ICU intubation

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Lightwand said:
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.
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I'm still amazed that there are places that allow a trainee to induce critically ill patients without supervision. Do your attendings allow you to take an elective case to the OR and get started without being there? Mine sure didn't.
 
Hamhock said:
And "i have seen the effects that 1-2mg/kg IV lidocaine has on the awake patient" is worthless anecdote.
Click to expand...

Uh, I have seen it too.

Have you ever sen someone after they get a lidocaine bolus and the effects that it has on the CNS.

I still am not sure that I buy the whole blunting the response to laryngoscopy jargon though.
 
As interns, we respond to all airways without backup. All of the upper levels and anesthesia attendings are at a different hospital. I guess our backup is the private EM attendings down stairs. But it is poor form to call them and frowned upon. I had to intubate two very large, very difficult to bmv, patients my first night on call (July 4th!).
 
BobBarker said:
As interns, we respond to all airways without backup. All of the upper levels and anesthesia attendings are at a different hospital. I guess our backup is the private EM attendings down stairs. But it is poor form to call them and frowned upon. I had to intubate two very large, very difficult to bmv, patients my first night on call (July 4th!).
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:scared: Holy balls
 
BobBarker said:
As interns, we respond to all airways without backup. All of the upper levels and anesthesia attendings are at a different hospital. I guess our backup is the private EM attendings down stairs. But it is poor form to call them and frowned upon. I had to intubate two very large, very difficult to bmv, patients my first night on call (July 4th!).
Click to expand...

Holy ****. That is scary.
 
BobBarker said:
As interns, we respond to all airways without backup. All of the upper levels and anesthesia attendings are at a different hospital. I guess our backup is the private EM attendings down stairs. But it is poor form to call them and frowned upon. I had to intubate two very large, very difficult to bmv, patients my first night on call (July 4th!).
Click to expand...

are you at OU? this always seemed like a draw when i was considering that program, looking back it seems like it would be terrifying
 
Yes, at OU. But overall, it has been a wonderful experience, you just have to grow up quick. For the year, I've put in over 100 central lines, ran over 30 codes, and over 50 intubations. 98% of the time with no higher level supervision.
 
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BobBarker said:
Yes, at OU. But overall, it has been a wonderful experience, you just have to grow up quick. For the year, I've put in over 100 central lines, ran over 30 codes, and over 50 intubations. 98% of the time with no higher level supervision.
Click to expand...

Christ, June of my CA3 year attendings were still watching me extubate ASA 1E appendectomies.
 
BobBarker said:
As interns, we respond to all airways without backup. All of the upper levels and anesthesia attendings are at a different hospital. I guess our backup is the private EM attendings down stairs. But it is poor form to call them and frowned upon. I had to intubate two very large, very difficult to bmv, patients my first night on call (July 4th!).
Click to expand...

This sounds quite dangerous. Just seems like a matter of time before a disaster happens.
 
BobBarker said:
Yes, at OU. But overall, it has been a wonderful experience, you just have to grow up quick. For the year, I've put in over 100 central lines, ran over 30 codes, and over 50 intubations. 98% of the time with no higher level supervision.
Click to expand...

wow. I am pretty jealous, I feel comfortable in the ICU but I have done maybe 10% of that during my pgy-1 year. I did have two difficult intubations though, a burn ICU pt with inhalation burns, but we intubated in the PACU and the anesthesia attending was right next to me, but I did shove an 8 in there. And a lady who's 5'2"x 5'2" 120kg in heart failure with pulmonary edema from OHS, we never got her sats above 86% but that's probably where she normally lives, at that time the ICU fellow was with me but, the fact that he turned to me and said "you're an anesthesia resident, so you should probably intubate this one" really scared me. I of course replied to him with "You know she's going to be a very hard intubation". To which he said "I know". good thing she wasn't very anterior and wore dentures so no teeth to knock into the trachea,


I am so happy I had the sense to take off the cpap mask even though she was satting in the 80's and look inside her mouth, to add to the adventure the lady only spoke polish, good thing I speak russian I asked her if i can take her teeth out with hand gestures and she nodded her head i quickly told her to take them out. I that gave me a little more confidence.
 
dhb said:
More on lidocaine and intubation:
the literature is pretty clear on the subject: iv lidocaine doesn't affect pressor response topical lidocaine does.
http://www.ncbi.nlm.nih.gov/pubmed/10861151
Click to expand...

whoa now, maybe you should re-read that article. topical lidocaine is certainly better but IV lidocaine clearly affected cardiovascular response to intubation and the source above agrees. i dont recall anyone arguing that IV is better than topical administration, just more convenient.
 
