Intubating style - what's yours?

[dotcb]

I would not even consider working at such a facility.

Having a 60% EM board certification goal is a marker that this ED is living in some kind of blast from the past. It's a marker that most of the time - the doc in the ED has no airway skills.

In my residency, I remember anesthesia being called to the ED for airway assist 2x - once for a septic pneumonia patient with jaw wired shut, another for stable angioedema - we wanted help with awake intubation.

Would any of you quit a job where the Hospital culture didn't let you intubate routinely in the ER; but instead, EPs called anesthesia to do them?

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[BLADEMDA]

I would not even consider working at such a facility.

Having a 60% EM board certification goal is a marker that this ED is living in some kind of blast from the past. It's a marker that most of the time - the doc in the ED has no airway skills.

In my residency, I remember anesthesia being called to the ED for airway assist 2x - once for a septic pneumonia patient with jaw wired shut, another for stable angioedema - we wanted help with awake intubation.

I agree with the blast from the past but why would you say the EP has no airway skills? The vast majority of the time there is a young, Board Certified ER Doctor available 24/7 in the ER.

I appreciate the candid response and see this issue is Institution specific which needs to be addressed.

 

[dotcb]

Yeah - that department has issues.

 

[Birdstrike]

The Institution had a long history of use IM/FP in the ER; so, for decades we intubated 100% of all patients in a timely manner (minutes)

Aha. This makes perfect sense, now. You're asking a bunch of ER physicians why your IM and FP physicians who didn't do ER residencies are having trouble intubating. I haven't seen or heard a better endorsement for EM board certification and residency training in a long time. Your hospital needs to buck up the cash to bring BC/BE EPs to your hospital so you don't have to constantly be running 2 departments. Or are they just going to hire an army of PAs and NPs to cut costs even more? LOL.

 

[Doctor Bob]

Would any of you quit a job where the Hospital culture didn't let you intubate routinely in the ER; but instead, EPs called anesthesia to do them?

No... because I wouldn't take a job at a place like that.

 

[Groove]

Yes, there are many more non EP Physicians on staff in the emergency room. The ER department is trying to "convert" to a 60% model of ER boarded Physicians as there are 2 ER Doctors available per shift in the ER. This means that 1 Boarded ER Physician should be present per shift.

I'm sorry you would think that at this point in my career I would care about going to the ER for anything including intubations. The Institution had a long history of use IM/FP in the ER; so, for decades we intubated 100% of all patients in a timely manner (minutes). Slowly, the EP staff has become more involved in airway management and I am glad about that fact.

Previous posts have explained clearly to me that if an EP can turf the intubation to anesthesia many will do so. Since we are readily available (minutes from call to response) I suspect that is the situation. I plan on talking with the young, Superstar EP Physician in the next few days. I'll see what he has to say about the subject.

(FYI, I have personally shown FP ER attendings how to intubate using the Glidescope in the ER.)

That sheds a great deal of insight into the bizarre and very unorthodox arrangement at your current institution. I take it from your "for decades we intubated 100%...." statement that you have been there for a protracted length of time and so that might explain your reticence in buying into the propaganda showing that most EP's from ACGME approved EM residency programs are quite adept at handling airways. That's what we're trained to do. Most of us are trained extremely well at it. You probably just haven't been around very many of them, nor have you worked in a more "normalized" institution and/or ED environment.

The ED there sounds seriously out of touch. I have no idea what your hospital admins or anesthesia group are trying to accomplish. 60% EM boarded? 40% Whatever? What kind of medico legally charged - standard of care cough syrup are they trying to mix up over there? If I fill the 60% full robitussin bottle back up with water, do I get a full bottle? Is it still cough syrup? Moreover, why do you guys pony up services to the ED? It's got to be about the money. I guarantee you, all these docs calling you for the Grade 1 airways are not pooping their pants in fear. Most of them would probably much rather be generating the RVU's that you are taking from them from an easy tube. Your group or hospital admin has got to be pushing this I would think... I can't imagine you guys are happy running down there though unless you are very light on cases.

Either way, to your second question... There's no way in hell that I would I work in a place like that. Not only would it be intensely unenjoyable but I would worry about pt perception, outcomes and lawsuits from such a hodgepodge of providers with an obvious lack of skill acumen along with bizarre pt care protocols that are very outside the norm in most hospital EDs.

If the acuity is so low and/or money is so tight, they should just go the NP/PA route and keep the IM/FM docs. Hire some CRNA's for the easy tube assistance. The EM docs keep the better jobs out there, and you get to stay upstairs in the OR where you'd rather be without having to pay an extra MDA.

