Induction on the wards

[CavGas]

Greetings to everybody!

I have been lurking on this forum since I was a medical student interested in anesthesia and now that I'm finally a resident my time has come to ask a clinical question, for all the wiser people than me to answer..

So I'm a CA-1 outside the States and here we are expected to carry the airway pager after some months of on the job training, so it will be pretty common for me to have to induce a patient by myself.
The thing is we aren't encouraged to use any paralytic, so my question is: What would be the drug/drugs of your choice to provide optimal(the best possible?) intubating conditions without NMB and furthermore, how to optimally treat the ensuing hypotension?
Patients are usually one of these types: type 2 resp failure/ pulm edema with hypoxemia due to various heart disease/ reduced GCS for any reason.

Thanks in advance to anybody taking the time to answer!

P.S: Excuse my English, it ain't my first language!

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[2buckchuck]

What reason do the powers that be have for not using NMB to intubate?

 

[vector2]

Greetings to everybody!

I have been lurking on this forum since I was a medical student interested in anesthesia and now that I'm finally a resident my time has come to ask a clinical question, for all the wiser people than me to answer..

So I'm a CA-1 outside the States and here we are expected to carry the airway pager after some months of on the job training, so it will be pretty common for me to have to induce a patient by myself.
The thing is we aren't encouraged to use any paralytic, so my question is: What would be the drug/drugs of your choice to provide optimal(the best possible?) intubating conditions without NMB and furthermore, how to optimally treat the ensuing hypotension?
Patients are usually one of these types: type 2 resp failure/ pulm edema with hypoxemia due to various heart disease/ reduced GCS for any reason.

Thanks in advance to anybody taking the time to answer!

P.S: Excuse my English, it ain't my first language!

I've heard of a couple places like this inside and outside the states where paralytic is "discouraged" and honestly this is very, very stupid policy. It is well-established that NMB increases first-pass intubation success in adults. Therefore, either paralytics should be used (assuming the patient isn't full-on flaccid coding and has some muscle tone), or intubation should be delayed.

If you are unable to use paralytics solo, I would suggest non-invasive airway maneuvers, call your attending, and then proceed to induce with paralytic when they are present. If your attending is not in house but you must intubate, call for a difficult airway cart, have videolaryngoscopy immediately available, induce, give rocuronium, and have sugammadex available.

 

[Beeftenderloin]

Not encouraged or not allowed? Those are very different things.

Sometimes the best way to intubate someone with a soft BP and poor mental status is a paralytic only induction (typically sux at my place), 1-2 of midazolam if you’re feeling charitable and have push dose pressers available.

little more room on BP and more awake, etomidate + sux/roc.

If you’re really not allowed to paralyze then an induction dose of ketamine would be my move. Patient keeps breathing with favorable effects on hemodynamics.

Also keep in mind, in patients that are hypotensive and/or decreased GCS, the induction dose of medications is a fraction of what it is in healthy people. Sometimes as little as 1/10 of the dose.

 

[morri493]

Our program also discourages paralytic use without an attending present. I concur that you want 'ideal' intubating conditions the first time, and that this includes paralysis - it has been somewhat frustrating to go to airways knowing you're making it harder on yourself. That being said, I always know the K, and any contraindications prior to induction in case we need to add SCh, and i have 10 mL of rocuronium drawn up and in my pocket. If it looks like it wont be an easy intubation, i'll call the attending and tell them that I plan on using paralysis if they want to come. I also now carry sugammadex in my pocket when I'm carry the airway pager.
When I don't paralyze, I use propofol on nearly everybody. I've had the masseter muscle rigidity too much with etomidate to use it without paralysis. We have a large number of pts with pulmonary HTN, so if possible I have them start an epi infusion prior to induction, or i'll bolus 4-10mcg prior to induction with propofol. Otherwise in a more 'urgent' induction ill give 200mcg phenyleprine prior to propofol induction, and usually chase it with another 100mcg. If they're really unstable and I need to induce with midazolam or fentanyl I'll do that, but knowing that it will take longer to get the meds and for them to take effect. Very frequently our pts in extremis will requrie much less than the 1-2.5 mg/kg dose of propfol - I'm much more of the start low and go slow style with propofol on the floor. Unfortunately, getting ketamine on the floors is usually a challenge as well and will take too long in a pt that needs emergent intubation.
With enough 'pressor premedication', you can safely induce AS, pulm HTN, etc with propofol.

