meds for ICU intubation

[bkell101]

Hey all,

I'm a first year doing prelim medicine before starting anesthesia....

I have 3 more months ICU this year (2 down) and have a few questions about medications used for induction in the critically ill.....

I see this scenario quite a bit....

70 yo M PMHX DM/CAD/EF of 30-35% on by TTE 2 months ago sent up from ED with BP 90's/50's , HR 110 , presumed sepsis along with hypoxic/hypercarbic respiratory failure from COPD exacerbation/pneumonia failing BiPap and now needs intubated. BMI 30ish, about 100 kilos with a huge neck and a beard. Looks agitated on bipap but slightly altered maybe from his CO2 rising and has obvious paradoxical breathing.

What meds do you reach for and how much do you start with for intubation? (We aren't allowed to use paralytics in the MICU)

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[bkell101]

I routinely see 50 fentanyl 4 of versed given by my senior medicine residents....sometimes it goes well and sometimes one of two things happens....

1. the patient was already more sedated from his CO2 narcosis that we thought, airway gets secured with ease, but the BP tanks

2. the fentanyl/versed sedates him just a little, he's still got a lid reflex and maybe even squirming a bit in the bed, then my 3rd year medicine senior says, "get him intubated I don't want to drop his pressure", He's fairly clamped down at the jaw, gags and kinda reaches up when I put the blade in his mouth.

How can these types of scenarios be avoided when attempting to secure the airway in a relatively emergent situation?

 

[bkell101]

how profound of an effect does 50 fentanyl/4 versed have on lowering SVR and depression myocardial contractility? how about compared to 20-30 of etomidate?

I was under the impression that etomidate is fairly hemodynamically stable from the introductory reading I've done, but several of my senior residents have told me that in the ICU even etomidate will lower BP.

 

[bkell101]

oh and also...how real are the effects of etomidate on adrenal function in septic patients?

 

[ssmallz]

It's not what meds you use it's how much you give and what pressor you will chase them with....many ways to skin a cat

 

[vector2]

That's silly you're not allowed to use paralytics in the MICU...you could consider paging anesthesia to do the intubation since it'll likely be smoother if certain agents can be utilized appropriately.

I'm also a CA-0, but hopefully this guy has already been a-lined, triple lumen in place, fluids running per whatever sepsis protocol you have, EF% permitting. If he's been appropriately fluid resuscitated and still dropping his BP, the order for the norepi gtt to bedside should already be in process. Ideally, it seems like there shouldn't be any contraindication to using around 0.4-0.5 mg/kg of etomidate for induction, perhaps with 100mg hydrocortisone IV since he's suspected sepsis. If his K+ is ok, succinylcholine 0.8-1 mg/kg should be all right. Etomidate is supposed to be pretty hemodynamically stable but I've seen geriatric sepsis folks still drop their pressures after induction. If there's no norepi gtt in place, anesthesia will usually have a couple phenylephrine bumps ready.

If you're still stuck in a situation where you can't call someone else or use paralytics, ketamine might be more helpful than (or in addition to) the fentanyl/midaz combo for a couple reasons. It provides profound dissociative analgesia, moderate amnesia, and in addition stimulates catecholamine release which can increase your MAPs and bronchodilate.

edit: also, can you clarify something for me....is that fentanyl 50/versed 4 thing just an example, or do your residents literally give those two drugs at those exact doses to every pt getting intubated?

 

[soonerfrog]

The "no paralytics" makes very little sense. Probably not even necessary but it's a bizarre stand to make, even in the MICU. It's like, "Intubate this guy, but no 7.0-7.5 ETT's".

 

[WholeLottaGame7]

how profound of an effect does 50 fentanyl/4 versed have on lowering SVR and depression myocardial contractility? how about compared to 20-30 of etomidate?

I was under the impression that etomidate is fairly hemodynamically stable from the introductory reading I've done, but several of my senior residents have told me that in the ICU even etomidate will lower BP.