 

[BLADEMDA]

The Published literature shows the success rate of ER Physicians intubating patients in the ER is very high. I have no doubt that is true.

But, there must be quite a few ERs with mixed staffing models of EP/FM/IM out there. It takes time to completely transform a department into 100% ER trained Physicians. Anyone have any anecdotal experience on this? Do all the FM/IM docs know they will lose their jobs in the high acuity ERs over time?

 

[deleted109597]

Do all the FM/IM docs know they will lose their jobs in the high acuity ERs over time?

If only. They keep trying to do fellowships or get credentialling in scary things like deep sedation. Then they bring up the lack of enough EM docs to do it. And then blame EM for making it a "turf battle" when someone brings it up, like the current thread in the FM forum.

 

[fahimaz7]

why wouldn't a bougie help? if you can get a tube past the cords, surely you could get a bougie past them. were they unbaggable?

The cords were paralyzed at the midline. Bag wouldn't have helped.

 

[Cerberus]

Throughout my residency/attending career I've called anesthesia a total of two times. Both times it was because the patient had an obstructing mass (we get a lot of throat CA patients here) who had enough time to go to the OR for fiberoptic intubation. One of them ending up being a disaster in the OR and died peri-intubation anyway.

 

[deleted547339]

Would any of you quit a job where the Hospital culture didn't let you intubate routinely in the ER; but instead, EPs called anesthesia to do them?

Only a resident, but I wouldn't ever consider taking a job where I was told that anesthesia intubated my patients.

 

[RustedFox]

Would any of you quit a job where the Hospital culture didn't let you intubate routinely in the ER; but instead, EPs called anesthesia to do them?

Would quit job. Would not take job. Byeeee.

 

[dotcb]

See this posting and the linked article on DL vs VL on ED intubations:

http://prehospitalmed.com/2013/09/08/video-is-killing-the-direct-laryngoscope-star/

 

[BLADEMDA]

If only. They keep trying to do fellowships or get credentialling in scary things like deep sedation. Then they bring up the lack of enough EM docs to do it. And then blame EM for making it a "turf battle" when someone brings it up, like the current thread in the FM forum.

Thank You for the link. What do you think of these 5 year FM/EM Programs? 5 years long and double board eligible in both specialties.



Family Medicine / Emergency Medicine Track
The combined EM/FM program is one of two in the country, and has been in existence since 2009. Our program accepts 2 residents a year, and integrates two 3 year residencies into a 5 year period. The intern year for each residency is remarkably similar, so there is not much to distinguish the first year of the combined program. Thereafter, our residents alternate between ER and FM rotations in quarterly segments throughout the year, spending three months focusing on ER or FM rotations at a time. Resident fulfill the graduation requirements of each residency independently; there is nothing missed that one would be exposed to if only doing ER or FM training. This means that throughout the 5 years our residents receive weekly didactics in ER and also have a weekly FM clinic.

There are several complimentary aspects of combining ER and FM training; the FM training is strengthened by education in trauma management and emergency procedures (intubation, chest tubes, bedside ultrasound) and the EM training is broadened by increased pediatrics and Ob/Gyn exposure, as well as training in skin procedures and endoscopy. The intended result is the production of physicians who are well equipped to handle most circumstances which may present to a health care setting in a rural or suburban environment, presumably in an underserved area.

 

[pinipig523]

Would any of you quit a job where the Hospital culture didn't let you intubate routinely in the ER; but instead, EPs called anesthesia to do them?

I dunno... not sure how I would feel if I was an anesthesia attending.

Personally, my favorite part is getting the tube in... how cool is it to be called just to tube and then walk away? That's what you get to do.

 

[pinipig523]

Do most newly boarded ER Attendings intubate on a routine basis? Do most feel comfortable being the only Physician on the scene for an intubation (no backup)?

I wouldn't say I intubate a ton since residency because it is hit/miss at my full time gig. I've probably intubated 8x in 3 months, but 3 times in the past 6 shifts. Do I feel comfortable? Yes I feel comfortable and I graduated 14 months ago... I'm usually the only one on the scene for an intubation (but we have anesthesia in house for back up).

First intubation out of residency... I was a little scared but it still went well.

 

[Birdstrike]

Thank You for the link. What do you think of these 5 year FM/EM Programs? 5 years long and double board eligible in both specialties.