Again.... I think using a paralytic alleviates most of the challenges/frustrations of floor intubations in an unstable pt.

 

[vector2]

Our program also discourages paralytic use without an attending present. I concur that you want 'ideal' intubating conditions the first time, and that this includes paralysis - it has been somewhat frustrating to go to airways knowing you're making it harder on yourself. That being said, I always know the K, and any contraindications prior to induction in case we need to add SCh, and i have 10 mL of rocuronium drawn up and in my pocket. If it looks like it wont be an easy intubation, i'll call the attending and tell them that I plan on using paralysis if they want to come. I also now carry sugammadex in my pocket when I'm carry the airway pager.
When I don't paralyze, I use propofol on nearly everybody. I've had the masseter muscle rigidity too much with etomidate to use it without paralysis. We have a large number of pts with pulmonary HTN, so if possible I have them start an epi infusion prior to induction, or i'll bolus 4-10mcg prior to induction with propofol. Otherwise in a more 'urgent' induction ill give 200mcg phenyleprine prior to propofol induction, and usually chase it with another 100mcg. If they're really unstable and I need to induce with midazolam or fentanyl I'll do that, but knowing that it will take longer to get the meds and for them to take effect. Very frequently our pts in extremis will requrie much less than the 1-2.5 mg/kg dose of propfol - I'm much more of the start low and go slow style with propofol on the floor. Unfortunately, getting ketamine on the floors is usually a challenge as well and will take too long in a pt that needs emergent intubation.
With enough 'pressor premedication', you can safely induce AS, pulm HTN, etc with propofol.

Again.... I think using a paralytic alleviates most of the challenges/frustrations of floor intubations in an unstable pt.

These kinds of policies about paralytic sound like something a nurse would come up with, and ultimately are more dangerous for the patient from an aspiration and too-much-induction-drug standpoint. Attendings either need to get their a$$ out of bed and help the resident intubate or allow the resident to push paralytic, end of story.

 

[Mikkel]

You don't need paralytics for every intubation. You just need to right scope and right amount of force to get a tube through the cords.

 

[vector2]

Usual caveat about observational study/single center/propensity matching, etc:

Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit. A propensity matched analysis - PubMed

After controlling for potential confounders, this propensity-adjusted analysis demonstrates improved odds of FAS at intubation in the ICU with the use of an NMBA. This improvement in FAS is seen even with the use of a video laryngoscope.

www.ncbi.nlm.nih.gov

 

[nimbus]

You don't need paralytics for every intubation. You just need to right scope and right amount of force to get a tube through the cords.

True but it makes it easier. That’s why we paralyze for 99% of intubations in the OR.

 

[deleted697535]

Why are you 'inducing' on the wards. Don't do that. What drugs are you inducing with?
No one needs a tube on the wards.
Even if they're cardiac arrest. You can tube those ppl if you want but there is evidence they do worse anyway.

Pop in an oral airway, get an ambu with 10 peep valve & move them to icu/hdu resus. Give them with some fluids and get an art line. Then decide if you want to tube. Remember most arrests in adults are not upper airway obstructions so even your tube probably won't help the majority

There are so many reasons not to tube even peri arrest ppl on the wards and almost no good reasons to do it. Staff and RNs are not familiar with it, you don't have any equipment. Beds are ****. No suction etc. No capnogram

If you intubate the esophagus and don't recognize it your patient is dead and it's 100% your fault. You will thank me when I save you going to court...

Paralyze if you wish or not. It doesn't really matter if you are skilled with 'awake sedated intubations' it's not too difficult to avoid paralysis on 99% of ppl but it takes years to get there plus patient selection good topicalisation sedation etc...

All these studies on paralysis vs none increases first pass success mean very little when one is an airway expert that does afoi or awake glides all the time. The practioners in these studies are not that expert.

 

[CavGas]

Didn't expect so many responses that fast! So..

@2buckchuck

They cite increased risk of anaphylaxis + avoidance of can't intubate/can't ventilate since theoretically pts maintain SV.



@vector2

Well.. the attending is usually 5mins away if we call them.. but unless it looks like a really bad airway we gotta try with the NO NMB method first so I can't just deny to intubate and go against departmental ''policy'' I guess... I'm aware of the studies about NMB's making it easier and nobody is actually gonna take the syringe of paralytic out of my hand, but if I come across any issues with ''unauthorized'' NMB I 'm gonna be in serious trouble.