The BP drop is probably more from initiating PPV in a septic patient than it is myocardial depression from 50mcg of fentanyl or the etomidate.

As ssmallz said, many ways to skin a cat/induce a patient. Fent/midaz, ketamine, prop/phenylephrine, etomidate, etc etc. The MICU residents probably use fent/midaz because that's what they are most familiar with.

 

[psychbender]

As others have said, it is less about what drugs you use, and more about how you use them. Etomidate will still tank pressures if you give a goodly dose, and slam it all in. The aforementioned 0.4-0.5mg/kg is rather high, especially for a sick ICU patient. I much prefer propofol + pressor as my ICU induction agent of choice, partly because I am much more comfortable with its use.

I can understand where the MICU is coming from in not wanting to use muscle relaxants (may take a long time for the propofol drip or other sedation to arrive, and then you have a relaxed, non-sedated patient), but I still disagree. Given that, in your situation, the person intubating is less-skilled, there is a higher likelihood that muscle relaxant may be needed to optimize the view for intubation. A coughing, retching, biting down, flailing, desatting, septic patient is less than ideal.

 

[sluggs]

DO NOT use etomidate in septic patients. It supresses the adrenal axis and causes INCREASED Mortality. Versed/fentanyl is ok. Ketamine/fentanyl is nice in non-neuro patients. A ban on paralytics in an ICU is crazy and will complicate things. I would personally use 100 mcg fentanyl, 150 mg ketamine, and 100 mg succs on your man as described.

 

[EternalMD]

Medicine residents aren't trusted with many drugs we routinely use. Just had dinner with a friend of mine who said she had to use 6mg of versed for induction, another resident apparently in that program used only 1mg of versed. They also only needed 5intubations under their belt to get "certified" much like respiratory therapists at the VA. Scary

 

[bkell101]

Thank you for the responses.

To adress some point brought up....

We get these type of patients lined up with central acess very quickly, early goal directed therapy is always initiated if it hasnt already been in the ed, sometimes the ggts are up from pharmacy and sometimes the pt needs tubed before ggts get there.

The hx behind no paralytics is 7-8 years ago a senior resident gave paralytic couldnt intubate couldnt ventilate and patient coded.

Can anybody point me to a good paper showing etomidate increasing mortality in septic patients?

Ive read other boards suggesting versed versed and more versed provides very good hemodynamic stability if titrated right. Can anyone comment?

does full dose of etomidate drop bp more than half dose?

Also, my first intuition was the same about the no paralytic thing...why not provide optimal view with paralytic, but another posted commented on his experince with tissue losing tone in obese patients and making for a less than ideal view...anybody else share this opinion?

Does bipap reduce afterload in addition to dropping preload?

4/50 versed/fent given back to back is pretty much all i see used because of the culture ofthe medicine residency, etomidate wasnt in the pyxis for a while, propofol scares them (i dont think theyve ever thought of not just slamming in the meds), and ketamine is treated like it doesnt even exist.

 

[psychbender]

Thank you for the responses.

To adress some point brought up....

We get these type of patients lined up with central acess very quickly, early goal directed therapy is always initiated if it hasnt already been in the ed, sometimes the ggts are up from pharmacy and sometimes the pt needs tubed before ggts get there.

The hx behind no paralytics is 7-8 years ago a senior resident gave paralytic couldnt intubate couldnt ventilate and patient coded.

Can anybody point me to a good paper showing etomidate increasing mortality in septic patients?

Ive read other boards suggesting versed versed and more versed provides very good hemodynamic stability if titrated right. Can anyone comment?

does full dose of etomidate drop bp more than half dose?

Also, my first intuition was the same about the no paralytic thing...why not provide optimal view with paralytic, but another posted commented on his experince with tissue losing tone in obese patients and making for a less than ideal view...anybody else share this opinion?

Does bipap reduce afterload in addition to dropping preload?

