcomes wise). Nevermind lidocaine.

HH

Add: I agree with above. I would have reached for ketamine. (but think etomidate is a fine choice).
 
I would like to see the reaction if I asked for scopolamine or ketamine for a floor intubation. I'm lucky if the nurse will even push some propofol.
 
Doctor4Life1769 said:
Lidocaine inhibits endothelium-dependent vasodilation, and the vasoconstrictor effect of lidocaine may lead to increased MAP, SVR, and PVR, and decreased cardiac index. Someone can correct me if I'm wrong.
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Whoa.

I would like to see any data on lidocaine. I don't really think it does much although I push it a lot on induction.
 
Man I hate when the unit (usually MICU) calls with a patient who needs a tube in this situation. Ketamine in an elderly patient in septic shock, no thanks... worsened diastolic filling from the tachycardia = potentially worsened (Q) perfusion, difficult neuro assesment afterwards, and i've seen 1mg of midazolam arrest this patient presented.

And what happens if this guy is a difficult airway? You have no reserve with the sat already 80%.

How much worse is the SaO2 really going to get while you topicalize?

They can't blame you for his arrest (or his lack of adrenal fx) if you don't push drugs...

Here's how I'd do this:

Titrate up pressors and push phenylephrine boluses while topicalizing to maximize the Q in the V/Q matching aspect of his oxygenation...

Nasal trumpet with lidocaine cream worked in slowly if he won't let me get an oral airway coated with lidocaine cream. Nasal canula cranked to 6L, jackson-reese SEALED to face assisting his breaths with a touch of positive pressure with each inspiration, no peep. Atomized lidocaine through the nasal trumpet or down the oral airway. If he coughs it will just help the topicalization.

Then ask him/her to open wide....(sometimes have to help them open up)

There's ALWAYS time if it means not having someone arrest on the tip of your laryngoscope.

I have trained with ICU/Anesthesia attendings that never push drugs for intubation in the critically ill and it's led to my appreciation for the above mentioned technique.
 
diceksox said:
I'm not an etomidate fan and do my best to avoid using it especially in the unit. 60 year old guy, lung CA, ARF last k = 6.5, HIT, septic, diagnosed adrenal suppression maxxed out on levophed and vaso now in severe respiratory distress, sats dropping needs a tube. I walk in and he is wide awake, looking right at me and understands what I tell him. Sat 80% on NRB, RR 40, BP 58/20!!!! I'm not used to guys with MAPs in the 30's being this with it. Ended up using etomidate and phenylephrine and he survived. Post induction BP 78/40.

I can't help but feel that although he made it through the induction/ intubation I've made things worse for this gentleman in the long run (not that his prognosis was great to begin with). However in this guy I really can't think of a better way to approach it given I didn't have time to do this awake. Thoughts?
Click to expand...

Sounds like a reasonable way to handle things to me.
 
Eh, this sounds like too much trouble to me.

Dhanwanthari said:
Man I hate when the unit (usually MICU) calls with a patient who needs a tube in this situation. Ketamine in an elderly patient in septic shock, no thanks... worsened diastolic filling from the tachycardia = potentially worsened (Q) perfusion, difficult neuro assesment afterwards, and i've seen 1mg of midazolam arrest this patient presented.

And what happens if this guy is a difficult airway? You have no reserve with the sat already 80%.

How much worse is the SaO2 really going to get while you topicalize?

They can't blame you for his arrest (or his lack of adrenal fx) if you don't push drugs...

Here's how I'd do this:

Titrate up pressors and push phenylephrine boluses while topicalizing to maximize the Q in the V/Q matching aspect of his oxygenation...

Nasal trumpet with lidocaine cream worked in slowly if he won't let me get an oral airway coated with lidocaine cream. Nasal canula cranked to 6L, jackson-reese SEALED to face assisting his breaths with a touch of positive pressure with each inspiration, no peep. Atomized lidocaine through the nasal trumpet or down the oral airway. If he coughs it will just help the topicalization.

Then ask him/her to open wide....(sometimes have to help them open up)

There's ALWAYS time if it means not having someone arrest on the tip of your laryngoscope.

