Modified rapid sequence?

Discussion in 'Anesthesiology' started by j fizz, Jun 15, 2008.

  1. j fizz

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    I was on call last night with a senior resident and an attending and we all agreed we would do a "modified" rapid sequence induction for a case we were about to put on. Turns out, though, that we had different ideas of how to do a modified rapid.

    Here was my understanding of a "modified" RSI (learned from other attendings)-
    1. Preoxygenate
    2. Induce unconsciousness, apply cricoid pressure
    3. Prove ability to ventilate by bag mask
    4. Paralyze (sux)
    5. +/- gentle ventilation with waiting for sux to circulate

    My attending's version-
    1. Preoxygenate
    2. Push induction agent and wait 10-15 seconds prior to pushing relaxant (to avoid patients having the sensation of weakness prior to unconsciousness)
    3. cricoid pressure
    4. gentle ventilation while waiting for sux to circulate

    Her critique of my version: what do most people do if they can't really ventilate? Push sux. Now you've wasted ~30 seconds of your preoxygenation waiting for your induction drug to hit and trying to ventilate. If it hits the fan, you might want that time back. In support of my version, if you can't ventilate and they have a mediocre airway exam, maybe you'd abort your modified RSI and go for awake fiberoptic.

    It was a little humbling, I felt like I should know this by now. But in trying to investigate I've found only a few papers and chapters and no good answer to the question. I'm wondering if there really is a "right" answer?

    What does modified rapid sequence mean to everyone, especially those in practice? Or do you think of "modified" as a more general descriptor, meaning you modify a classic RSI in different ways depending on the situation?

    Also, does anybody have a reference?
     
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  3. Planktonmd

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    It appears that you and your attending are not very clear on what rapid sequence induction is.
    A rapid sequence induction is a situation where you try to make the time between loss of reflexes and intubation as short as possible.
    This means you push the induction agent and the muscle relaxant (most frequently Sux) Simultaneously, you don't ventilate and you intubate as soon as the facial fasciculation is over. the whole process from injection to tube should not be more than 20 seconds.
    If you want to do a modified rapid sequence then you do exactly what I mentioned above but you give a couple of breaths while waiting for the muscle relaxant to work.
    Applying cricoid pressure is really not essential but it looks good on paper.
    I hope this was helpful.
     
  4. 2ndyear

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    I always thought of modified as being a bad in-between that probably just makes us feels better. A big grey area, maybe for those patients that you didn't want to use sux on, but still had a bad GERD history or something. You give your 0.6/kg of roc, apply cricoid, ventilate, and intubate in 2.5 minutes. Is anyone hurt by this, probably not, and if having someones hand on the neck lets you sleep at night, then so be it.

    I happen not to like the gray areas, I like black and white. Not NPO, emergency surgery, RSI with sux. Period. Real contraindication to sux, and I mean real, not ESRD and K is 3.5? Use roc at 1.2 mg/kg, but be prepared to wait a while for reversal until we get sugammadex.
     
  5. Arch Guillotti

    Arch Guillotti Senior Member
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    Almost everyone I work with does the following:

    pre-O2
    push induction agent then sux immediately after
    cricoid as pt. loses consciousness
    gentle ventilation
    tube after fasiculation

    I think gentle ventilation is fine and that it probably doesn't matter whether if we hold cricoid or not but we all do the drill anyhow. If you can't ventilate during the "modified" part (gentle ventilation) you had best be able to intubate. If you can't do either you might not ought to have put them to sleep (like the ED clown in another thread).
     
  6. fakin' the funk

    fakin' the funk ASA Member
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    I know some of you guys on here aren't big fans of cricoid.

    It was my task to hold cricoid on a failed-epidural -> GA C-section the other day. I held until the balloon was up and the vent connected. As soon as I let go the mouth filled w/ gastric fluid. To me this was a clear case of cricoid working, but I'd love to hear your input.

    As well, any citations/pointers to the papers showing cricoid is/ain't effective would be helpful.
     