@Beeftenderloin

So in some cases 20mg of prop would be enough? I 'll keep it mind and try to titrate. How about ketamine and propofol combination? Have you come across that?


@Newtwo

I know.. The situation on the wards is horrible but these pts probably need ICU/HDU care which many times is in a different hospital ( limited ICU beds ). Thus the ICU people require a secure A/W before they come to evaluate for admittance/transfer.
On the other part of the question, these are not ''awake'' looks. More senior residents I ' ve seen push induction doses of etom/prop or midaz +- fent and DL with a mac blade..

 

[NICMAN]

I can’t tell you how many times I gave 4% lido through a BIPAP and did an awake FOI. the first thing I did every single time was check for a gag/cough, and depending on the amount of gag response i would topicalize accordingly . It is the safest way to intubate. if the patient is in extremis then you practically need no induction or paralytic. Hypoxia is a pretty good muscle relaxant. On the other hand, there are airways that will require either NMB or an awake technique depending on the patient state or anatomy.

also, alfentanyl provides a nice relaxed airway but only gives you one shot. I have used that fairly often in ICU settings With a little midazolam.

 

[nimbus]

also, alfentanyl provides a nice relaxed airway but only gives you one shot. I have used that fairly often in ICU settings With a little midazolam.

Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil - PubMed

We have noted that tracheal intubation can be accomplished in many patients after induction of anesthesia with propofol and alfentanil without the simultaneous use of muscle relaxants. This study was designed to evaluate airway and intubating conditions after administration of propofol and...

www.ncbi.nlm.nih.gov

I’ve done propofol/alfenta a few times during residency. Worked about as well as mivacurium. Never really felt a need to do it in practice.

 

[caligas]

It’s not just patient safety at stake.

I was also trained NOT to use paralysis for floor intubation.

During floor Intubation of hep c patient with UGI bleed 12 years ago, he coughed a bunch of black blood into my face and eyes.

100mg of roc for everyone since!

 

[agolden1]

CA-2 chiming in. Appreciate the great discussion. We start carrying the code pager as CA2s.

Agree with only using a fraction of propofol to induce people. As do more vascular/cardiac/SICU/90 year old ortho trauma, you'll get a better sense of how much to use to induce people if you're going to use it. No magic formula, just a matter of knowing the history and eyeballing. I've put people in the aforementioned category to sleep with 10-20 mg of propofol and had a stiff drop in BP as a result. I always have some phenylephrine on hand during code calls if I decide to go this route just in case.

If I'm even the least bit nervous, I'll have a nurse grab midazolam and fentanyl. Ketamine hard to come by on the floors. Given that we have easier access to midazolam and fentanyl I usually just go this route, but we can call for ketamine if need be. Still not using a lot of etomidate, but that seems to be global across the institution. My best friend in EM thinks we're nuts. While I realize it is becoming more commonly used in certain scenarios, I figured the last thing I would need is to push it on some patient who is more ill than I anticipate then end up with admin asking why I was pushing etomidate in critically ill patients...

We can push paralytic at my shop, but don't have access to sugammadex. If there's a prior history of difficult airway or it looks like something bad, attendings have our backs and will show up. Haven't had to do solo awake FOI on floors. If I was that concerned, attending would know first before I proceeded.

 

[nimbus]

CA-2 chiming in. Appreciate the great discussion. We start carrying the code pager as CA2s.

Agree with only using a fraction of propofol to induce people. As do more vascular/cardiac/SICU/90 year old ortho trauma, you'll get a better sense of how much to use to induce people if you're going to use it. No magic formula, just a matter of knowing the history and eyeballing. I've put people in the aforementioned category to sleep with 10-20 mg of propofol and had a stiff drop in BP as a result. I always have some phenylephrine on hand during code calls if I decide to go this route just in case.

If I'm even the least bit nervous, I'll have a nurse grab midazolam and fentanyl. Ketamine hard to come by on the floors. Given that we have easier access to midazolam and fentanyl I usually just go this route, but we can call for ketamine if need be. Still not using a lot of etomidate, but that seems to be global across the institution. My best friend in EM thinks we're nuts. While I realize it is becoming more commonly used in certain scenarios, I figured the last thing I would need is to push it on some patient who is more ill than I anticipate then end up with admin asking why I was pushing etomidate in critically ill patients...