I have trained with ICU/Anesthesia attendings that never push drugs for intubation in the critically ill and it's led to my appreciation for the above mentioned technique.
Click to expand...
 
BobBarker said:
I would like to see the reaction if I asked for scopolamine or ketamine for a floor intubation. I'm lucky if the nurse will even push some propofol.
Click to expand...

it is appropriate for the nurses to voice their concerns and question your request, but ultimately you are the consultant/specialist and the (best) choice of induction drug is up to you. do the right thing.

and why are the nurses pushing your drugs? i always push my own, and tell them what i gave afterwards...
 
Arch Guillotti said:
Eh, this sounds like too much trouble to me.
Click to expand...

ditto. you're just going to give him a bloody nose, freak him out, make him more tachy - less diastolic filling.

step up to the MIKE, control the hemodynamics, induce, and put the tube in. get in, get out.
 
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Intern at a private hospital, nurses do my bidding.. Except when they don't. I don't have access to a Pyxis. The other day they were bolusing the propofol off of a pump while I was trying to induce. It took lots of coaxing for them to draw some up and push it, but they finally did.
 
diceksox said:
I'm not an etomidate fan and do my best to avoid using it especially in the unit. 60 year old guy, lung CA, ARF last k = 6.5, HIT, septic, diagnosed adrenal suppression maxxed out on levophed and vaso now in severe respiratory distress, sats dropping needs a tube. I walk in and he is wide awake, looking right at me and understands what I tell him. Sat 80% on NRB, RR 40, BP 58/20!!!! I'm not used to guys with MAPs in the 30's being this with it. Ended up using etomidate and phenylephrine and he survived. Post induction BP 78/40.

I can't help but feel that although he made it through the induction/ intubation I've made things worse for this gentleman in the long run (not that his prognosis was great to begin with). However in this guy I really can't think of a better way to approach it given I didn't have time to do this awake. Thoughts?
Click to expand...

Just to pop in....🙂
Sat 80% on NRB and BP 58/20 - and the poor guy is perfectly awake tells me that he doesn't have signs of end organ hypoperfusion ( AWAKE and he UNDERSTANDS...).
We don't have enough data at this moment - me I would suggest as a temporizing measure a noninvasive mode of ventilation BiPAP, optimize the CV ( preload, contractility, HR, SVR).
I would also be concerned that with positive pressure ventilation the preload will decrease - BP decrease. I supposed that the guy had at that moment a Flotrak or a Swan. Etomidate is fine. However the guy is on replacement therapy for his adrenal failure.
Overall - I think you did fine. I wouldn't chose awake intubation.
One interesting dilema is that when we are called for intubation we don't have to much to say about the management - we are there just to put the tube in. Good and bad...
 
I used etomidate for the first time in months on Thursday.

85 year old woman with appendicitis in the ER, surgeon wants to take her to the OR right now. She has coronary disease s/p CABG 7 years ago, but no followup data is available. Daughter says she's been "fine" since then, except for all the TIAs and "mini-strokes" ... apparently CEAs were offered but the patient declined. Had just finished up some prednisone for bronchitis.

HR 130 sinus, BP 70-80/20-30, tachypneic, with the patient in at least 30 deg of trendelenberg. Mental status - confused, not baseline per the daughter. ER has a 20 g IV in an AC and has her tucked away in a back room with 1:3 nurse coverage. Their sole interventions so far has been Zosyn, Flagyl, and two 250 mL LR "boluses" run in by the pump. Early goal directied therapy, nah, who needs that. Par for the course unfortunately.

No murmurs, no old ECG to look at but the ER one had a LBBB.

I opened up the LR and started working in some phenylephrine while consenting the daughter. By the time we got to the OR her HR was down to 100, SBP was up to about 100, mental status better. Gave her some steroids. A-line while circ RN pre-O2'd her.

Reached for the propofol and phenylephrine, thought about the uncertainty of her coronary and carotid disease, rationalized that her adrenals were already suppressed by the prednisone, thought oh screw it, and used etomidate.

I felt dirty, but I think it was the best drug for her.
 