4/50 versed/fent given back to back is pretty much all i see used because of the culture ofthe medicine residency, etomidate wasnt in the pyxis for a while, propofol scares them (i dont think theyve ever thought of not just slamming in the meds), and ketamine is treated like it doesnt even exist.

Sounds like the patient 7-8 years ago would have died from an uncontrolled airway whether or not relaxant was used by that resident.

There are plenty of articles out there suggesting an increase in mortality after etomidate (the original papers dealt with infusions for sedation), but here's a nice one from Chest about how it actually does not increase mortality. Outcomes of Etomidate in Severe Sepsis and Septic Shock. Here's one regarding midazolam vs etomidate in the ED for septic shock: A Comparison of the Effects of Etomidate and Midazolam on Hospital Length of Stay in Patients With Suspected Sepsis: A Prospective, Randomized Study

Versed as a sole induction agent is hemodynamically stable, and can work well in the debilitated, critically ill patient. However, for some of these patients, you could probably instrument their airway with nothing at all, because they are so weak from their illness.

First off, 0.2-0.3mg/kg etomidate is not half-dose. That is 'regular' induction dose. Second, there is of course a dose-response curve for drop in blood pressure from etomidate. It is not a binary action, whereby any amount will drop the blood pressure by a fixed measure. I have seen plenty of people choose to give etomidate because it is 'more hemodynamically stable than propofol,' bolus 0.3mg/kg for induction, and wonder why it is that the pressure dropped so much.

 

[cchoukal]

DO NOT use etomidate in septic patients. It supresses the adrenal axis and causes INCREASED Mortality.

This is probably an overstatement, or at least it overcalls the available data (very little of which is randomized). Lots of circumstantial evidence (retrospective, underpowered, etc), and it's probably best to avoid.

The topic of how to intubate MICU patients comes up about annually here, and you might be able to search for some longer, interesting threads on the topic.

As others have said, HOW you use your drugs is at least as important as WHAT you use, every drug (yes, even midaz and fent) can drop the BP in the right dose in the wrong patient, and don't forget the virtues of the un-induced, topicalized intubation.

 

[bkell101]

Thank you for the references ill read those articles.

So what im gathering so far....

Etomidate can in fact drop your bp, especially when you give more than you need

Etomidate in sepsis is controversial , probably just better to stay away from it if you have other options

Push your drugs slow and be stingy / patient to avoid hemodynamic instability

Unclear on....

Is etomidate in small and slow doses better than small and slow doses of fentanyl/versed in terms of hemodynamic stability in the non septic patient?

What type of shape does the dose response cure for etomidate on the effects on bp have? Any good references?

 

[nap$ter]

Hey all,

I'm a first year doing prelim medicine before starting anesthesia....

I have 3 more months ICU this year (2 down) and have a few questions about medications used for induction in the critically ill.....

I see this scenario quite a bit....

70 yo M PMHX DM/CAD/EF of 30-35% on by TTE 2 months ago sent up from ED with BP 90's/50's , HR 110 , presumed sepsis along with hypoxic/hypercarbic respiratory failure from COPD exacerbation/pneumonia failing BiPap and now needs intubated. BMI 30ish, about 100 kilos with a huge neck and a beard. Looks agitated on bipap but slightly altered maybe from his CO2 rising and has obvious paradoxical breathing.

What meds do you reach for and how much do you start with for intubation? (We aren't allowed to use paralytics in the MICU)

if paralytics are not available to you you should not be intubating. it is in my humble opinion malpractice to prepare to intubate without at least having them available to you. it's like saying you aren't allowed to use suction.

 

[Idiopathic]

DO NOT use etomidate in septic patients. It supresses the adrenal axis and causes INCREASED Mortality.

uh, the best available data claims an ASSOCIATION with mortality, but there is plenty of data to suggest NO RELATIONSHIP with mortality. i have no problem with using etomidate in unstable emergent intubations.