We can push paralytic at my shop, but don't have access to sugammadex. If there's a prior history of difficult airway or it looks like something bad, attendings have our backs and will show up. Haven't had to do solo awake FOI on floors. If I was that concerned, attending would know first before I proceeded.

1. Etomidate has its problems but it is the most hemodynamically stable induction agent. You should at least try it.

2. They have and use sugammadex in Mexico. It is god’s gift to anesthesia. Hard to believe you can’t get access to it at an academic hospital.

 

[Quixotic2501]

If the patient is coding, they don't get a thing from me. Tube goes in.

Otherwise, etomidate/roc are my go-tos with push dose pressors or an infusion of norepi or epi if the patient's current physiology calls for it. I was never able to find any convincing evidence that a single dose of etomidate was linked to worse outcomes. Sometimes you have all the time in the world to actually intubate the patient, and I have placed a-lines in patients prior to induction if I am really worried. I've also gone down to the pharmacy and grabbed a box of suggamadex for a patient that I though could be a potential difficult airway.
Roc is my go to because a lot of the times these patients have been immobile for a while and the covering team may not know the full story--or at least the parts that are important to me. If you didn't think you'd find yourself in a "can't intubate, can't ventilate scenario," and you've induced in an already tenuous patient, you're most likely hosed whether or not you used paralytic. In this situation, stabilize and get the patient to a place where you can safely do an awake.
If the patient has been marked a difficult airway or you think the patient will be difficult, call back up. As a resident, you should always have attending back up available. I was called to intubate a patient that had been marked difficult in our EMR twice. I checked the notes--unfortunately, the documentation was poor. It looked like the prior MDs had difficulty visualizing the cords (use of a D-blade, 2-3 attempts with a CMAC). Patient didn't look difficult in terms of masking or intubating. Patient just needed a secured airway and wasn't about to die in the next few minutes. Being the cocky CA-3 that I was, I induce, paralyze, and use an AirTraq. No problem visualizing the cords, but I absolutely cannot pass the tube. Come out, ventilate. Try another attempt with a McGrath and a different curve, but I have the same issue. Come out again, ventilate. Look at the patient's neck, and I see that he has a tracheostomy scar. I pass a 6.5 tube with a little bit more force than I typically have to use to get the tube in. Obviously, the next step would have been to place an LMA and get the patient to the ICU, but I wish I had another set of trained eyes in that situation.

Basically, evaluate the situation, come up with an appropriate plan A and a plan B, and execute. More often than not, you should probably paralyze. Inform the receiving team that the patient is PARALYZED and will need SEDATION.

 

[Paingas]

Lots of dumb way to academic answers here IMO. If a patient is that sick and they need to be tubed on the floor. Etomidate and ROC no questions asked. RAMP RAMP RAMP to get the best view. Use the blade your most comfortable, make sure you have back up coming to help you out before you push drugs , have an LMA ready, bougie next to you and if you have to cric. remember the patient is already paralyzed and sedated and just do it. I did an emergency cric as a trainee and it saved patients lives as an attending.

 

[MoMoGesiologist]

Never delayed an airway to place an aline... if youre that worried, give roc and nothing else. CHANGE. MY. MIND!

 

[Beeftenderloin]

Never delayed an airway to place an aline... if youre that worried, give roc and nothing else. CHANGE. MY. MIND!

Much easier to apologize to a patient for recall than to a family for killing their relative.

 

[abolt18]

Got called to a floor intubation that MICU was trying to tube and admit to ICU the other night after they were unable to intubate. The remarkable thing is that after they took a first look with glidescope and couldn't pass the tube, he was rapidly desatting (got to the 40s) and they immediately decided to place an LMA and call for help. Maybe their threshold was low because as they pushed midazolam he told them he had a hx of difficult intubation. I was just surprised and impressed that they quickly went to the rescue with LMA and called for help rather than keep digging around creating a bloody gross airway

SpO2 was 100% when I got there so it was clear we had plenty of time to take it slow. Just got a peds scope w aintree through the LMA then slide tube over the aintree. Worked great.

 

[Ronin786]

Never delayed an airway to place an aline... if youre that worried, give roc and nothing else. CHANGE. MY. MIND!