BobBarker said:
Intern at a private hospital, nurses do my bidding.. Except when they don't. I don't have access to a Pyxis. The other day they were bolusing the propofol off of a pump while I was trying to induce. It took lots of coaxing for them to draw some up and push it, but they finally did.
Click to expand...

ahh. i can empathize. as an attending just yesterday i had a circulator telling me in her most take-charge condescending manner the BP was too low during a 2-level spine and that the patient was going to be blind. (guy was on lisinopril, isolated bp of 80, the student had already given phenylephrine, baseline bp 120, no blood loss, etc...)

instead of telling her to f-off and mind her circulating gopher business (which was my first instinct), i very politely took her hand and showed her the record, what we were doing, and some papers about peri-op blindness. she later thanked me, and i hope we paved the way to some future increase in respect and trust.

as an intern, though you can't win. which is why i think you should be supervised, even if you have done a thousand tubes. you don't have the clout (or pyxis access) to safely intubate patients in the ICU.

and why the heck was a pt without a tube on a propofol gtt in the first place?
 
pgg said:
I used etomidate for the first time in months on Thursday.

85 year old woman with appendicitis in the ER, surgeon wants to take her to the OR right now. She has coronary disease s/p CABG 7 years ago, but no followup data is available. Daughter says she's been "fine" since then, except for all the TIAs and "mini-strokes" ... apparently CEAs were offered but the patient declined. Had just finished up some prednisone for bronchitis.

HR 130 sinus, BP 70-80/20-30, tachypneic, with the patient in at least 30 deg of trendelenberg. Mental status - confused, not baseline per the daughter. ER has a 20 g IV in an AC and has her tucked away in a back room with 1:3 nurse coverage. Their sole interventions so far has been Zosyn, Flagyl, and two 250 mL LR "boluses" run in by the pump. Early goal directied therapy, nah, who needs that. Par for the course unfortunately.

No murmurs, no old ECG to look at but the ER one had a LBBB.

I opened up the LR and started working in some phenylephrine while consenting the daughter. By the time we got to the OR her HR was down to 100, SBP was up to about 100, mental status better. Gave her some steroids. A-line while circ RN pre-O2'd her.

Reached for the propofol and phenylephrine, thought about the uncertainty of her coronary and carotid disease, rationalized that her adrenals were already suppressed by the prednisone, thought oh screw it, and used etomidate.

I felt dirty, but I think it was the best drug for her.
Click to expand...

sounds like spot on management - strong work. i wouldn't have given steroids though for just a recent pulse, and with an aline in i still would have used propofol (50 or so) and neo. post-induction bp will be the same and you won't feel so dirty.
 
I wanted to intubate on the general med floor but the house supervisor RN wanted to wait to intubate until we get to the ICU. I said fine as long as you have the following doses of versed, propofol, nimbex, a tube, a blade, and a vent waiting on us when we get there. They had about half my requested gear when I got there and the propofol on a pump in the room.
 
slavin said:
sounds like spot on management - strong work. i wouldn't have given steroids though for just a recent pulse,
Click to expand...

Agree the steroids were a soft call. It's not like she had refractory hypotension in the ER, just untreated hypotension.

slavin said:
and with an aline in i still would have used propofol (50 or so) and neo. post-induction bp will be the same and you won't feel so dirty.
Click to expand...

Yeah, felt like a wuss 🙂 but the nagging bit at the back of my head was afraid that propofol might cause a bit more direct myocardial depression that wasn't phenylephrine-fixable and I felt like I didn't know anywhere near as much as I wanted to know about her heart. Maybe an unfounded concern.


I've posted here before that I don't like etomidate and that in these sick old people even <50 mg of propofol will get them induced and phenylephrine is enough, but push came to shove and I backed off that stance.
 
monday night quarterbacking is easy, but i wasn't there...

if you went with your gut and it went well - kudos.
 
clarification, lidocaine does not raise BP or decrease pressor requirement as far as I know. It decreases the hypertensive/tachycardic response to laryngoscopy. If you have a patient with elevated ICP, a contained ruptured aortic aneurysm or some other reason not to be hypertensive or tachycardic, lidocaine blunts the hemodynamic response to laryngoscopy without the hypotension you might get from another agent (such as esmolol or fentanyl).

Obviously it is not useful for the hypotensive patient.