 

[Idiopathic]

what your post describes is a system that advocates high sedation/no paralytic intubations, which are generally more dangerous than those using high paralytic/light sedation, unless you dont really sedate the patient for intubation (i.e. 4/50 versed/fent)

generally speaking, the sicker the patient, the less sedative they need to avoid remembering intubation, but they will still move/cough/laryngospasm/fight and get tachycardic, none of which help you in any way. i wont deny that you can intubate people with some versed and fentanyl or whatever combination, but it isnt elegant.

 

[Idiopathic]

ive never given any patient as much as 0.2mg/kg of etomidate. its value is seen at around 0.15 in my opinion (i.e. 12mg for the 80kg patient). you just need them to close their eyes, you dont need to make them comatose

edit: of course if you cant use paralytics you may need two or three vials of etomidate

 

[seinfeld]

My favorite is to draw up in 10ml syringe is 1ml of phenylephrine (200mcg), 5 ml of zemuron (50mg) and 4 ml of versed (4 mg). That is my induction for the unstable if I would be unable to just intubate without anything which is quite frequent during codes. In the semielective without BP issues ill use propofol and zemuron. 3 years of working in the ICU have never needed/used Etomidate.

Much better to lightly sedate and paralyze, than deeply sedate and not paralyze. Most septic patients will not remember anything about the ICU until they are ready to leave.

 

[Arch Guillotti]

ive never given any patient as much as 0.2mg/kg of etomidate. its value is seen at around 0.15 in my opinion (i.e. 12mg for the 80kg patient). you just need them to close their eyes, you dont need to make them comatose

edit: of course if you cant use paralytics you may need two or three vials of etomidate

I don't really use it much anymore but my standard dose is about 20 mg.

 

[Idiopathic]

I don't really use it much anymore but my standard dose is about 20 mg.

cause thats whats in a vial?

 

[pgg]

We get these type of patients lined up with central acess very quickly, early goal directed therapy is always initiated if it hasnt already been in the ed, sometimes the ggts are up from pharmacy and sometimes the pt needs tubed before ggts get there.

How early can egdt be under those circumstances?

The hx behind no paralytics is 7-8 years ago a senior resident gave paralytic couldnt intubate couldnt ventilate and patient coded.

This is ******ed.

Ive read other boards suggesting versed versed and more versed provides very good hemodynamic stability if titrated right. Can anyone comment?

Versed might be fine for induction, it is generally hemodynamically stable but ALL induction drugs can push someone over the edge if the patient is sick enough.

Also, be careful when doing "titrated" inductions. Usually, "titrated" inductions in floor and ICU patients means
- give a tiny bit
- attempt DL and patient bucks, oops, not deep enough
- give a tiny bit more
- manhandle the patient's epiglottis again, oops, not deep enough
- is that vomit I see? all the blood in the airway makes it hard to tell
- give a bit more
- now that we've titrated in enough drug, enough hypercarbia, and enough hypoxia, the patient is ready for DL #3
- whew, the tube's in, someone pull up Uptodate for a refresher on aspiration pneumonitis

Give enough induction agent in the first place, give a paralytic, and get the tube in promptly, the first time.

but another posted commented on his experince with tissue losing tone in obese patients and making for a less than ideal view...anybody else share this opinion?

This is ******ed.

Does bipap reduce afterload in addition to dropping preload?

Yes

4/50 versed/fent given back to back is pretty much all i see used because of the culture ofthe medicine residency, etomidate wasnt in the pyxis for a while, propofol scares them (i dont think theyve ever thought of not just slamming in the meds), and ketamine is treated like it doesnt even exist.

It matters little what you use, provided you use it correctly.

Some choices are less punishing if you use them incorrectly or clumsily, and this leads some people to make the claim that some choices are right or wrong.

Etomidate might not be ideal for septic patients, but to be honest, I'd rather see the patient induced and tubed with etomidate, than induced with propofol if the intubater isn't familiar enough with propofol to choose a good dose, and anticipating and prepared to manage the other effects.

Push your drugs slow and be stingy / patient to avoid hemodynamic instability

It depends what you're doing and why you're doing it.