Did it before in fellowship. Poorly mentating, morbidly obese gentleman with terrible pancreatitis and what turned out to be a GDA bleed. SPO2 is hovering around 90-92% and cant get an accurate NIBP. Entire MICU running around with their heads chopped off. I was the rotating fellow and attending called the anesthesia team to intubate due to privileges.

No matter what combination of drugs we would have pushed on this guy, with a crappy cuff and the added PPV was going to result in chest compressions IMO. I dropped a femoral arterial line in and everybody calmed the **** down, despite SBP being in 60s to 70s. Allowed us to get a vasopressor hanging and did a controlled intubation.

Could we have done the same with 2 of midazolam (+/-), 100mg of roc and 6 sticks of phenylephrine? Yes. But people routinely forget about the human element and how uncontrolled scenarios result in poorer care.

I know you know that PPV can often times be lethal in these patients and having the ability to rapidly titrate meds is important to me. We do it in the OR before putting these patients to sleep, so why not in the ICU? Similarly I've had dozens of scenarios where the floor team tries to get me to intubate a crashing patient on the floor. I can do it and make it look easy, but I've also seen enough sick patients to know that I can safely transport them to a more controlled setting and do it there.

 

[Shimmy8]

There’s a reason it’s prop-sux-tube and not just prop-tube.

 

[vector2]

Did it before in fellowship. Poorly mentating, morbidly obese gentleman with terrible pancreatitis and what turned out to be a GDA bleed. SPO2 is hovering around 90-92% and cant get an accurate NIBP. Entire MICU running around with their heads chopped off. I was the rotating fellow and attending called the anesthesia team to intubate due to privileges.

No matter what combination of drugs we would have pushed on this guy, with a crappy cuff and the added PPV was going to result in chest compressions IMO. I dropped a femoral arterial line in and everybody calmed the **** down, despite SBP being in 60s to 70s. Allowed us to get a vasopressor hanging and did a controlled intubation.

Could we have done the same with 2 of midazolam (+/-), 100mg of roc and 6 sticks of phenylephrine? Yes. But people routinely forget about the human element and how uncontrolled scenarios result in poorer care.

I know you know that PPV can often times be lethal in these patients and having the ability to rapidly titrate meds is important to me. We do it in the OR before putting these patients to sleep, so why not in the ICU? Similarly I've had dozens of scenarios where the floor team tries to get me to intubate a crashing patient on the floor. I can do it and make it look easy, but I've also seen enough sick patients to know that I can safely transport them to a more controlled setting and do it there.

How did you induce?

 

[dannyboy1]

My go to in residency was one 10 cc syringe, half filled with etomidate, the other half with paralytic. Push and tube. Glidescope every time (I don’t fool around on the floor). Never had a problem.

 

[Timeoutofmind]

Got called to a floor intubation that MICU was trying to tube and admit to ICU the other night after they were unable to intubate. The remarkable thing is that after they took a first look with glidescope and couldn't pass the tube, he was rapidly desatting (got to the 40s) and they immediately decided to place an LMA and call for help. Maybe their threshold was low because as they pushed midazolam he told them he had a hx of difficult intubation. I was just surprised and impressed that they quickly went to the rescue with LMA and called for help rather than keep digging around creating a bloody gross airway

SpO2 was 100% when I got there so it was clear we had plenty of time to take it slow. Just got a peds scope w aintree through the LMA then slide tube over the aintree. Worked great.

Can you just use a regular scope with the aintree? U need a peds scope specifically? Just curious...

 

[deleted162650]

Can you just use a regular scope with the aintree? U need a peds scope specifically? Just curious...

Skip the aintree, and just intubate over the scope through the LMA. If you put a bronch adapter on the ETT, you can do all this while continuously ventilating until it’s time to remove the LMA. When sliding out the LMA, you can use a 2nd ETT that’s one size smaller as a plunger to prevent the ETT from backing out with the LMA.

 

[cchoukal]

Awake, topical glide vs DL. No paralytic necessary. Screaming kept to a minimum.

 

[abolt18]

Skip the aintree, and just intubate over the scope through the LMA. If you put a bronch adapter on the ETT, you can do all this while continuously ventilating until it’s time to remove the LMA. When sliding out the LMA, you can use a 2nd ETT that’s one size smaller as a plunger to prevent the ETT from backing out with the LMA.

Never considered this. I like it though! On the other hand, I think it would have forced is to place a smaller tube in this huge guy.