As I've told the ED docs, whatever induction agent you are FAMILIAR WITH using in a SAFE manner is the right induction agent for you. In our ED, they know only one induction agent -- etomidate. Therefore it's the only one they know how to use SAFELY. In my practice, on the (admittedly rare) occasion that I push etomidate, I make sure the patient's physician (i.e. the MICU, the CCU, the surgeon etc) knows I pushed the etomidate and I remind them etomidate can cause adrenal suppression. Then I walk away.
 
I intubate about 70% of my icu patients "awake" and topicalized, but I avoid doing anything through the nose. Maybe takes more time up front but I topicalize in stages, intermittently, while preoxygenating (even on bipap), so I doubt it's much more time. Plus, I save all that time and more on the back end by not having to stand around afterwards pushing phenylephrine and exPlaining to the micu team why 2 cc Propofol isn't still make the patient hypotensive an hour later.
 
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Arch Guillotti said:
I have always thought that lidocaine really didn't do much at all with the whole blunting thing.
Click to expand...

I had seen a better study that was really a slam dunk on this subject but i can't find it anymore.
The conclusion was basically topicalization works iv lido doesn't.
 
future intensivist here, not anesthesiologist.

quick question for those of you against the awake intubation.... For the example of the first patient saturating 80s, why don't you do preoxygenate with a little cpap? it's the ICU, vents are right there, and many of these patients are saturating low because they are shunting - so giving them increased FI02 can only get you so far. Then once you have pre-oxygenated, you can do your thing. Most vents are easy to set up with a peep of say 5 with no additional inspiratory force.

thoughts?
 
europeman said:
future intensivist here, not anesthesiologist.

quick question for those of you against the awake intubation.... For the example of the first patient saturating 80s, why don't you do preoxygenate with a little cpap? it's the ICU, vents are right there, and many of these patients are saturating low because they are shunting - so giving them increased FI02 can only get you so far. Then once you have pre-oxygenated, you can do your thing. Most vents are easy to set up with a peep of say 5 with no additional inspiratory force.

thoughts?
Click to expand...

not a great idea for this patient

his rr was 40 - he's tired and ain't gonna be able to ventilate against cpap. the pressure may drive his CO down further, he might lose consciousness, puke into the mask, etc. atelectasis isn't a part of this equation you can improve until a tube is in and he's a bit more stable on pressors/fluids.

it's best not to get too fancy and futz around with these guys - they will continue to crump before your eyes. they need their airway controlled quickly so that the icu docs can move on through the hemodynamics management. he's pre-o2'd on the NRB - optimize position, pressors/induction, put the tube in.

that being said, i do like cpap for the biguns with their pre-o2 - it can buy valuable time...
 
pgg said:
I used etomidate for the first time in months on Thursday.

85 year old woman with appendicitis in the ER, surgeon wants to take her to the OR right now. She has coronary disease s/p CABG 7 years ago, but no followup data is available. Daughter says she's been "fine" since then, except for all the TIAs and "mini-strokes" ... apparently CEAs were offered but the patient declined. Had just finished up some prednisone for bronchitis.

HR 130 sinus, BP 70-80/20-30, tachypneic, with the patient in at least 30 deg of trendelenberg. Mental status - confused, not baseline per the daughter. ER has a 20 g IV in an AC and has her tucked away in a back room with 1:3 nurse coverage. Their sole interventions so far has been Zosyn, Flagyl, and two 250 mL LR "boluses" run in by the pump. Early goal directied therapy, nah, who needs that. Par for the course unfortunately.

No murmurs, no old ECG to look at but the ER one had a LBBB.

I opened up the LR and started working in some phenylephrine while consenting the daughter. By the time we got to the OR her HR was down to 100, SBP was up to about 100, mental status better. Gave her some steroids. A-line while circ RN pre-O2'd her.

Reached for the propofol and phenylephrine, thought about the uncertainty of her coronary and carotid disease, rationalized that her adrenals were already suppressed by the prednisone, thought oh screw it, and used etomidate.

I felt dirty, but I think it was the best drug for her.
Click to expand...



I am just starting my CA-1 year, our last month of pgy-1 is an ansethesia rotation with 2 to 3 hours of lectures daily in the afternoon. And we just talked about propofol and phenylephrine and how they can keep a patient just as stable as etomidate, if not more stable. I love our field, we get paid to experiment with drugs .
 