BobBarker said:
Yes, at OU. But overall, it has been a wonderful experience, you just have to grow up quick. For the year, I've put in over 100 central lines, ran over 30 codes, and over 50 intubations. 98% of the time with no higher level supervision.
Click to expand...
Wow, that would never fly in the east coast, too much malpractice risk.
That's awesome training, you probably have balls of steels at this point hah.
 
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...

I'm ABSOLUTELY SURE you did nothing to alter your patient's circling the toilet course.

Here's something to consider next time:

Have the nurses acquire for you a 5mg/mL midazolam vial.

It's green lettered I think.

Thank her upon possession.

Pull it up in a 5mL syringe with IVF from pt so you have 1mg/mL.

Gotta tell ya man:

MIDAZOLAM IS A GREAT AMNESTIC FOR HEMODYNAMICALLY UNSTABLE PATIENTS THAT NEED A SNORKEL.

We use midazolam every day in the pre-op area for our ultrasound guided nerve blocks/epidurals, most of the time giving all five milligrams.

I've used it extensively in the ICU as well.

I've been in your position. Here's how it would go if I were where you were, after acquiring and appropriately diluting said midazolam:

Jet gives 2mg (2 mL) midazolam via IV...

BTW wanna the most important parts of a situation like this is for you the anesthesiologist to have a

FREE FLOWING IV


so the drugs administered will work.

In the ICU all IVs are on pumps.

Take ONE off a pump so it's FLOWING.

Can't emphasize this enough.

Free flowing IV. Don't compromise on this. You are gonna give some drugs in the IV. You are in a foreign environment. The last thing you need to worry about is

"DID THE DRUG GET TO THE PATIENT?"

Trust me.

Free flowing IV.

Back to the midazolam...

give two.

Stand back, wait a minute or so, think about whatcha want for dinner.

SPAGHETTI!!!

BAck to reality, minute passed, interact with pt to see if he's buzzed out or not. Here's the answers:

1) Jet: "DUDE?"

If response is "YEAH?"

give the rest.

2) Jet: "DUDE?"

If no response, Dude's a lightweight but more importantly

you've achieved your amnestic goal so go ahead with the 40 mg succinylcholine

so you can put the tube in.

MIDAZOLAM.

The best drug for

INTUBATION IN THE ICU

in my humble opinion.

Give a little.

If forced

GIVE MORE.

It's still all good.

With minimal-to-no hemodynamic swings.

And no adrenal suppression worries in an already compromised ICU pt who may need every molecule of circulating corticosteroid so they don't show up as a number in the

Etomidate May Clandestinely Kill Patients

studies.
 
Last edited:
jetproppilot said:
MIDAZOLAM.

The best drug for

INTUBATION IN THE ICU


Etomidate May Clandestinely Kill Patients

studies.
Click to expand...

yep and yep.

By the way, this question comes up a lot on SDN.

I have attached a great article - this is part 1 or a 2 part series. I want to draw attention to the chart on page 161. Interesting stuff. Basically, etomidate has a higher incidence of hypotension than propofol, and the same incidince as using nothing. The point is, when patients are in extremis, intubation is often a hit to the system, regardless of what you use. It is what it is.

But at least morphine, midazolam, propofol, nothing, these don't kill patients. Etomidate does.
 

Attachments

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turkeyjerky said:
Why Sux and not Rocuronium? Just wondering how you guys think about these things
Click to expand...

Succinylcholine works faster. Not even 1.2 mg/kg of roc reliably produces the same level of relaxation as quickly. Succ is still the gold standard for rapid optimal intubation conditions.

Some people think the fact that it wears off in a few minutes is important if you have an unexpected can't-intubate/can't-ventilate situation, but I think that's bunk.

1.2 mg/kg of roc lasts much longer than the induction drug. The only thing that spurs ICU nurses to titrate sedation up to an appropriate level is patient movement. Using roc greatly increases the likelihood of having a paralyzed but cruelly inadequately sedated patient in my estimation.
 
turkeyjerky said:
Why Sux and not Rocuronium? Just wondering how you guys think about these things
Click to expand...

turkeyjerky,

Why not sux?