 

[abolt18]

Can you just use a regular scope with the aintree? U need a peds scope specifically? Just curious...

Aintree is a snug fit over the peds scope.

 

[dhb]

I don’t fool around on the floor

Such a waste of your MD name tag

 

[deleted162650]

Never considered this. I like it though! On the other hand, I think it would have forced is to place a smaller tube in this huge guy.

Depends on the particular LMA you’re using. Most 5’s will take a 7.0 no prob and some will even accommodate bigger (giggidy). In your downtime, experiment passing tubes through LMA’s to see what fits. Lube is your friend (giggidy, giggidy).

 

[coffeebythelake]

True but it makes it easier. That’s why we paralyze for 99% of intubations in the OR.

not to mention gag reflex, coughing, resistance against your efforts, etc...
there's a reason why we use paralytics in most cases

 

[Ronin786]

How did you induce?

Can't remember the exact cocktail, but we started vaso/levo gtts and the MAP immediately stabilized. I think it was a little propofol/roc and they did ok.

Main point being, half the time you're called to intubated somebody you can afford to wait a decent amount of time unless it's a code.

 

[agolden1]

1. Etomidate has its problems but it is the most hemodynamically stable induction agent. You should at least try it.

2. They have and use sugammadex in Mexico. It is god’s gift to anesthesia. Hard to believe you can’t get access to it at an academic hospital.

1) Absolutely and I have. Its just no one else in my program uses it. Don't want to stand out like a sore thumb. But I'll ask around some more. I don't think I'd have a problem using it out of training.

2) Seriously. We don't have access to it. I know a grand total of one attending in our program who has pushed it. Pharmacy severely restricted access because of cost

 

[coffeebythelake]

1) Absolutely and I have. Its just no one else in my program uses it. Don't want to stand out like a sore thumb. But I'll ask around some more. I don't think I'd have a problem using it out of training.

I love using etomidate on sick ass patients. Do you know what sticks out like a sore thumb more? When your patient codes with a heavy hand of propofol. You can bet people will ask why not using something more hemodynamically stable?

 

[MoMoGesiologist]

Skip the aintree, and just intubate over the scope through the LMA. If you put a bronch adapter on the ETT, you can do all this while continuously ventilating until it’s time to remove the LMA. When sliding out the LMA, you can use a 2nd ETT that’s one size smaller as a plunger to prevent the ETT from backing out with the LMA.

Genius! Will need to try.

 

[Quixotic2501]

Never delayed an airway to place an aline... if youre that worried, give roc and nothing else. CHANGE. MY. MIND!

Probably won't change your mind, but these are non-emergent situations typically. Not all of our airway pages are emergencies. We are called not too uncommonly to the cardiac unit where they infamously have pressors going through a PIV with no a-line sometimes. In these situations, if it can wait, I like to have an a-line.

 

[Arch Guillotti]

Genius! Will need to try.

I think the Aintree method is better.

 

[dannyboy1]

Probably won't change your mind, but these are non-emergent situations typically. Not all of our airway pages are emergencies. We are called not too uncommonly to the cardiac unit where they infamously have pressors going through a PIV with no a-line sometimes. In these situations, if it can wait, I like to have an a-line.

What’s wrong with pressors through a PIV. works just fine. Nothing magical about a central line. Etomidate, sux, tube in and back to the call room.....

 

[deleted162650]

I think the Aintree method is better.

Gotta at least give a reason dude.

 

[WholeLottaGame7]

Didn't expect so many responses that fast! So..

@2buckchuck

They cite increased risk of anaphylaxis + avoidance of can't intubate/can't ventilate since theoretically pts maintain SV.

C'mon man/woman, what's going to kill this patient? The .02% chance of anaphylaxis to a NMB, or not getting the airway? Would you also avoid using succinylcholine in these patients because of the risk of undiagnosed MH?'

Also, you're intubating the patient for one of two reasons: you can't ventilate them, or you can't oxygenate them. "Maintaining SV" only helps with one of those, really, and only for a limited amount of time. If they're reasonably stable, as others have said, you have time to figure out what the alternative plans are.

There is no cut and dried answer to floor intubations. Most of the time it's a whiff of midaz/prop/ketamine/etomidate, then pressors, then sux or roc, then tube. Sometimes it's nothing. Sometimes it's something awake. Sometimes it's page ENT and go to the OR. Sometimes it's ativan for the ICU staff.