Family Medicine / Emergency Medicine Track
The combined EM/FM program is one of two in the country, and has been in existence since 2009. Our program accepts 2 residents a year, and integrates two 3 year residencies into a 5 year period. The intern year for each residency is remarkably similar, so there is not much to distinguish the first year of the combined program. Thereafter, our residents alternate between ER and FM rotations in quarterly segments throughout the year, spending three months focusing on ER or FM rotations at a time. Resident fulfill the graduation requirements of each residency independently; there is nothing missed that one would be exposed to if only doing ER or FM training. This means that throughout the 5 years our residents receive weekly didactics in ER and also have a weekly FM clinic.

There are several complimentary aspects of combining ER and FM training; the FM training is strengthened by education in trauma management and emergency procedures (intubation, chest tubes, bedside ultrasound) and the EM training is broadened by increased pediatrics and Ob/Gyn exposure, as well as training in skin procedures and endoscopy. The intended result is the production of physicians who are well equipped to handle most circumstances which may present to a health care setting in a rural or suburban environment, presumably in an underserved area.

Except it doesn't make you board eligible in both specialties. You can only get EM board eligibility from an EM residency. These fellowships were locked out many years ago for better or for worse. (I'd say, "For worse", but that's a whole different thread.) This path will get you FM boarded, but not EM boarded. These "EM fellowships" are non-accredited, unless something's changed in recent years I'm not aware of.

 

[RustedFox]

Except it doesn't make you board eligible in both specialties. You can only get EM board eligibility from an EM residency. These fellowships were locked out many years ago for better or for worse. (I'd say, "For worse", but that's a whole different thread.) This path will get you FM boarded, but not EM boarded. These "EM fellowships" are non-accredited, unless something's changed in recent years I'm not aware of.

I don't think its a 'fellowship' in the sense that you first graduate, and then pursue fellowship. I think what Blade has here is from an official EM/FM residency program.

 

[Daiphon]

I don't think its a 'fellowship' in the sense that you first graduate, and then pursue fellowship. I think what Blade has here is from an official EM/FM residency program.

That was my read, too. I know CCOM/Midwestern has one of these. Just like accredited IM/EM, completing the combined residency makes you eligible for both boards.

It's not the same as the backdoor shenanigans that are EM "fellowships."

-d

Sent from my DROID BIONIC using Tapatalk

 

[Birdstrike]

That was my read, too. I know CCOM/Midwestern has one of these. Just like accredited IM/EM, completing the combined residency makes you eligible for both boards.

It's not the same as the backdoor shenanigans that are EM "fellowships."

-d

Sent from my DROID BIONIC using Tapatalk

Got it. You're right, big difference, and much better. I personally think the EM/IM programs makes more sense, and there's plenty I could say about that, but it's an entirely different thread, I suppose.

 

[joeDO2]

On a related note, observed an intubation by a resident this week. Used 100 fentanyl, 5 versed, 20 etomidate. Thought this was a rather unusual combination. Haven't seen anyone use this combo in the past. Has anyone here been using something similar?

 

[RustedFox]

On a related note, observed an intubation by a resident this week. Used 100 fentanyl, 5 versed, 20 etomidate. Thought this was a rather unusual combination. Haven't seen anyone use this combo in the past. Has anyone here been using something similar?

No paralytic ? Thought I was badass like that once. Had the cords snap shut in front of my eyes. Then I got wise; I always paralyze. Woo for rhymes.

 

[joeDO2]

No paralytic ? Thought I was badass like that once. Had the cords snap shut in front of my eyes. Then I got wise; I always paralyze. Woo for rhymes.

yeah, I asked about the paralytic. they said they didn't use one because there are no paralytics available on the med/surg floors so it was good practice to learn how to do it without?

also, if using etomidate what is the thought behind adding versed? better to use combination rather than just increasing etomidate dose if needed?

 

[Rendar5]

yeah, I asked about the paralytic. they said they didn't use one because there are no paralytics available on the med/surg floors so it was good practice to learn how to do it without?

also, if using etomidate what is the thought behind adding versed? bettetr to use combination rather than just increasing etomidate dose if needed?

No clue. Seen versed fentanyl, and etomidate fentanyl make sense. Maybe someone from the gas forums could shed some light on this.

 

[Doctor Bob]

yeah, I asked about the paralytic. they said they didn't use one because there are no paralytics available on the med/surg floors so it was good practice to learn how to do it without?

When I was a resident, it was hospital policy that residents could not intubate patients in the ICU (or the floor during an emergency) with paralytics. Only the OR and ER could use paralytics during intubation. It was a ridiculous policy but we had to live with it.

 

[BLADEMDA]

No clue. Seen versed fentanyl, and etomidate fentanyl make sense. Maybe someone from the gas forums could shed some light on this.