  7. Planktonmd

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    We had this discussion here previously and my stand on the subject hasn't changed: Cricoid pressure is not harmful and possibly beneficial but there is no current evidence in it's favor.
    When DR. Sellik came up with the idea 50 years ago he conducted a small elegant study on cadavers using fluroscopy and was able to show that cricoid pressure does compress the esophagus and concluded that it could prevent aspiration.
    After that the sellik maneuver became very popular until recently when people started questioning it's usefulness and even suggest that it might make the intubation more difficult which makes it actually harmful.
    There were a couple of evaluations of cricoid pressure using MRI on healthy volunteers and they demonstrated that cricoid pressure did not occlude the esophagus most of the time.
    So, the maneuver is still taught to everybody, the evidence for it or against it is not very strong, and it's difficult to design a study that can
    really evaluate it's usefulness.
     
  8. KungPOWChicken

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    I don't think cricoid matters as much as not ventilating. Fakin the funk I bet as soon as you let go is the same time they started ventilating when the circuit was connected. I had an incident where a hospitalized patient had been "burping a little bit" a little nausea but no vomiting. We decided to do a RSI as soon as that ventilator was turned on green bilious fluid started pouring out of his mouth. We sucked 1.5 liters out of this guy who turned out to have an ileus. The bottom line is once you increase intraabdominal pressure by positive pressure is when the **** will hit the fan. At my institution we had a guy recently who had been hospitalized for an orthopedic injury. Young guy in his thirties. He must of had a similar situation because once they started ventilating he vomited and aspirated. Ended up on ECMO. Anyways. I think you've got to seriously way the risk and benefit of not doing a RSI on inpatients. At least make sure you assess for obstruction or ileus.
     
  9. Arch Guillotti

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    Agree w/above.
     
  10. SleepIsGood

    SleepIsGood Support the ASA !
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    Best description of how we do it at our place.
     
  11. Idiopathic

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    modified rapid sequence the way it is described is pretty silly when you think about it. unless you are worried about toxic levels of CO2 arising from the minimal apneic time, then what do you gain by ventilating? I sometimes do it just to make myself feel better, but honestly, what good is it?
     
  12. Planktonmd

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    Some patients don't tolerate any apnea time and you will encounter one of them sooner or later.
    Here an example: Patient comes emergently for a ruptured abdominal aneurysm, he happens to be in full pulmonary edema and just had a good old big mac.
    Saturation is 75% on 100% FIO2 and RR is 60/min (this is a real story by the way).
    Do you think he will tolerate apnea even for 20 seconds?
     
  13. dhb

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    you can do an inverted sequence induction: sux before versed later :laugh:
     
  14. urge

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    For me, if you ventilate it's not a rapid sequence. That's just a regular induction with cricoid. What was the indication for the "sort of doing a rapid sequence, but not really" induction? I think the 3 of you were kidding yourselves.
     
  15. SleepIsGood

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    Per my former chair...

    when Sellick originally created used Cric pressure he did this while performing what we now call the 'modified rapid sequence'. In essence the mod RSI is the original RSI.

    I say why not ventilate, even if it's just for a little bit. The more you can get into the FRC the better. It buys you that extra time and makes you feel good:smuggrin:
     
  16. jetproppilot

    jetproppilot Turboprop Driver
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    Man, I just love some of the USELESS NOMENCLATURE our publishing-academicians come up with!

    BTW, OP, your question is a good one.

    Plank's response is the most reasonable response to a TOTALLY CONTRADICTORY MADE-UP SEQUENCE OF WORDS BY OUR PUBLISHING COLLEAGUES THAT ARE "IN THE KNOW". :)lol:)

    Lets think about this a minute.

    Whats the MOST IMPORTANT part of a rapid sequence induction?

    ANYONE? Jet looks around the room and homes in on NOYAC who is sitting in the back reading the most recent issue of SNOWBOARDER.......

    "Noy?"

    "Yeah, Dude, the most important part of a rapid sequence induction is that you don't ventilate the patient."