Sometimes the most important part of an RSI is the R.

 

[Idiopathic]

Sometimes the most important part of an RSI is the R.

this

 

[bkell101]

what your post describes is a system that advocates high sedation/no paralytic intubations, which are generally more dangerous than those using high paralytic/light sedation, unless you dont really sedate the patient for intubation (i.e. 4/50 versed/fent)

Yes I definitely agree and that's why I posted. I'm confused about the way I've recently seen things done. Seems like what we do is more just give what we always give and hope things go well rather than asses pt/situation and chose our medications accordingly. Seems wrong.

generally speaking, the sicker the patient, the less sedative they need to avoid remembering intubation, but they will still move/cough/laryngospasm/fight and get tachycardic, none of which help you in any way. i wont deny that you can intubate people with some versed and fentanyl or whatever combination, but it isnt elegant.

No it's not elegant. Just like one my scenarios in the original post. Fighting patient combined with an unconfident/unexperienced medicine intern is usually ugly and results in a failed attempt and other problems that commonly ensue.


What I'm gathering is that our policy of no paralytic makes for a less than ideal situation in the patient with low bp and semi difficult airway that needs just the slightest bit of induction medication with additional paralytic to avoid tanking the bp and struggling through intubation and causing aspiration/trauma/spasm ect....is that accurate?

 

[bkell101]

if paralytics are not available to you you should not be intubating. it is in my humble opinion malpractice to prepare to intubate without at least having them available to you. it's like saying you aren't allowed to use suction.


The policy recognizes the fact that at we are not competent in all areas of aiway management yet still allows us to manage airways. Who would hire a carpenter that can use a hammer and saw but not a screwdriver? He might not be able to build what you need him to. Maybe you are right. Doesn't make me feel good about myself at work, but maybe we need to become more competent.

 

[bkell101]

My favorite is to draw up in 10ml syringe is 1ml of phenylephrine (200mcg), 5 ml of zemuron (50mg) and 4 ml of versed (4 mg). That is my induction for the unstable if I would be unable to just intubate without anything which is quite frequent during codes. In the semielective without BP issues ill use propofol and zemuron. 3 years of working in the ICU have never needed/used Etomidate.

Much better to lightly sedate and paralyze, than deeply sedate and not paralyze. Most septic patients will not remember anything about the ICU until they are ready to leave.

Thank you for this example. If the 4 mg of versed doesn't cause the patient to close their eyes...more versed? Or something else? Seems like this is an example of light sedation/paralytic that others have pointed out is much safer as compared to our system of high sedation and no paralytic

 

[bkell101]

Versed might be fine for induction, it is generally hemodynamically stable but ALL induction drugs can push someone over the edge if the patient is sick enough.

Also, be careful when doing "titrated" inductions. Usually, "titrated" inductions in floor and ICU patients means
- give a tiny bit
- attempt DL and patient bucks, oops, not deep enough
- give a tiny bit more
- manhandle the patient's epiglottis again, oops, not deep enough
- is that vomit I see? all the blood in the airway makes it hard to tell
- give a bit more
- now that we've titrated in enough drug, enough hypercarbia, and enough hypoxia, the patient is ready for DL #3
- whew, the tube's in, someone pull up Uptodate for a refresher on aspiration pneumonitis

Give enough induction agent in the first place, give a paralytic, and get the tube in promptly, the first time."

The scenario you just described is spot on what I've seen and why I initially posted. Giving the right amount of induction agent in the first place is what we have really struggled with. Unfortunately, since every scenario and pt is different, learning how much and what to give is difficult to learn from a book. You all have really helped to put things in perspective,but seems like on the job training is the only way to acquire this skill/clinical sense. Crazy thing is I've had the opportunity to perform about 15 code situation intubations and around 30-40 "emergent" intubations in the ICU thus far. I know it's beans in comparison, but you'd think I would have a better grasp at this point. Most instances, I've been at the head of the bed with one of my senior medicine residents that is just pushing the "usual stuff" and not able to point out the important subtleties in each case that could help make for better outcomes and learning experience.