OP - great job, don't feel bad for providing great care.

I don't know if it's just me, but there are some CRACKED UP ideas in this thread. Like, (roughly in order of posting)

1. Norepi doesn't have a "max dose" according to "nurse's parameters" as Jennyboo posted -- it's PHARMACY that determines those max doses (which are BS nonetheless). Pharmacy does a lot of fake doctorin', IMO. Side story: at a code yesterday, one of the cardiology people asked out loud, "are we at the max dose on the epi drip?"

2. Doctor4Life -- I'm sorry but your post about lidocaine is total hooey.

3. Dhanwanthari -- several of the things you posted seem kinda reactionary and over-the-top conservative. "Arrest on the tip of your laryngoscope"? "Arrest from 1mg of midazolam?" C'mon. As far as how bad the sat will get while you topicalize, it can get WAY worse while you're f*cking around with atomized lido and lidocaine paste instead of applying hiflow oxygen.

4. 2win -- BiPAPping this guy? The dude needs a tube and positive pressure ventilation to take away his WOB and get 100% oxygen like, right now.

5. CChoukal -- since you're an anesthesia intensivist I imagine your "awake" topicalized intubations are done on people who you've recognized EARLY are developing oxygenation/ventilation issues. Bravo. I think the OP is encountering the MUCH more common scenario where the anesthesiologist is called WAYYY late in the respiratory failure course, and the primary team has been ostrich'ing for the last 4-6 hours.

6. Slavin -- Europeman was suggesting CPAP for preoxygenation IN GENERAL, not necessarily in this case. I think the idea isn't a bad one -- assuming you're watching the decreased-preload effect closely.
 
fakin' the funk said:
OP - great job, don't feel bad for providing great care.

I don't know if it's just me, but there are some CRACKED UP ideas in this thread. Like, (roughly in order of posting)

1. Norepi doesn't have a "max dose" according to "nurse's parameters" as Jennyboo posted -- it's PHARMACY that determines those max doses (which are BS nonetheless). Pharmacy does a lot of fake doctorin', IMO. Side story: at a code yesterday, one of the cardiology people asked out loud, "are we at the max dose on the epi drip?"

2. Doctor4Life -- I'm sorry but your post about lidocaine is total hooey.

3. Dhanwanthari -- several of the things you posted seem kinda reactionary and over-the-top conservative. "Arrest on the tip of your laryngoscope"? "Arrest from 1mg of midazolam?" C'mon. As far as how bad the sat will get while you topicalize, it can get WAY worse while you're f*cking around with atomized lido and lidocaine paste instead of applying hiflow oxygen.

4. 2win -- BiPAPping this guy? The dude needs a tube and positive pressure ventilation to take away his WOB and get 100% oxygen like, right now.

5. CChoukal -- since you're an anesthesia intensivist I imagine your "awake" topicalized intubations are done on people who you've recognized EARLY are developing oxygenation/ventilation issues. Bravo. I think the OP is encountering the MUCH more common scenario where the anesthesiologist is called WAYYY late in the respiratory failure course, and the primary team has been ostrich'ing for the last 4-6 hours.

6. Slavin -- Europeman was suggesting CPAP for preoxygenation IN GENERAL, not necessarily in this case. I think the idea isn't a bad one -- assuming you're watching the decreased-preload effect closely.
Click to expand...

you're spot-on with all of your points, except, of course, for #6.

Europeman was addressing the case of the OP SPECIFICALLY -

"Originally Posted by europeman
future intensivist here, not anesthesiologist.

quick question for those of you against the awake intubation.... For the example of the first patient saturating 80s, why don't you do preoxygenate with a little cpap?"

for the pt presented by the OP, CPAP is a BAD IDEA for the reasons I have already given.

In general, CPAP with preoxygenation is UNNECESSARY.

HOWEVER, for big'uns or folks with suspected pre-existing atelectasis (ie the slug on POD 3 from ex-lap coming back for whatever) - CPAP with preoxygenation is likely useful.
 
fakin' the funk said:
OP - great job, don't feel bad for providing great care.