    Noy flips his feet up on the chair in front of him and returns to flipping thru SNOWBOARDER

    "EXACTLY, NOY! Thanks!" Jet replies.

    And to accomplish not ventilating someone, said anesthesiologist has to do several things, like Plank eloquently posted above:

    1)PREOXYGENATE.....denitrogenates the alveoli, fills patient's FRC with pure O2, giving the clinician time to not ventilate.

    2)PUSH DA INDUCTION AGENT FOLLOWED BY DA SUX IMMEDIATELY AFTER PUSHING THE INDUCTION AGENT. Don't wait. You're wasting time you may need later.

    3)CRICOID PRESSURE. :)lol:)..Yeah, whatever. For the lawyers.

    All the above is performed for one, single, solitary, unified, stand-alone objective:

    SO YOU DON'T HAFFTA VENTILATE!!!

    IMHO, the most important part of RSI is not pushing air into the stomach....cuz that, over anything else, is what causes stomach contents to eject in a true full stomach, like a true bowel obstruction.

    SOOOOOOOOOOOO....

    somebody in our biz thought if you give justa cuppla puffs during this process, it needed a name.:laugh:

    There you go....Modified Rapid Sequence Induction.

    An induction where you shouldnt ventilate but you do, but justa little.

    Man, if I were a plaintiff attorney I could make some MAJOR C NOTES with that concept.
     
  17. jennyboo

    jennyboo Senior Member
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    As a resident I've been told to do all sorts of different things that called "modified RSI." Ranging from:

    - Preoxygenate, propofol, cricoid, one breath, sux, tube.

    to

    - Preoxygenate, propofol, cricoid, one breath, cisatracurium or vecuronium, mask for 3 minutes while the NMDB kicks in, tube. (Note that the only difference between this and a regular, non-RSI induction is CRICOID which probably is useless anyway!)

    Most of the time in cases where patient is NPO, gets reflux in chest a couple times a month spontaneously, etc. Vague half-hearted indications for RSI in an NPO patient who may not actually need it.
     
  18. bluewater

    bluewater Cardiac Anesthesiologist
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    Mod RSI= garbage, no such animal, either you ventilate and its not an RSI or you dont ventilate after pushing the drugs and it is an RSI.

    Our ED is famous for not understanding this concept- nothing like a difficult AW with a pt the is chunking from all the air in the belly.
     
  19. Bougie

    Bougie Junior Member
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    MRSI = BS

    One pearl learned from one of my attendings:

    If there is no huge rush (i.e you have a few minutes) and there is a high risk patient (AAA who just ate posted above) just stick in an NG tube and drain that stomach prior to pushing any meds. Leave it in while intubating.

    Sure it may be uncomforable for the patient but so is ECMO after an aspiration. Jeez....

    Worked well for me on those rare occasions it's needed. Most patients don't mind once you explain your reasoning.
     
  20. Planktonmd

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    Do you really want to put an NG tube AWAKE in someone who is in the process of rupturing his aortic aneurysm?
     
  21. ZA_Gasman

    ZA_Gasman Running with scissors...
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    Good grief!

    My 2c? Doesn't matter what you call it, as long as you can justify that it is safe. For what it is worth... In my training we had 2 RSI sequences. The bog standard RSI (PreOx x3min, Push Induction agent, chaser of Scoline (The Lord's own muscle relaxant :D) with cricoid, and shlonk that snorkel in as soon as fasciculations pass) AND the "Modified Rapid Sequence"

    The Modified Rapid sequence usually was used in patients who you don't want to give Sux to i.e. Renal failure with hyperkalaemia etc. We used to give 10% of the intubation dose of Atracurium, wait until patient develops diplopia then proceed to give induction and the rest of the atracurium, with the obligatory cricoid pressure, tube after 60seconds. Bougie is right... it is BS - all the patients bucked on the tube, and most of them couldn't tolerate the weakness pre-induction.

    What some of you are describing as modified RSI, I thought was the "safe sequence" induction. - But it is all BS. My first statement stands. Don't get caught up on the terminology. Just be safe.