Evaluate the patient and the situation. The usual drugs for an intubation are the following:

1. Propofol- not rcommended in Trauma or unstable patients (at usual induction doses will drop BP significantly)
2. Etomidate- Controversial in Trauma patients and patients with sepsis
3. Ketamine- Works well if you can keep the dosage around 1mg/kg; higher doses assoc. with more adverse effects
4. Midazolam- Amnesia agent (may drop BP at higher doses)
5. Fentanyl- Pure Mu receptor agent, stable but no amnesia

More likely to get sustained Apnea when you combine agents 4 and 5; low dose combo (like 2-3 mg of Midazolam IV and 100 ug Fentanyl) usually very hemodynamically stable but Amnesia not guaranteed.

My favorite cocktail in the trauma room is low dose propofol (0.5 mg/kg combined with ketamine 0.75 mg/kg up to 1 mg/kg). This works great in maintaining BP while giving amnesia and analgesia.

On younger patients I recommend muscle relaxants for intubations while older, sicker patients don't always need to be paralyzed. I routinely use muscle relaxants for all my intubations.

 

[BLADEMDA]

http://resus.me/tag/ketamine/

The use of ketamine with low dose propofol is vastly underutilized in the USA. In my ER they prefer Etomidate over everything else.

 

[WilcoWorld]

http://resus.me/tag/ketamine/

The use of ketamine with low dose propofol is vastly underutilized in the USA. In my ER they prefer Etomidate over everything else.

Not sure how much time you spend here, so forgive me if you already knew this, but board certified EP's have grown quite fond of ketamine...for good reason.

 

[BLADEMDA]

Not sure how much time you spend here, so forgive me if you already knew this, but board certified EP's have grown quite fond of ketamine...for good reason.

With the use of low dose propofol to smooth out the induction? I'm advocating a combined induction agent of propofol 0.5 mg/kg with ketamine 0.75 mg/kg.
That's my preferred cocktail these days for Trauma.

http://www.ncbi.nlm.nih.gov/pubmed/22743378

 

[BLADEMDA]

My dosage is fairly low for these agents based on the published studies. If you want to start using Ketofol on a daily basis I would start a little higher with the mixture; more like 0.75 mg/kg or 1 mg/kg for each agent in a hemodynamically stable patient.

When I get a trauma I use low dose propofol, 0.5 mg/kg IV combined with a bit more Ketamine 0.75-1.0 mg/kg IV with excellent results. Most of the studies use a higher dosage of propofol 1 mg/kg combined with 1 mg/kg of ketamine. I can tell you that combo (1 mg/kg for each) will certainly get the job done.

 

[WilcoWorld]

With the use of low dose propofol to smooth out the induction? I'm advocating a combined induction agent of propofol 0.5 mg/kg with ketamine 0.75 mg/kg.
That's my preferred cocktail these days for Trauma.

http://www.ncbi.nlm.nih.gov/pubmed/22743378

With or without, depending on the context. Straight ketamine when I'd like to keep the respiratory drive/airway reflexes intact, ketamine + propofol when I'm just trying to get 'em down so I can do what I need to do.

 

[BLADEMDA]

With or without, depending on the context. Straight ketamine when I'd like to keep the respiratory drive/airway reflexes intact, ketamine + propofol when I'm just trying to get 'em down so I can do what I need to do.

What I'm posting here is that perhaps the BEST agent(s) for an emergency induction is
a combo of Propofol and Ketamine. The next time you need to do an intubation give it a try: 1 mg/kg of propofol IV followed Immediately by 1 mg/kg IV of ketamine then the muscle relaxant (Sux). Great hemodynamics with amnesia and analgesia. If you are concerned about the EF, CHF, frail patient, etc reduce the dosage of propofol a bit as that would be the drug which causes the drop in BP.

Once the patient wakes up from the cocktail consider low dose midazolam IV to smooth out the ketamine ride. Or, add a low dose propofol drip if the vitals are stable.

 

[BLADEMDA]

With or without, depending on the context. Straight ketamine when I'd like to keep the respiratory drive/airway reflexes intact, ketamine + propofol when I'm just trying to get 'em down so I can do what I need to do.

Ketofol is better than plain ketamine even for procedural sedation.


The concept of ketofol has been around for many years, with anesthesiologists mixing their own cocktail combinations in the operating rooms, titrating different agents to achieve optimal results.