I had a wise attending once tell me that while most people have to think of a reason TO use sux, he tries to think of a reason NOT to use it.

It is FAST, profound paralysis, and wears of quickly (assuming you don't have one of those pesky genetic freaks).

The only time I have had a serious aspiration was when I was using ROC for an RSI on a SBO (told to by my attending by the way...) and put the blade in too early and the patient bucked or moved. (yes I know...., RSI is defined as sux and pentathol, blah blah blah).

I hate Roc. Never use it. It is the least predictable drug of everything in the drawer.

If you need fast - sux. If not, use nimbex - old faithful type predictability. (only 2 bucks more than roc).
 
I use sux every day, my attendings love it because it's cheap and quick. I can't imagine using anything else at this point. It would seem like an eternity.
 
My only issue with using sux in the ICU is when you've got these guys that have been laying around up there languishing for weeks. And half of them are in renal failure with hyperkalemia.

Sux isn't benign- I've seen sux-induced hyperkalemic arrest, but it's fast and reliable and when you don't have time to jack around, it'll get the job done.
 
You dont need to use paralytics on the majority of ICU intubations. I gave some nimbex a couple of times after the patient clinched up after some etomidate. By the end of the year, I quit using etomidate and just used Versed, and if that didnt't do the trick then 50mg of Propofol would.
 
doesn't matter how sick - optimize your conditions. roc or sux and etomidate or midaz. patients vomit when they're light. don't be afraid to use your drugs.
 
RussianJoo said:
I use sux every day, my attendings love it because it's cheap and quick. I can't imagine using anything else at this point. It would seem like an eternity.
Click to expand...

If you were to follow up on your patients to get a sense of the incidence and severity of myalgias, you'd probably stop doing this routinely.

Sux myalgias really, really suck.
 
turkeyjerky said:
Why Sux and not Rocuronium? Just wondering how you guys think about these things
Click to expand...

As someone pointed out - you may not even need paralysis.

There is data - where the intubater was blinded to the drug given, and a propofol and alfentanil induction was viewed the same as propofol and sux for intubating conditions.

Alfentanil is really cool - way fast, and lasts just a moment.
 
Hawaiian Bruin said:
If you were to follow up on your patients to get a sense of the incidence and severity of myalgias, you'd probably stop doing this routinely.

Sux myalgias really, really suck.
Click to expand...

I see all the in patients on POD#1 none thus far complained about myalgias. What's their frequency?
 
epidural man said:
As someone pointed out - you may not even need paralysis.

There is data - where the intubater was blinded to the drug given, and a propofol and alfentanil induction was viewed the same as propofol and sux for intubating conditions.

Alfentanil is really cool - way fast, and lasts just a moment.
Click to expand...

Propofol and alfentanil make a great intubating combo. Just watch out for hypotension depending on the patient and the doses.
 
yeah i like remi to facilitate the floor intubation, definitely have seen bradycardia bordering on asystole with big boluses though,
 
Yeah... but dang expensive floor intubation. 😱

As far as I know the smallest amount of remi comes in 1mg vials.

What is wrong with good 'ol prop/sux for floor intubations. I never give alfenta for floor intubations. I like alfenta for MAC/pins for crani's/LMA's/bone marrow biopsies/eyeballs (retrobulbar)/etc.
 
unless you guys are talking 'bout awake intubations....🙄

I doubt prop/alfenta is anywhere near as good as prop/sux. I'd be very skeptical of such a paper....:uhno:

But... maybe I just have to try it and see...🙂
 
dhb said:
Well it's from what i've read i've never tried with alfentanil. Do you use 40mcg/kg?
Click to expand...

Have you ever given all 1000mcg to an awake 70kg 30 y/o patient? It is not as dramatic as you'd think.
 
Thanks... but still a little skeptical. Biggin's with potential diff. aw will get prop/sux over prop/alfenta(or remi). I just can't imagine "intubating conditions" being any better than prop/sux. Paralysis is nice to have on these biggn's. Nothing beats sux IMHO.

Now.... there is the pedi population... for which an inhalational induction + a slug of propi works extremely well... 🙄

Blocking the "hemodynamic response to intubation" can be achieved in a billion different ways. Not just remi or alfenta.... although they are great agents if you are getting in and out.