    Jet, at the risk of blowing sunshine.... You DA MAN!
    My commandments of RSI:
    1.Thou shalt NOT ventilate the lungs (or the stomach for that matter) during a RSI until that cuff is blown up!
    2. The whole point of RSI is that it is RAPID! Man, it rides my goat when I see residents slowly injecting Propofol during rapid sequence.
    3. Thou shalt not ventilate the lungs during RSI UNLESS you can't put the blo*dy tube in!
    4.Muscle pains are temporary. Hypoxic brain damage can last forever. Unless there is a real contra-indication, use the Lord's own muscle relaxant (see above)
    5. NEVER try RSI with Etomidate and Alfentanil. You just end up looking silly, and then giving Sux. Ask me how I know? I've done it myself.

    And now, I will climb down from my albeit little soapbox, and run, in a dignified fashion, for cover.
     
  22. Tsutsugamushi

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    I'm doing my anesthesiology rotation now and was wondering if you still give versed and fentanyl prior to your induction for modified rapid induction?

    Also, is nimbux traditionally used before sux for modified rapid induction or just in general?

    Thanks in advance!!!!
     
  23. Tsutsugamushi

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    bump

    I wasn't able to find any answers on the web or in books so any help would be great. Thanks!!!!
     
  24. anesthesiadoc

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    Nimbex (cisatracurium) would probably be a poor choice for rapid intubation (it's onset time is measured in minutes, whereas succinylcholine is significantly faster, followed by rocuronium).
     
  25. pgg

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    There's a lot of variability between anesthesiologists with regard to how "modified" a modified RSI is. So you probably won't just see one method. Some people premed with Versed and/or fentanyl. I'll sometimes give Versed prior to an RSI. Usually not fentanyl.

    Remember the point of an RSI is to rapidly secure the airway to minimize the risk of a full stomach. A little bit of careful anxiolysis is OK, but if you obtund the patient with benzos and narcs prior to inducing them, then you're giving up the primary benefit: a mostly-awake patient with intact airway reflexes until seconds before you stick a tube in them.

    The reason some people give a defasciculating dose (a small dose of a nondepolarizer before the succinylcholine) is so the patient doesn't wiggle when the succ hits. The disadvantage is that a larger dose of succ is needed and it doesn't work quite so quickly.

    Given that the most important part of an RSI is the 'R' I don't see much point in ever giving a defasciculating dose of a nondepolarizer for an RSI, modified or not.

    If you do give a defasciculating dose of a nondepolarizer, Nimbex (cis-atracurium) isn't the only option. Roughly 1/10th the intubating dose of any nondepolarizer will work.
     
  26. Tsutsugamushi

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    Thanks for the reply everyone. Is there any reason why an obese patient would receive nondepolarizing muscle relaxant before succinylcholine? That's sort of counter intuitive to me because sux increases abdominal contractions and increase lower esophageal sphincter tone this preventing aspiration. Why would you give a nondepolarizing relaxant then? I don't quite understand why it was done? Any thoughts? Thanks in advance!!!!
     
  27. ProRealDoc

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    Exactly how we do it.
     
  28. Idiopathic

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    no one has given me a good reason to give a defasciculating dose of NMB in an RSI situation. often times it is given in non-RSI situations to help prevent myalgias but also to not force the provider to bag the patient for 3+ minutes
     
  29. pgg

    pgg Laugh at me, will they?
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    I don't believe there's any data that a defasciculating dose of a nondepolarizer reduces the incidence of postop myalgias. Correct me if I'm wrong.
     
