Induction questions

[TorpedoSN18]

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Long time lurker here, currently a senior resident. This question is inspired by a recent thread of anesthesia dogma. Can proponents of "push paralytic before establish BMV" expand on their rationale? I understand the argument that pushing induction agent is the point of no return, but I have MANY attendings who are adamantly opposed to this technique. They give a good argument that paralyzing the patient before establishing ventilation will not be defensible in court. Is that legitimate concern? Is there ever a scenario where waking up the patient is a reasonable airway management plan?

A followup question is your choice of Sux vs non-depolarizer as paralytic agent (Assuming no sux contraindications, not an RSI, and not a super short case). What is your rationale? What is your dose?

Thanks in advance!

 

[Ezekiel2517]

Not being able to establish ventilation is much more indefensible in court. The paralytic helps you ventilate. At the end of the day, do what you're comfortable with and stay out of court. Personally, I never mask ventilate at all. The mask doesn't even come out of its plastic packaging

 

[nimbus]

Let me pose this question. Has anybody ever given the induction agent and then NOT given nmb after attempting to ventilate?

I personally mix the prop/roc/lido in the same syringe, skip mask ventilation, and go straight to intubation when they become apneic.

 

[dhb]

Not being able to establish ventilation is much more indefensible in court. The paralytic helps you ventilate. At the end of the day, do what you're comfortable with and stay out of court. Personally, I never mask ventilate at all. The mask doesn't even come out of its plastic packaging

Do you use sux on everybody?

 

[urge]

Not being able to establish ventilation is much more indefensible in court. The paralytic helps you ventilate. At the end of the day, do what you're comfortable with and stay out of court. Personally, I never mask ventilate at all. The mask doesn't even come out of its plastic packaging

Do you pre oxygenate? How?

 

[facted]

Easiest mask ventilation is paralyzed. If you can't ventilate, you'll try to intubate. Easiest intubation is paralyzed. If you can't ventilate, and then struggle for 30-45 seconds and then decide to paralyze, you've just wasted 45 seconds of O2 reserve.

Your ability to identify a patient you can't intubate AND can't ventilate before putting them to sleep is why you're an anesthesiologist.

 

[skypilot]

Easiest mask ventilation is paralyzed. If you can't ventilate, you'll try to intubate. Easiest intubation is paralyzed. If you can't ventilate, and then struggle for 30-45 seconds and then decide to paralyze, you've just wasted 45 seconds of O2 reserve.

Your ability to identify a patient you can't intubate AND can't ventilate before putting them to sleep is why you're an anesthesiologist.

Agree. If I have concerns about securing the airway quickly I will use sux and have a videolaryngoscope ready. If I am really concerned then its fiberoptic awake. Every rapid sequence is without ventilation, and there are many reasons to do a rapid sequence. In residency, you need to develop your bag mask ventilation skills, and you have plenty of backup, so you ventilate every patient. When you are working alone, out in practice, you don't need to prove you can properly use a bag and mask, so you use your judgement and may choose not to ventilate, just secure the damn airway as quickly as possible.

 

[anbuitachi]

Let me pose this question. Has anybody ever given the induction agent and then NOT given nmb after attempting to ventilate?

I personally mix the prop/roc/lido in the same syringe, skip mask ventilation, and go straight to intubation when they become apneic.

thats really quick. do you give a huge dose of roc to everyone

 

[pgg]

A followup question is your choice of Sux vs non-depolarizer as paralytic agent (Assuming no sux contraindications, not an RSI, and not a super short case). What is your rationale? What is your dose?

Succinylcholine myalgias are real and miserable. I don't use succinylcholine unless I have an indication for it (RSI, or a desire to achieve optimal conditions very quickly).

For a short case consider
1) Not using any relaxant at all.
2) Using less relaxant - 0.6 mg/kg is the "standard" intubating dose of rocuronium, but the ED95 is 0.3 mg/kg. You probably don't need zero twitches to intubate and the surgeon definitely doesn't need zero twitches to operate. Either wait a couple minutes, or just intubate without a completely relaxed patient.

 

[anbuitachi]

Succinylcholine myalgias are real and miserable. I don't use succinylcholine unless I have an indication for it (RSI, or a desire to achieve optimal conditions very quickly).