I don't know if it's just me, but there are some CRACKED UP ideas in this thread. Like, (roughly in order of posting)

1. Norepi doesn't have a "max dose" according to "nurse's parameters" as Jennyboo posted -- it's PHARMACY that determines those max doses (which are BS nonetheless). Pharmacy does a lot of fake doctorin', IMO. Side story: at a code yesterday, one of the cardiology people asked out loud, "are we at the max dose on the epi drip?"

2. Doctor4Life -- I'm sorry but your post about lidocaine is total hooey.

3. Dhanwanthari -- several of the things you posted seem kinda reactionary and over-the-top conservative. "Arrest on the tip of your laryngoscope"? "Arrest from 1mg of midazolam?" C'mon. As far as how bad the sat will get while you topicalize, it can get WAY worse while you're f*cking around with atomized lido and lidocaine paste instead of applying hiflow oxygen.

4. 2win -- BiPAPping this guy? The dude needs a tube and positive pressure ventilation to take away his WOB and get 100% oxygen like, right now.

5. CChoukal -- since you're an anesthesia intensivist I imagine your "awake" topicalized intubations are done on people who you've recognized EARLY are developing oxygenation/ventilation issues. Bravo. I think the OP is encountering the MUCH more common scenario where the anesthesiologist is called WAYYY late in the respiratory failure course, and the primary team has been ostrich'ing for the last 4-6 hours.

6. Slavin -- Europeman was suggesting CPAP for preoxygenation IN GENERAL, not necessarily in this case. I think the idea isn't a bad one -- assuming you're watching the decreased-preload effect closely.
Click to expand...

And why not noninvasive respiratory support? Bipap is not positive pressure ventilation??? Get the textbook 🙂
Because of WOB?
What's your definition of WOB?
Why right now? Because you have pulseox of 80% for somebody who most likely is vasoconstricted and the number is just a number???
Remember the patient is totally awake. Brain perfusion plus oxygenation OK.
 
2win said:
Why right now? Because you have pulseox of 80% for somebody who most likely is vasoconstricted and the number is just a number???
Remember the patient is totally awake. Brain perfusion plus oxygenation OK.
Click to expand...

👍

Even if you have a tube in this guy, you are going to have to worry about decreased preload... I agree that CPAP wouldn't necessarily be the best choice with this guy (depending where he was on the compliance curve), but a little Bi-PAP wouldn't hurt - especially since he is mentally intact. If there is a decent ICU vent, it should be able to do NIPPV as well. Your RT should have the vent in the room, set up for you... grab a mask (WITHOUT an exhalation port) and have RT slap/hold that on the patient while you are getting your drugs/tube set up. You MIGHT be able to get by on NIPPV... Obviously if he is having a problem protecting his airway, NIPPV isn't a good choice... but it sounds like this guy is alert enough to tolerate it.

Now, if there is no mask in sight and/or you need different equip to do NIPPV? Well... probably best to tube him, right? At least if he is actively crashing.

Just my M1 thinking... which is probably shoddy at best! 🙂
 
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fakin' the funk said:
5. CChoukal -- since you're an anesthesia intensivist I imagine your "awake" topicalized intubations are done on people who you've recognized EARLY are developing oxygenation/ventilation issues. Bravo. I think the OP is encountering the MUCH more common scenario where the anesthesiologist is called WAYYY late in the respiratory failure course, and the primary team has been ostrich'ing for the last 4-6 hours.
Click to expand...

Not necessarily. I think people overestimate how long it takes to do a thorough job of topicalization (and the MAC of respiratory failure). I topicalize in a stepwise fashion, intermittently removing and replacing whatever mask they're wearing (yes, even BiPap). I start with whatever paste/ointment is available, then move on to spray the cords and/or transtracheal depending on my mood.

Sure, every once in awhile a patient is gorked out enough not to be able to cooperate yet still too with it to just go for it, but this is the minority.

I have never regretted at least trying the awake approach, but I have, albeit rarely, regretted the ICU induction.
 
I'm not sure what all the debate is about? You gave a drug, got the tube in and the pt did fine. Who cares if you used etomidate, propofol, or whatever other concoction of drugs you can think of. It worked so who cares? Theres no such thing as style points in ICU intubations
 
G-Man82 said:
Hah, just don't let the drug testers know that! I just went for my pre-employment physical, which coincidentally included a drug test - blood/urine, and breath! Hardcore!
Click to expand...

not like that. i meant test the drug actions on the patients.... if they didn't test Hair they're not that hard core.
 