 

[BLADEMDA]

Could Ketofol Be the Perfect Drug Combo?



http://www.epmonthly.com/clinical-skills/emrap/could-ketofol-be-the-perfect-drug-combo/

 

[BLADEMDA]

What's New in the Patient Safety World

April 2012

Problems with "Ketofol"





The increasingly popular practice of mixing ketamine and propofol together for use in patient procedures has come under fire recently. The practice stems from the idea that using lower doses of both agents together can provide adequate patient sedation with less toxicity. The May 2011 issue of The Annals of Emergency Medicine had several articles addressing the use of this combination for procedural sedation/analgesia. The article by Green et al. (Green 2011) nicely summarizes the pros and cons of use of this combination.



But ISMP has recently warned about some safety issues associated with this practice (ISMP 2012). They are especially concerned about sterility, since the mixing of these two drugs often takes place in the emergency room under less-than-ideal circumstances for sterility. They caution against puncturing single-dose vials multiple times, ensuring that the proper expiration date is included on the syringe label, and that the medication is appropriately disposed of after use. They also note that there is no standardized concentration or volume of each drug in the combination and that there is little literature on the compatibility of these two agents. Moreover, look-alike/sound-alike issues may occur. Because "ketofol" does not appear in standard drug dictionaries or CPOE lists it would be easy to choose the wrong drug from a list. Similarly, a syringe filled with "ketofol" might be mistaken for a syringe filled with just propofol. ISMP recommends that, if you use "ketofol", you conduct a FMEA (failure mode and effects analysis) to determine your vulnerabilities.



A second paper (Andolfatto 2010) has also raised safety issues about ketofol. Contrary to the widely-held view that the combination is safer than individual drugs, the authors found in a randomized controlled trial that "ketofol" does not result in a reduced incidence of adverse respiratory events compared to propofol alone. In an emergency department setting they found that "ketofol" resulted in adverse respiratory events in 30% of patients, compared to 32% of patients receiving propofol alone. Deep levels of sedation were common and several patients required bag/mask ventilation. Moreover, several patients receiving "ketofol" developed recovery agitation, the side effect that had largely displaced ketamine from frequent use in the past.



So evidence has raised significant safety concerns to the use of this combination. Be very wary. You may not even know what areas of your organization may be using this potentially dangerous combination. Use your pharmacy IT systems to identify patients in whom both agents were used but bear in mind that many ED's, OR's, and radiology suites (the 3 areas most likely to use this combination) are not connected to the main hospital IT systems so you may need to do some good old detective work to find out who is using it.

 

[WilcoWorld]

Ketofol is better than plain ketamine even for procedural sedation.


The concept of ketofol has been around for many years, with anesthesiologists mixing their own cocktail combinations in the operating rooms, titrating different agents to achieve optimal results.

I use ketofol routinely for proc. sed. and have been doing so for several years. With intubations, I like to minimize the number of drugs my nurses have to push, so I'm more likely to use straight ketamine + a paralytic.

If what you've posted here about ketofol is news to your ED docs, than they're behind the times.

 

[WilcoWorld]

What’s New in the Patient Safety World

April 2012

Problems with “Ketofol”





The increasingly popular practice of mixing ketamine and propofol together for use in patient procedures has come under fire recently. The practice stems from the idea that using lower doses of both agents together can provide adequate patient sedation with less toxicity. The May 2011 issue of The Annals of Emergency Medicine had several articles addressing the use of this combination for procedural sedation/analgesia. The article by Green et al. (Green 2011) nicely summarizes the pros and cons of use of this combination.



But ISMP has recently warned about some safety issues associated with this practice (ISMP 2012). They are especially concerned about sterility, since the mixing of these two drugs often takes place in the emergency room under less-than-ideal circumstances for sterility. They caution against puncturing single-dose vials multiple times, ensuring that the proper expiration date is included on the syringe label, and that the medication is appropriately disposed of after use. They also note that there is no standardized concentration or volume of each drug in the combination and that there is little literature on the compatibility of these two agents. Moreover, look-alike/sound-alike issues may occur. Because “ketofol” does not appear in standard drug dictionaries or CPOE lists it would be easy to choose the wrong drug from a list. Similarly, a syringe filled with “ketofol” might be mistaken for a syringe filled with just propofol. ISMP recommends that, if you use “ketofol”, you conduct a FMEA (failure mode and effects analysis) to determine your vulnerabilities.



A second paper (Andolfatto 2010) has also raised safety issues about ketofol. Contrary to the widely-held view that the combination is safer than individual drugs, the authors found in a randomized controlled trial that “ketofol” does not result in a reduced incidence of adverse respiratory events compared to propofol alone. In an emergency department setting they found that “ketofol” resulted in adverse respiratory events in 30% of patients, compared to 32% of patients receiving propofol alone. Deep levels of sedation were common and several patients required bag/mask ventilation. Moreover, several patients receiving “ketofol” developed recovery agitation, the side effect that had largely displaced ketamine from frequent use in the past.