It's almost never "whonking doses of anesthetic agents to compensate for not using NMB." Don't worry, you'll figure it out over time. For now, just play the game. Ask them to tell you what they want you to do if they don't want to be there. They'll either tell you some stupid-ass plan like "just give 200 of propofol and go for it" and then you can do it, and when bad things happen, it'll be their fault, and you'll know what not to do when you're calling the shots. Or they'll say "do whatever you think is best," and you can come up with your own plan and be responsible for your own outcomes.

 

[fakin' the funk]

What’s wrong with pressors through a PIV. works just fine. Nothing magical about a central line. Etomidate, sux, tube in and back to the call room.....

Pressors through peripheral IVs can easily extravasate and cause tissue necrosis. The magical thing about CVCs is that that theoretically can't happen. Back to your call room, then.

 

[fakin' the funk]

My go to in residency was one 10 cc syringe, half filled with etomidate, the other half with paralytic. Push and tube. Glidescope every time (I don’t fool around on the floor). Never had a problem.

You're describing 10mg etomidate and 50mg rocuronium. Sounds reasonable.

 

[nimbus]

What’s wrong with pressors through a PIV. works just fine. Nothing magical about a central line. Etomidate, sux, tube in and back to the call room.....

In my experience, about 60% of our floor IV’s are actually intravascular.

 

[coffeebythelake]

In my experience, about 60% of our floor IV’s are actually intravascular.

i never trust floor IVs

 

[dannyboy1]

i never trust floor IVs

Yeah. But if you are about to push etomidate and roc through it I’m assuming you flushed it first. If it’s good enough for the induction then it’s good enough for pressors pushes too....

 

[Bryan O’Blivion]

Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil - PubMed

We have noted that tracheal intubation can be accomplished in many patients after induction of anesthesia with propofol and alfentanil without the simultaneous use of muscle relaxants. This study was designed to evaluate airway and intubating conditions after administration of propofol and...

www.ncbi.nlm.nih.gov

I’ve done propofol/alfenta a few times during residency. Worked about as well as mivacurium. Never really felt a need to do it in practice.

I really like this technique. I’ve found the time until ideal intubating conditions to be pretty similar to RSI dose roc. The alfenta does drop the blood pressure, I’ve noticed, so it seems wise to choose carefully when to employ this, but overall, it’s a pretty smooth technique. Maybe I’ve not done it enough, but I haven’t seen any chest wall rigidity, which I have seen with remi inductions.

Regarding the original question, there is no one solution to every problem regarding an airway page. In an arrest, you don’t need anything, and a lack of paralysis can be helpful for ascertaining the return of consciousness post ROSC. If called for an intubation for anaphylaxis, angioedema, asthma, etc. would strongly encourage the use of paralytic and induction agent.

Agree with above posters about the use of etomidate, with the caveat that even low dose etomidate can kill the fragile patient, severe sepsis, hemorrhagic shock, etc. and it’s wise to consider epinephrine or phenylephrine. Vasopressin is great but it’s almost never nearby unless you are in the ICU, cath lab, or coding someone in the pharmacy.

In short, you kind of have to know the patient’s pathology. Kind of like you do everyday.

 

[fakin' the funk]

Thinking about this as "inducing" on the wards is very wrong. Inducing GA is not something you should do on the ward.

If there is a need for intubation it is almost always either because a code is going on (no need for hypnotic, maybe no need for NMB) or it can wait until the patient is moved to ICU (probably have better equipment, meds, personnel, etc).

Rarely, there is an emergent need for intubation where the patient hasn't coded yet but might very soon if oxygenation/ventilation arent assisted. Think decompensated sepsis/PNA or GI bleed etc. Probably, this patient is obtunded (or combative) and needs little or no meds other than NMB. Maybe 10-20mg propofol along with your NMB. Remember - pts in shock generally have no recall whatsoever of their "extremis" period. Midazolam/fentanyl is what most nonanesthesiologists will do here and it doesn't help for the reasons above (NMB facilitates intubation).

If you have one of these above scenarios and the patient looks truly difficult/impossible to intubate, then grab your scalpel while you call your surgeon colleagues.

 

[deleted697535]

Never delayed an airway to place an aline... if youre that worried, give roc and nothing else. CHANGE. MY. MIND!

Junior trainees please ignore this.
There is no never in this business.

Each one is a case by case basis.