 

[bkell101]

How early can egdt be under those circumstances?R.

In our ICU the attendings really stress following the sepsis protocol they have created. I re-read some stuff about egdt. It seems like it should be in the first six hours and not finally rolling 4-5 hours from the time the pt was seen in the Ed and being carried out over a 24 hour period. Thoughts? (sorry this is a little off topic)

 

[vector2]

The first six hours comes from the protocol in Rivers' original paper. Per their methods, the goals were met in the ED in the first six hours and then the pt was transferred to the unit. The claim is that hitting those goals so early is what lead to such a marked decrease in mortality, and that's taken seriously to the point in our protocol where the ICU won't bother with putting in a presep over a regular triple lumen if the admit by some chance slipped through the ED screening and they've been here well over 6 hours. In other words, monitoring and then getting their scvo2 to >70 after they've already been decompensated for 16 hours likely provides no benefit compared to how you were going to treat them anyway.

In addition to being better for the pt, attendings and other support personnel are stressing such protocols because the majority of hospital and provider reimbursement in the future will likely depend on adherence rates to guidelines like these.

edit: forgot to mention, keep in mind the big picture regarding goals you're trying to hit and how good the evidence really is. for example Should We Monitor ScVO2 in Critically Ill Patients?

 

[jennyboo]

If they're slack-jawed and cadaveric: No drugs.

If they need muscle relaxant (most of the time):
... and have hyperkalemia or other sux contraindication: rocuronium 100mg
... and do not have sux contraindication: succinylcholine 100mg

If they're vegetative:
... with hypertension: lidocaine 100mg +/- muscle relaxant
... with nurses watching: 2ml of innocuous induction agent of choice +/- muscle relaxant (a long time ago in a past decade in my training program someone got "written up" by some dumb***** staff for "assaulting" a patient by intubating a difficult airway awake)

If they have bad hearts or are hypotensive: ketamine 20-100mg + muscle relaxant

If they're young and strong:
... and have no brain injury: propofol 100mg OR ketamine 100mg + muscle relaxant
... and have brain injury: propofol 100mg + rocuronium 100mg + phenylephrine

If they are getting chest compressions: no drugs, and do not ask to hold chest compressions

Used at appropriate doses, muscle relaxant increases the success of first-time direct laryngoscopy by an experienced intubator.

 

[ssmallz]

One of the biggest points that most novice intubators miss is that muscle relaxants are the key to optimizing intubating conditions, not induction agents. Pts in the ICU, especially the sick ones are most likely to have some baseline level of dementia so you don't need to use much to achieve an adequate level of sedation for proper intubating conditions. Will they still react? Yes....but your goal for induction, especially in those really sick pts where we don't want to bottom them out, is just to get them sedated enough so they don't remember the actual intubation. As anyone who has intubated a pt before the muscle relaxant has fully hit knows, induction agents are poor drugs to prevent the pt from reacting. The solution is to give muscle relaxants. They provide optimal intubating conditions and are minimally hemodynamically stable. Muscle relaxants make intubation and ventilation easier. There are plenty of good articles out there demonstrating the myth about proving ventilation prior to giving muscle relaxation. So if you don't feel comfortable paralyzing your pt, you should try an awake technique or call someone who does feel comfortable.

 

[bkell101]

If they're slack-jawed and cadaveric: No drugs.