So evidence has raised significant safety concerns to the use of this combination. Be very wary. You may not even know what areas of your organization may be using this potentially dangerous combination. Use your pharmacy IT systems to identify patients in whom both agents were used but bear in mind that many ED’s, OR’s, and radiology suites (the 3 areas most likely to use this combination) are not connected to the main hospital IT systems so you may need to do some good old detective work to find out who is using it.

I draw and push them separately. I like to titrate to effect, and the two drugs have different effects, so I don't see much benefit to pre-mixing.

Everyone's a critic.

 

[BLADEMDA]

My response:

The drugs are stable when mixed together; but, I would date and time any cocktail made up by an RN or MD. That cocktail should be discarded after 4-6 hours regardless of whether it was used or not.

Second, all these side effects are dosage related. When giving propofol in doasges of 0.5 mg/kg IV the chance of respiratory depression is fairly low. At 1 mg/kg IV the chance is significant. This is why you should not start with the full dose up front for procedural sedation. Usually, a chin lift or jaw thrust is all that is required to relieve airway obstruction (0.5 mg/kg dose). We use large doses of propofol IV for hundreds of cases a week so don't be afraid here provided you start slowly with the drug. We rarely bag/mask anyone even after large doses as a jaw thrust or chin lift works 99% of the time.

Ketamine is a nasty PCP like drug in high doses. I rarely every exceed 1 mg/kg IV over a short time frame (1 hour) or up 2 mg/kg iv over several hours. Patients will not be happy with high dose ketamine and will have nightmares. Excessive salivation and tachycardia occurs with high dose ketamine and not low dose. So, stick with low dose ketamine 1mg/kg iv or less to minimize these side-effects.

Ketofol remains a great agent for the Physician who has basic airway management skills and titrates the drug to effect (avoid large bolus doses).

 

[BLADEMDA]

I use ketofol routinely for proc. sed. and have been doing so for several years. With intubations, I like to minimize the number of drugs my nurses have to push, so I'm more likely to use straight ketamine + a paralytic.

If what you've posted here about ketofol is news to your ED docs, than they're behind the times.

It must be nice to know everything. For the rest of us Ketofol as an induction agent of choice has been around for only 3-4 years or so. Ketofol avoids the tachycardia seen with higher dosages of Ketamine while giving effective amnesia to the patient.

Ketamine as a solo induction agent (2 mg/kg IV) is associated with tachycardia and hypertension. I prefer to avoid that whenever possible.

 

[BLADEMDA]

As an Anesthesiologist with over 2 decades of experience in the field here is what I recommend:

1. Don't mix the drugs. Dilute the ketamine in a separate syrine.
Ketamine comes 50 mg/ml or 100 mg/ml. I like 10 mg/ml dilution. This is the same dilution as propofol 10 mg/ml.

2. Propofol- 10 mg/ml. One of the best all around sedative drugs ever invented.

3. I use Ketamine on a regular basis in the operating room as an adjunct for my anesthetic. For short procedures in the ER it would be nice of you to limit the dosage of ketamine to 0.5 mg/kg. This should all but eliminate unwanted side-effects. Ketamine should be given after the propofol or mixed with the propofol but not before the propofol.

By administering low dose ketamine to the patient in the ER you will be providing analgesia and reducing the amount of propofol needed for the procedure. This reduction in propofol will diminish the chance of apnea or respiratory depression (which is usually just airway obstruction 99% of the time).

 

[Arcan57]

yeah, I asked about the paralytic. they said they didn't use one because there are no paralytics available on the med/surg floors so it was good practice to learn how to do it without?

also, if using etomidate what is the thought behind adding versed? better to use combination rather than just increasing etomidate dose if needed?

Something that Blade touched on but I think we tend to ignore is what happens once the sedation wears off. I usually do etomidate and sux (although I've been doing more ketamine in septic pts recently) and what invariably happens is that the patient comes up from the etomidate very quickly and starts struggling and going for the tube and then gets put down with another sedating agent while the drip is being started. If this is propofol they go back down quickly, but if you're doing a versed gtt because of hemodynamic concerns then they're probably still conscious for a couple of minutes before you get an effective dose. I'm not sure pre-dosing with versed is a magic, side-effect free bullet for this problem but at least it shows they're thinking about what happens to the pt after the tube besides just getting them to the unit ASAP.