For a short case consider
1) Not using any relaxant at all.
2) Using less relaxant - 0.6 mg/kg is the "standard" intubating dose of rocuronium, but the ED95 is 0.3 mg/kg. You probably don't need zero twitches to intubate and the surgeon definitely doesn't need zero twitches to operate. Either wait a couple minutes, or just intubate without a completely relaxed patient.

yea the surgeons need negative twitches. i keep telling them my twitch monitor is getting 0 twitches but they keep telling me the muscle fibers twitch when they bovie and ask for more paralysis

 

[nimbus]

thats really quick. do you give a huge dose of roc to everyone

No. Never more than 50mg. I often used 30mg for our 15min (operative time) lap choles until we got sugammadex. Sometimes they cough a little but who cares.

 

[anbuitachi]

No. Never more than 50mg. I often used 30mg for our 15min (operative time) lap choles until we got sugammadex. Sometimes they cough a little but who cares.

Haha I saw some guy intubate after patient went apneic. Roc hasn't really kicked in fully yet. Tubed the patient and tube came back out cause he bucked

 

[Aether2000]

Intubating without paralytics risks vocal cord injury when the tube is forced through the cords- I have seen two cases of this where anesthesiologists intubated with propofol plus fentanyl only. See the discussion at Endotracheal Intubation Without Neuromuscular Blocking Agents: Is It a Good and Safe Option? . Perhaps a safe sequence would be preoxygenate, induction, mask ventilation x 1-2 breaths at least, if unable to ventilate place oral airway, if unable to ventilate place intubating LMA, then neuromuscular blocker if able to ventilate then intubation.

 

[Robotic Wis-Hipple]

I feel like I've voiced my opinion here a few times so I'll just provide this link for you to review.

https://www.mc.vanderbilt.edu/docum...k ventilation before administering the MR.pdf

 

[Aether2000]

Nice article! Good references, excellent arguments.

 

[nimbus]

I would also add that sugammadex changes the game. You are no longer irreversibly burning a bridge by giving NMB up front.

 

[nimbus]

Haha I saw some guy intubate after patient went apneic. Roc hasn't really kicked in fully yet. Tubed the patient and tube came back out cause he bucked

Interesting. I've never seen that. Even when they aren't fully paralyzed the patients are pretty damn weak by the time I go to intubate. Most of the time they seem fully relaxed. If they cough at all it's very weak. Maybe that guy doesn't mix the induction agent and NMB in the same syringe. I do it that way because it works. I can hold the mask and push my 1 syringe without assistance and I get great intubating conditions.

 

[nimbus]

Intubating without paralytics risks vocal cord injury when the tube is forced through the cords- I have seen two cases of this where anesthesiologists intubated with propofol plus fentanyl only. See the discussion at Endotracheal Intubation Without Neuromuscular Blocking Agents: Is It a Good and Safe Option? . Perhaps a safe sequence would be preoxygenate, induction, mask ventilation x 1-2 breaths at least, if unable to ventilate place oral airway, if unable to ventilate place intubating LMA, then neuromuscular blocker if able to ventilate then intubation.

That seems like a whole bunch of unnecessary steps. How about just pre-O2, RSI, tube for the average patient.

 

[TorpedoSN18]

I've never had GA w sux, so don't know what post myalgia feels like. It seems from what several of you say is best to avoid sux for the average patient to avoid myalgia. If using roc at non-RSI dose (like 0.6mg/kg), then RSI for average patient will not be possible. Also thanks for the article.

 

[anbuitachi]

Never had any issues here , or heard of anyone here w issues intubating w remifentanil instead of paralytic

 

[nimbus]

I've never had GA w sux, so don't know what post myalgia feels like. It seems from what several of you say is best to avoid sux for the average patient to avoid myalgia. If using roc at non-RSI dose (like 0.6mg/kg), then RSI for average patient will not be possible. Also thanks for the article.

Have you tried it? I do it every day.

 

[TorpedoSN18]

No I haven't, I'll try it next week. So good enough intubating conditions in about 60seconds even though the books say need about 3 minutes? (Still talking about ~0.5mg/kg dose roc)

 

[Arch Guillotti]

Never had any issues here , or heard of anyone here w issues intubating w remifentanil instead of paralytic

Need to be very careful with old and/or sick patients. Be ready to give prophylactic neo, glyco, robinul, etc. Very elegant if done properly.