If they need muscle relaxant (most of the time):
... and have hyperkalemia or other sux contraindication: rocuronium 100mg
... and do not have sux contraindication: succinylcholine 100mg

If they're vegetative:
... with hypertension: lidocaine 100mg +/- muscle relaxant
... with nurses watching: 2ml of innocuous induction agent of choice +/- muscle relaxant (a long time ago in a past decade in my training program someone got "written up" by some dumb***** staff for "assaulting" a patient by intubating a difficult airway awake)

If they have bad hearts or are hypotensive: ketamine 20-100mg + muscle relaxant

If they're young and strong:
... and have no brain injury: propofol 100mg OR ketamine 100mg + muscle relaxant
... and have brain injury: propofol 100mg + rocuronium 100mg + phenylephrine

If they are getting chest compressions: no drugs, and do not ask to hold chest compressions

Used at appropriate doses, muscle relaxant increases the success of first-time direct laryngoscopy by an experienced intubator.

Thanks, this breakdown is nice. I think most pt's I've seen so far fit in the not vegetatitive, slightly hypotensive bad heart and def not young and strong and strong category. Which means learning how to use ketamine would be fairly beneficial. Ive never seen it used. Any clinical pearls on the usage of ketamine? From some basic reading drawbacks include salivation, nausea/vomiting, inc icp (controversial?), tachycardia in cad pt, and myocardial depressant in the catecholamine depleted patient are all listed. Which of these are most real and concerning in your experience? Also, does one time dose of ketamine have effect on ICU delirium or nightmare/hallucinations? Any good review articles on the usage of ketamine for intubation that I can read?

If you didn't have ketamine available what would be your second choice/strategy in this category of pt's?

Would anybody else like to share something similar to what jennyboo posted based on how they initially evaluate and approach certain situations? I realize there are a ton of different variables in play and many ways to skin the cat but having an initial organization or framework to build upon would be beneficial.

 

[bkell101]

One of the biggest points that most novice intubators miss is that muscle relaxants are the key to optimizing intubating conditions, not induction agents. Pts in the ICU, especially the sick ones are most likely to have some baseline level of dementia so you don't need to use much to achieve an adequate level of sedation for proper intubating conditions. Will they still react? Yes....but your goal for induction, especially in those really sick pts where we don't want to bottom them out, is just to get them sedated enough so they don't remember the actual intubation. As anyone who has intubated a pt before the muscle relaxant has fully hit knows, induction agents are poor drugs to prevent the pt from reacting. The solution is to give muscle relaxants. They provide optimal intubating conditions and are minimally hemodynamically stable. Muscle relaxants make intubation and ventilation easier. There are plenty of good articles out there demonstrating the myth about proving ventilation prior to giving muscle relaxation. So if you don't feel comfortable paralyzing your pt, you should try an awake technique or call someone who does feel comfortable.

This is great perspective, thank you. I am without a doubt guilty of being the novice you describe early in your post. I guess not having paralytic as an option exacerbates this. I can't count the number of times I recall thinking after a less than elegant intubation "man if we gave more induction agent I wouldnt have had an easier time" , instead of, "we really need to be using paralytic".

I'll do some research, but any article in particular that does a good job dispelling the ventilation prior to relaxant myth?

 

[jennyboo]

I use ketamine because its hemodynamic effects seem to be less dose dependent than, say, propofol or midazolam. If they're frail and already obtunded, 20-30mg seems like enough; if they're strong, I'll give 100mg+. None of these doses is anywhere near a "true" induction dose, so how do I know they won't remember the laryngoscopy? I don't. I've never asked the patient afterward. But in the unstable patient you cannot always guarantee against awareness.

Ketamine is probably delirium inducing. I don't think it has been studied in the ICU population. But here are your choices:
... ketamine = probable brain dysfunction (delirium)
... midazolam = definite brain dysfunction (delirium)
... etomidate = possible adrenal dysfunction
... propofol = probable cardiac dysfunction or, worse, cardiovascular collapse
... opioid only or IV lidocaine only = awareness if the patient does not already have brain dysfunction
... topical (spray the throat and say "open wide") = many ICU patients in respiratory failure no longer have the brain function to cooperate

So pick your poison. If ketamine is not available I use midazolam or propofol in the hemodynamically unstable, and usually give 2cc (midazolam 2mg, or propofol 20mg) chased down by a muscle relaxant. More to appease the nurse than to appease the patient.