I'll definitely try the propofol/ketmaine combo Blade describes on my next intubation, as the more I think about it the crappier I'm feeling thinking about the patient struggling.

 

[BLADEMDA]

Something that Blade touched on but I think we tend to ignore is what happens once the sedation wears off. I usually do etomidate and sux (although I've been doing more ketamine in septic pts recently) and what invariably happens is that the patient comes up from the etomidate very quickly and starts struggling and going for the tube and then gets put down with another sedating agent while the drip is being started. If this is propofol they go back down quickly, but if you're doing a versed gtt because of hemodynamic concerns then they're probably still conscious for a couple of minutes before you get an effective dose. I'm not sure pre-dosing with versed is a magic, side-effect free bullet for this problem but at least it shows they're thinking about what happens to the pt after the tube besides just getting them to the unit ASAP.

I'll definitely try the propofol/ketmaine combo Blade describes on my next intubation, as the more I think about it the crappier I'm feeling thinking about the patient struggling.

That's right. Those young guys wake up like a crazy animal after the Etomidate/sux wears off. Not so with the Propofol 1mg/kg Iv plus Ketamine 1 mg/kg IV combo. You get nice sedation and analgesia with this combo. Then, you can titrate in a little Midazolam IV as needed or start a propofol infusion. Give it a try.

For the hemodynamically stable patient (includes most traumas) the Ketofol is great stuff. The data strongly supports the use of the 1 mg/kg IV dose for Propofol followed by the 1 mg/kg IV dose of the Ketamine then the Sux.

One last thing is that I bring a little Phenylephrine with me in a syringe to handle any transient hypotension which may occur. Are you guys familiar with low dose Phenylephrine for transient hypotension post induction (or post propofol sedation)?

The dose is usually just 100-200 ug IV post induction or post procedural sedation if the BP is low. You do get a transient, reflex decrease in HR from the Phenylephrine so avoid it if the patient is already bradycardic. I apologize if you already know about this common anesthesia treatment of hypotension in the O.R.

I like to carry a big stick (of phenylephrine) with me to the ER whenever possible.

 

[Xerxes1729]

On the issue of VL versus DL, I have never seen a "VL only" advocate give an adequate explanation of how to handle the patient with profuse vomiting or bleeding. Mostly because I don't think there is a way to handle that with VL aside from crossing your fingers that your camera won't get fouled.

 

[BLADEMDA]

This must be diluted in Normal Saline or LR or D5W, etc. Usual dilution is to 50 ug/ml or 100 ug/ml. Be careful here as RN errors with dilution can and do occur resulting in large doses of phenylephrine. It is best to dilute in 100 ml bag or 250 ml bag of fluid.

 

[Doctor Bob]

Are you guys familiar with low dose Phenylephrine for transient hypotension post induction (or post propofol sedation)?

There was a good EMCrit podcast on this topic... push-dose pressors. And phenylephrine for post-induction hypotension was one of the topics covered.

It still hasn't made its way into my practice though. Then again the vast majority of my intubations are trauma victims (a downside of practicing in a warzone) and they don't usually have a blood pressure to start with...

 

[Arcan57]

That's right. Those young guys wake up like a crazy animal after the Etomidate/sux wears off. Not so with the Propofol 1mg/kg Iv plus Ketamine 1 mg/kg IV combo. You get nice sedation and analgesia with this combo. Then, you can titrate in a little Midazolam IV as needed or start a propofol infusion. Give it a try.

For the hemodynamically stable patient (includes most traumas) the Ketofol is great stuff. The data strongly supports the use of the 1 mg/kg IV dose for Propofol followed by the 1 mg/kg IV dose of the Ketamine then the Sux.

One last thing is that I bring a little Phenylephrine with me in a syringe to handle any transient hypotension which may occur. Are you guys familiar with low dose Phenylephrine for transient hypotension post induction (or post propofol sedation)?

The dose is usually just 100-200 ug IV post induction or post procedural sedation if the BP is low. You do get a transient, reflex decrease in HR from the Phenylephrine so avoid it if the patient is already bradycardic. I apologize if you already know about this common anesthesia treatment of hypotension in the O.R.

I like to carry a big stick (of phenylephrine) with me to the ER whenever possible.

Push dose pressors are becoming more in vogue thanks to Scott Weingart (an EM/ICU doc from NY that made quite a name for himself with podcasts and lectures). That being said, the average community doc running into a situation that calls for a short-acting vasoconstrictor is pretty rare. I know it's a thing but would have to look up how to mix it. In the era I trained, it was typically thought that if you're giving something just to buff the BP that you've screwed up the resuscitation. However, we don't play with as many cardioactive meds as you guys do and it's typically to treat things were there are alternate treatment pathways (such as electricity or waiting for dig to work for a.fib w/ RVR). The hypotensive, going to die as soon as they lose their sympathetic tone pt is fortunately quite rare.