 

[nimbus]

No I haven't, I'll try it next week. So good enough intubating conditions in about 60seconds even though the books say need about 3 minutes? (Still talking about ~0.5mg/kg dose roc)

My usual practice:

Pt to OR.
Fent 50-100mcg IV (rarely use versed)
Moniters
O2 mask to face
Prop 120-200mg/roc30-50mg/lido50 all mixed in one 30ml syringe.(I don't wait for official pre-O2. Just however many breaths they get while I'm pushing the syringe plunger)
Look at capnograph....watch for breaths to trail off.
Tape eyes (one long strip across both eyes)
Intubate

Often I think it's less than 60sec between the time I finish pushing the plunger and when I insert the blade. I've been doing it for years. If I didn't get great intubating conditions, I wouldn't keep doing it.

 

[TorpedoSN18]

nice, thanks for tips

 

[deleted162650]

I'll occasionally mix the PPF/lido/roc in 1 syringe, but it's pretty much just on the younger/healthier patients. I don't typically do it for the older/sicker ones because it takes away my ability to titrate the propofol but still give the dose of roc I want.

I also like to ventilate for at least a few breaths while the roc soaks in. I think knowing just how easy or not easy the patient is to ventilate is helpful information to know when extubation time rolls around.

Never had any issues here , or heard of anyone here w issues intubating w remifentanil instead of paralytic

Never with Remi, but I have used alfentanil in this fashion a number of times back in residency, and yes - it works remarkably well. That being said, I just don't see the need to do it in the real world. 25-30mg of roc is enough to get adequate intubating conditions in damn near everybody, and yet most of the time they never lose all their twitches and are therefore always reversible (even on the shortest of cases). Granted sugga makes this a bit irrelevant.

Intubating without paralytics risks vocal cord injury when the tube is forced through the cords

Uhhh. . . then how 'bout don't force it. If you find yourself intubating a non-paralyzed patient, park the tube just outside the cords and wait for an inhale. With inhalation the cords will abduct nice and wide - tube slides in like buttah.

 

[vector2]

No I haven't, I'll try it next week. So good enough intubating conditions in about 60seconds even though the books say need about 3 minutes? (Still talking about ~0.5mg/kg dose roc)

Give 5mg roc at the end of preox about 10 sec before you push prop/lido and the rest of 0.6mg/kg roc. Intubating conditions will arrive in ~40 secs.

 

[Psai]

Give 5mg roc at the end of preox about 10 sec before you push prop/lido and the rest of 0.6mg/kg roc. Intubating conditions will arrive in ~40 secs.

why not just push all the roc at the beginning

 

[IlDestriero]

Intubating without paralytics risks vocal cord injury when the tube is forced through the cords- I have seen two cases of this where anesthesiologists intubated with propofol plus fentanyl only. See the discussion at Endotracheal Intubation Without Neuromuscular Blocking Agents: Is It a Good and Safe Option? . Perhaps a safe sequence would be preoxygenate, induction, mask ventilation x 1-2 breaths at least, if unable to ventilate place oral airway, if unable to ventilate place intubating LMA, then neuromuscular blocker if able to ventilate then intubation.

At the Children's Hospitals I've worked in, the anesthesiologists rarely paralyze anyone unless it's necessary for the surgery.
And I don't confirm the ability to vent before paralysis when I'm doing an IV induction when I do use paralytics.


--
Il Destriero

 

[Hawaiian Bruin]

I also almost never mask. I use between 30-60mg roc depending on the pt and procedure. I give the lido then prop first, I wait a few seconds for the roc because it hurts going in and lido doesn't blunt it the way it does with prop. I usually wait 30-60 seconds before DL depending on the dose.

I never use sux outside of true emergent situations for the reasons pgg mentions. Sux myalgias suck!

 

[vector2]

why not just push all the roc at the beginning

Comparison of intubating conditions between rocuronium with priming and without priming: Randomized and double-blind study

 

[IlDestriero]

3 minutes after I pushed induction drugs I'm putting the tube in and charting already, not pushing a second set of drugs and twiddling my thumbs. Repeat the study and add pushing all the drugs at T=0 and who do you think has the fastest intubating conditions?


--
Il Destriero

 

[Psai]

Comparison of intubating conditions between rocuronium with priming and without priming: Randomized and double-blind study

why not just push all the roc at the beginning

waiting 3 minutes for a baby dose of roc to kick in then pushing the rest is a waste of time

 

[deleted697535]

Tubing without paralysis is a real good skill to have

999 patients out of 1000 I'll push roc without a care in the world...

The ones I'm worried about pushing roc to, I certainly won't give them an induction dose of propofol and then bag

 

[pgg]

why not just push all the roc at the beginning

It hurts more than propofol.