  30. Idiopathic

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    yes there is data supporting either rocuronium/lidocaine/NSAID pretreatment i believe
     
  31. proman

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    Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials.
    1: Anesthesiology. 2005 Oct;103(4):877-84.
    Fifty-two randomized trials (5,318 patients) were included in this meta-analysis. In controls, the incidence of fasciculation was 95%, and the incidence of myalgia at 24 h was 50%. Nondepolarizing muscle relaxants, lidocaine, or magnesium prevented fasciculation (number needed to treat, 1.2-2.5). Best prevention of myalgia was with nonsteroidal antiinflammatory drugs (number needed to treat, 2.5) and with rocuronium or lidocaine (number needed to treat, 3). There was a dose-dependent risk of blurred vision, diplopia, voice disorders, and difficulty in breathing and swallowing (number needed to harm, < 3.5) with muscle relaxants. There was evidence of less myalgia with 1.5 mg/kg succinylcholine (compared with 1 mg/kg). Opioids had no impact. Succinylcholine-induced fasciculation may best be prevented with muscle relaxants, lidocaine, or magnesium. Myalgia may best be prevented with muscle relaxants, lidocaine, or nonsteroidal antiinflammatory drugs. The risk of potentially serious adverse events with muscle relaxants is not negligible. Data that allow for a risk-benefit assessment are lacking for other drugs.
     
  32. Narcotized

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    Oxygen.
     
  33. Idiopathic

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    you can oxygenate with high flow passive ventilation if you need to without ventilating right? and this is why your preoxygenate, if your patient cant tolerate 30-60 seconds of apnea to prevent critical deoxygenation then maybe you have a bigger problem than a full stomach.
     
  34. Idiopathic

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    imagine how theyd look if you didnt give it? i have never induced a patient without lidocaine so maybe i should try it next week.
     
  35. proman

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    If I do an RSI for a real reason they get oxygen, induction agent + succ or roc. No lidocaine, no midazolam, no fentanyl nothing else. The patients don't have time to complain. Maybe it's harsh but I'll only RSI when I really really care about immediately securing the airway.
     
  36. Licoricestick

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    Pissed about what?
    I have almost NEVER induced with lignocaine. I'm not quite sure why the absence of it would cause the patient to throw the facemask!
     
  37. pgg

    pgg Laugh at me, will they?
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    Also, patients don't like the "propofol Bier block technique" which is what you get when you push propofol into a hand IV when the cuff is up on that arm ...

    Patient: "Ow!"
    Me: "Uh, yeah, sir, you'll feel a little warmth in your hand as you're drifting off to sleep. It'll go away pretty quickly."

    15 seconds passes. Grimace of pain on patient.

    Patient: "Ow!"
    Me (silently to myself as I hit the stop button to deflate the cuff): "God ****ing **** it, I did it again. ****."
    Me (aloud in my most soothing voice): "Nice deep breaths, we'll take good care of you."
     
  38. Idiopathic

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    so what do you do for your lap appys who ate 4 hours ago?
     
  39. proman

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    We would wait 2-4 more hours depending on the attending. Bicitra, I'd still use succ, maybe cricoid, ventilate once and tube.
     
  40. Arch Guillotti

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    I don't really understand why you are waiting 2-4 hours if you are going to give sux, maybe cricoid and a single ventilation. Sounds like you still consider the patient a full stomach. What does waiting 2-4 hours accomplish? Does it make the patient less of a full stomach?

    I also don't understand the need to ventilate once unless the pts oxygenation and FRC are horrible or if you just want to make yourself feel better about knowing you can ventilate the patient.
     
  41. Idiopathic

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    acute appendicitis is a full stomach until after surgery, as far as im concerned. waiting 4 more hours just makes you do the case later, it certainly doesnt change the situation. i wouldnt modify the rapid sequence, but i also wouldnt rush into the situation without midaz/lidocaine prior to induction agent...you will admit that most of your RSI patients are not unstable traumas but rather suspected full stomachs in ASAI-III. i think you do them a disservice by not offering amnestic and lidocaine
     
  42. Jeff05

    Jeff05 Senior Member
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    to the poster who mentioned that patient regurgitated after cricoid was released...how do you know that it was cricoid that prevented the regurgitation? the patient could have regurgitated at that time because (i know you weren't looking) the OBs were already in the uterus and pushing on the abdomen to pop the baby out. perhaps the release of pressure on the esophagus initiated a peristaltic wave that resulted in regurgitation (not really).