 

[BLADEMDA]

Push dose pressors are becoming more in vogue thanks to Scott Weingart (an EM/ICU doc from NY that made quite a name for himself with podcasts and lectures). That being said, the average community doc running into a situation that calls for a short-acting vasoconstrictor is pretty rare. I know it's a thing but would have to look up how to mix it. In the era I trained, it was typically thought that if you're giving something just to buff the BP that you've screwed up the resuscitation. However, we don't play with as many cardioactive meds as you guys do and it's typically to treat things were there are alternate treatment pathways (such as electricity or waiting for dig to work for a.fib w/ RVR). The hypotensive, going to die as soon as they lose their sympathetic tone pt is fortunately quite rare.

Phenylephrine is fantastic to buy you time like 5-10 minutes. This allows time for your fluid resuscitation to work and/or your RN to get your favorite vasoactive drip ready. Simply push the 1 ml (10 mg/ml) into a 250 ml fluid bag and you have 40 ug/ml. A quick 3-5 ml bolus from that bag results in better BP immediately.

Of course, a low C.O. state, massive blood loss, etc, and the Pheny1ephrine won't do a darn thing for you. This when a quick push of Epi (5-10 ug)is in order. Low dose Epi is fantastic for when the low dose Phenylephrine fails. By keeping Epi in the 10-20 ug range you get a boost in C.O. without tachycardia. Please note I'm talking less than 50 ug here. Again, low dose buys you time without overshooting the BP and HR.

 

[BLADEMDA]

On the issue of VL versus DL, I have never seen a "VL only" advocate give an adequate explanation of how to handle the patient with profuse vomiting or bleeding. Mostly because I don't think there is a way to handle that with VL aside from crossing your fingers that your camera won't get fouled.

If you need the VL for more than 1/3 of your intubations then your skills pretty much suck. The VL is for anterior airways and anticipated difficult airways. DL is the preferred method and my preference in the E.R. (usually a Miller 2 or 3).

If you need help getting better with DL then intubate your COPDers and CHFers old school. These patients are rarely difficult to intubate.

If you don't intubate more than 2 times a month then I certainly cant fault you for going VL every single time.

 

[WilcoWorld]

It must be nice to know everything. For the rest of us Ketofol as an induction agent of choice has been around for only 3-4 years or so. Ketofol avoids the tachycardia seen with higher dosages of Ketamine while giving effective amnesia to the patient.

Ketamine as a solo induction agent (2 mg/kg IV) is associated with tachycardia and hypertension. I prefer to avoid that whenever possible.

I never claimed to know "everything". I was simply trying to let you know that ketofol isn't news to a lot of EM docs. It's relatively new (3-4 years, as you say), but something that a lot of us have 100's of experiences with by now. Since your experience is that EM docs call Anesthesia for every airway, I thought it might be good to let you know that many US EDs function differently than the one you are familiar with.

To be clear, my experience with ketofol is mostly for procedural sedation, not induction. I tend to use etomidate or propofol for induction, except for hypotensive patients, or in patients who I think are likely to become hypotensive, which is when I use ketamine alone. In such cases, I am not bothered by the hypertension side effect of ketamine.

Also, in essentially every patient that I intubate, I will start post-intubation sedation within 5-10 minutes of placing the tube.

 

[BLADEMDA]

I never claimed to know "everything". I was simply trying to let you know that ketofol isn't news to a lot of EM docs. It's relatively new (3-4 years, as you say), but something that a lot of us have 100's of experiences with by now. Since your experience is that EM docs call Anesthesia for every airway, I thought it might be good to let you know that many US EDs function differently than the one you are familiar with.

To be clear, my experience with ketofol is mostly for procedural sedation, not induction. I tend to use etomidate or propofol for induction, except for hypotensive patients, or in patients who I think are likely to become hypotensive, which is when I use ketamine alone. In such cases, I am not bothered by the hypertension side effect of ketamine.

Also, in essentially every patient that I intubate, I will start post-intubation sedation within 5-10 minutes of placing the tube.

Ketofol can replace Etomidate in almost every situation. There is also no "theoretical" risk of increased morbidity/mortality due to Adrenocortical suppression like you get from Etomidate.

Perhaps, you have learned something about using Ketofol for induction on a routine basis.