Give 30-40 mg of esmolol before intubation on someone with a decent heart rate and you'll "blunt the hemodynamic response to intubation"
 
Last edited:
jetproppilot said:
I'm ABSOLUTELY SURE you did nothing to alter your patient's circling the toilet course.

Here's something to consider next time:

Have the nurses acquire for you a 5mg/mL midazolam vial.

It's green lettered I think.

Thank her upon possession.

Pull it up in a 5mL syringe with IVF from pt so you have 1mg/mL.

Gotta tell ya man:

MIDAZOLAM IS A GREAT AMNESTIC FOR HEMODYNAMICALLY UNSTABLE PATIENTS THAT NEED A SNORKEL.

We use midazolam every day in the pre-op area for our ultrasound guided nerve blocks/epidurals, most of the time giving all five milligrams.

I've used it extensively in the ICU as well.

I've been in your position. Here's how it would go if I were where you were, after acquiring and appropriately diluting said midazolam:

Jet gives 2mg (2 mL) midazolam via IV...

BTW wanna the most important parts of a situation like this is for you the anesthesiologist to have a

FREE FLOWING IV


so the drugs administered will work.

In the ICU all IVs are on pumps.

Take ONE off a pump so it's FLOWING.

Can't emphasize this enough.

Free flowing IV. Don't compromise on this. You are gonna give some drugs in the IV. You are in a foreign environment. The last thing you need to worry about is

"DID THE DRUG GET TO THE PATIENT?"

Trust me.

Free flowing IV.

Back to the midazolam...

give two.

Stand back, wait a minute or so, think about whatcha want for dinner.

SPAGHETTI!!!

BAck to reality, minute passed, interact with pt to see if he's buzzed out or not. Here's the answers:

1) Jet: "DUDE?"

If response is "YEAH?"

give the rest.

2) Jet: "DUDE?"

If no response, Dude's a lightweight but more importantly

you've achieved your amnestic goal so go ahead with the 40 mg succinylcholine

so you can put the tube in.

MIDAZOLAM.

The best drug for

INTUBATION IN THE ICU

in my humble opinion.

Give a little.

If forced

GIVE MORE.

It's still all good.

With minimal-to-no hemodynamic swings.

And no adrenal suppression worries in an already compromised ICU pt who may need every molecule of circulating corticosteroid so they don't show up as a number in the

Etomidate May Clandestinely Kill Patients

studies.
Click to expand...

there has been some literature out there that has suggested that benzos also contribute to adrenal suppression however the mech is unknown. Although a little benzos, and fent plus paralytic is what i use for these guys with minimal HD swings. I personally seen 2 people (responded to codes) die in the ICU because of pushing propofol on respiratory cripples.
 
sevoflurane said:
unless you guys are talking 'bout awake intubations....🙄

I doubt prop/alfenta is anywhere near as good as prop/sux. I'd be very skeptical of such a paper....:uhno:

But... maybe I just have to try it and see...🙂
Click to expand...

The only thing that beats propofol/sux is pentothal/sux.

Try propofol/alfenta and see how it works. You may be surprised.

When I was a resident doing ICU intubations and stuff I never really fooled around with narcotics/benzos. Too much trouble to get ahold of them.
 
Arch Guillotti said:
The only thing that beats propofol/sux is pentothal/sux.

Try propofol/alfenta and see how it works. You may be surprised.

When I was a resident doing ICU intubations and stuff I never really fooled around with narcotics/benzos. Too much trouble to get ahold of them.
Click to expand...

Same here. Hard to get quickly. More paperwork.
 
Well i don't think it's dramatic it's just that 30mcg/kg of alfentanil is not as good a 4mcg/kg of remi
Click to expand...
How do you give the remi? Small boluses or infusion with a pump?
 
epidural man said:
As someone pointed out - you may not even need paralysis.

There is data - where the intubater was blinded to the drug given, and a propofol and alfentanil induction was viewed the same as propofol and sux for intubating conditions.

Alfentanil is really cool - way fast, and lasts just a moment.
Click to expand...

I like it too. Have been burned with chest wall rigidity, though. I've always got the sux ready to go.
 
cchoukal said:
I'm in this camp. If you want to blunt the hemodynamic response, then blunt the HEMODYNAMIC response.
Click to expand...

Esmolol controls the heart rate, not the hypertension. So you can mix different drugs to get the desired effect or just use 2 prop/alfenta or remi easy fast and 100% effective (for the hemodynamics not the quality of intubating conditions)
 
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