    everyone has seen the cadaver imaging study that revealed that cricoid pressure very unreliably occludes the esophagus.

    also, it has been shown that cricoid pressure may be harmful at times, due to WORSENING of laryngoscopic views and prolonged period of an unsecured airway.

    i personally like a slight reverse trendelenburg. keeps the stuff downhill. some may argue that if stuff does come up then it runs downhill into lungs. however, i think once the stuff is actually UP, things are BAD anyway. my goal is the prevention of regurgitation, not so much the minimization of aspiration once regurgitation occurs.
     
  43. Arch Guillotti

    Arch Guillotti Senior Member
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    OK I understand your logic (I think). Lets say you had a guy that ate a Big mac at 8 am, mangled his leg at 8:30 am and is now posted as an urgent case (needs to go within the hour) and it is noon. He received some morphine in the ED but his leg hurts like a sumbitch. The OR nurses haven't finished surfing facebook and playing sudoku and they need 30 more minutes to get ready and the preop is done. He is in pain and nervous as hell.

    So you are still not going to give him anything - either in the holding room, on the way to the OR or pre-induction?
     
  44. Arch Guillotti

    Arch Guillotti Senior Member
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    all good points.

    Remember that not all full stomachs regurgitate, not all aspirate and not everyone gets sick from aspiration. Sometimes you just have to take the risk of a full stomach - for example a kid with unobtainable IV access for an urgent case that you choose to do an inhalational induction on.
     
  45. proman

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    I think it's fine to treat his pain in holding, I'm just not going to give anything as part of my induction. I've also seen patients half induced after midazolam and fentanyl given for no good reason.
     
  46. Jeff05

    Jeff05 Senior Member
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    i would do a CSE in holding.
     
  47. proman

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    Do you have evidence that appendicitis delays gastric emptying? I'm not convinced it does. We're not talking a bowel obstruction or recent meal. I would argue that midazolam is completely optional. It's nice to have that extra buffer of amnestic but it's only an added risk. As for lidocaine, I don't think that it offers much. It's not as if lidocaine is perfect for preventing burning either. If you really care about pain on induction, just use thiopental.
     
  48. proman

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    I'm not convinced it's a full stomach. I ventilate once because I think that's a valuable piece of information to pass on (I don't like not knowing if I'd be able to mask).

    I think patients vomit from 1) light anesthesia 2) gastric insufflation from masking. I'm picking a technique that reduces both. It's a judgement call. Do you think my way is unsafe?
     
  49. 6stringsdown

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    I didn't know much about the more recent discussion, so i investigated. Isn't there any chance that an acute appendix could stimulate the small bowel and/or the gastroduodenal junction via some abdominal neurogenic response?
     
  50. Arch Guillotti

    Arch Guillotti Senior Member
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    I'm not convinced it's a full stomach, but I'm not convinced it isn't a full stomach either. I agree with both your points, although I think the test ventilation is dumb. What are you going to do if your test ventilation sucks? Ventilate some more, this time more aggressively? No - you put the tube in.

    I don't think your way is unsafe at all. I think its dogmatic.

    Induction agent and paralytic only for EVERY RSI? I think you can titrate in some versed/fent/whatever safely and easily.

    Now if you are talking about a TRUE FULL STOMACH -obstruction, s/p esophagectomy, severe gastric emptying I believe your approach may have some merit (maybe). Whats the harm in giving some lidocaine? I don't see how it can hurt and it may help some (I think blunting the response to laryngoscopy is debatele but IRRC it can decrease the incidence of post sux myalgias).
     
  51. proman

    proman Member
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    Maybe I didn't say my point well. If I have the "true full stomach" then I'll do induction/paralytic only. That is what I consider to be RSI. All the other instances aren't RSI. I've had patients complain of tinnitus/perioral numbness after IV lidocaine. Probably no where near the seizure threshold but lidocaine really doesn't add much.
     

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