RussianJoo said:
not like that. i meant test the drug actions on the patients.... if they didn't test Hair they're not that hard core.
Click to expand...

haha i was kidding. That sentence taken out of context is kinda funny especially given that it was spoken by an anesthesiologist. I think we all knew what you meant, and yeah, it's mad cool to get paid to experiment with drugs (on patients that is) :laugh:

To keep on topic, I've actually never seen awake intubations on medical ICU patients. Over here, an anesthesia resident or CRNA would just come by, tube the patient, and then walk out. Occasionally with the obese ones the CRNAs would call their Attending. Seeing as I'm finishing my medical internship, I can't really say what's happened in the SICU, but I doubt anything different b/c our SICU, here at my med school/internship hospitals have no anesthesiology presence whatsoever. One of the pulmonologists I was talking to during my micu month said that he thinks fiberoptic scopes will become a regular part of most ICUs in the next 5 or so years. Any one agree? And what about glidescopes? Do those make intubations that much easier versus direct laryngoscopies? Is there any advantage to glidescopes in certain patient populations?
 
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MRW said:
Thank you - it's nice to see some data behind that as I was taught, like many of us, that it blunts the response to laryngoscopy.
Click to expand...

lets not get carried away by 40 or so ASA1/2 chinese patients. previous studies have demonstrated the general anesthetic properties of lidocaine. this material is quoted in textbooks. it is useful, cheap and safe, and in high doses, it works synergystically with opioids and other methods to blunt hemodynamic changes. i have seen the effect that 1-2mg/kg IV lidocaine has on the awake patient and let me tell you it is a general anesthetic.
 
G-Man82 said:
haha i was kidding. That sentence taken out of context is kinda funny especially given that it was spoken by an anesthesiologist. I think we all knew what you meant, and yeah, it's mad cool to get paid to experiment with drugs (on patients that is) :laugh:

To keep on topic, I've actually never seen awake intubations on medical ICU patients. Over here, an anesthesia resident or CRNA would just come by, tube the patient, and then walk out. Occasionally with the obese ones the CRNAs would call their Attending. Seeing as I'm finishing my medical internship, I can't really say what's happened in the SICU, but I doubt anything different b/c our SICU, here at my med school/internship hospitals have no anesthesiology presence whatsoever. One of the pulmonologists I was talking to during my micu month said that he thinks fiberoptic scopes will become a regular part of most ICUs in the next 5 or so years. Any one agree? And what about glidescopes? Do those make intubations that much easier versus direct laryngoscopies? Is there any advantage to glidescopes in certain patient populations?
Click to expand...

the problem in this settings is that the patients are so poorly optimized...i mean the absolute worst patient we take to the OR is likely better off than most of the patients we intubate in the MICU. there is something to be said for being quick, efficient and safe in this situations. you definitely have to pause before saying "prop/sux/tube" for these guys. they are typically obtunded, volume overloaded, have poor access, crummy vitals and extensive comorbidities, not to mention unknown airway anatomy (often impossible to truly assess), dried secretions/blood in the airway, possibly old trach/radiation scars, esophageal varices, full stomachs...i have no problem going to an airway adjunct QUICKLY in these patients and i never get complacent. i performed an awake intubation on someone who i know had a CO2 of 80 because we were convinced she wouldnt tolerate going to sleep, not because her airway looked difficult. i like to use the video devices (we have a mcgrath that the residents can check out, as well as glidescopes) so that everyone (me) can see the anatomy and there isnt a 90-second pause until you hear..."i cant really see anything" or "i think that is the epidglottis"
 
Idiopathic said:
lets not get carried away by 40 or so ASA1/2 chinese patients. previous studies have demonstrated the general anesthetic properties of lidocaine. this material is quoted in textbooks. it is useful, cheap and safe, and in high doses, it works synergystically with opioids and other methods to blunt hemodynamic changes. i have seen the effect that 1-2mg/kg IV lidocaine has on the awake patient and let me tell you it is a general anesthetic.
Click to expand...

HA.

I disagree.

It's all theoretical BS.

"quoted in textbooks" is the biggest bunch of BS.

And "i have seen the effects that 1-2mg/kg IV lidocaine has on the awake patient" is worthless anecdote.

Dear Anesthesiology forum: please forgive me for contradicting a well-respected poster in his/her home environment, but this lido ICP nonsense has got to end.

As some of you may remember from a few years ago, I asked about lido ICP on this forum. I have since looked into it extensively and have come to this conclusion: lido ICP is just fodder for lawyers to ask: "Isn't the standard for care for head-injured patients lido?"

And we all know there are too many old docs out there who will sell out the airway doc - be the doc an anesthesiolgist or EM doc - for a nice lay and a bit of extra cash.

It must stop.

HH

Extra: at least 25% of my EM attendings state they give lido pre-treatment in the head-injured RSI because it is the standard of care defined by anesthesiology and EM.

:barf:

HH
 
i would say you misunderstand me but im not even sure we are having the same argument. im not dogmatic. i believe lidocaine has a place as IV adjunct for intubation and general anesthesia (notably TIVA). it reduces propofol requirements in TIVA and has shown outcome benefits. i use it in neuro cases, spines, ENT and the occasional carotid. i wouldnt do this if i didnt appreciate results. i dont need your validation, i only seek to enlighten.

who mentioned anything about ICP?

edit: oh sorry jenny one-offed an ICP comment (and she is right about that), but in your infinite wisdom and "looking things up" you clearly have the better of the practicing anesthesiologists.
 
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Idiopathic said:
the problem in this settings is that the patients are so poorly optimized...i mean the absolute worst patient we take to the OR is likely better off than most of the patients we intubate in the MICU. there is something to be said for being quick, efficient and safe in this situations. you definitely have to pause before saying "prop/sux/tube" for these guys. they are typically obtunded, volume overloaded, have poor access, crummy vitals and extensive comorbidities, not to mention unknown airway anatomy (often impossible to truly assess), dried secretions/blood in the airway, possibly old trach/radiation scars, esophageal varices, full stomachs...i have no problem going to an airway adjunct QUICKLY in these patients and i never get complacent. i performed an awake intubation on someone who i know had a CO2 of 80 because we were convinced she wouldnt tolerate going to sleep, not because her airway looked difficult. i like to use the video devices (we have a mcgrath that the residents can check out, as well as glidescopes) so that everyone (me) can see the anatomy and there isnt a 90-second pause until you hear..."i cant really see anything" or "i think that is the epidglottis"
Click to expand...

Agree x 1,000,000. We go to airways alone as the CA-2 on call and can call the 3 for backup. There's a small handful of attendings that want to be called about airways, otherwise the only time I called the attending was when we were about 10 seconds away from putting blade to neck for an emergent cric, and by the time they got there, there was a piece of plastic in the neck.

Point being, I am MUCH more likely to do things awake in the ICU because of this. We get great airway training and are comfortable with doing awakes early and often. In MICU patients that are right on the edge of falling off the curve, even a gentle induction will lead to a quick spiral of nastiness. If you can avoid it, why not? A suboptimal airway in the OR is an entirely different story than a suboptimal airway in the ICU.

Granted, we are often called too late in the game to have time to topicalize, so if the person isn't a candidate for airway blocks, then you're back to square one.

Besides, you look like a total badass when you do a slick 15 minute awake on a 550 pound patient. 😀

Respect for the potential for an ICU/floor airway to go badly quickly is step number one in planning how to get a tube in these patients, if you ask me.

One of the pulmonologists I was talking to during my micu month said that he thinks fiberoptic scopes will become a regular part of most ICUs in the next 5 or so years. Any one agree? And what about glidescopes? Do those make intubations that much easier versus direct laryngoscopies? Is there any advantage to glidescopes in certain patient populations?
Click to expand...

That being said, our MICU crew has a scope, but lots of them don't have the skill set to use it properly. Having scopes available in the MICU doesn't mean much if people aren't facile with them.

The glidescope is a great tool in the right patient. I think people that have less experience with it can get into trouble thinking that it can be used to intubate everyone or that it will always save your butt.
 
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