Neonatal airway nightmare.

[VentdependenT]

Anesthesia on-call overhead.

Walk in with one of my anes buddies to tackle this one. Attending right behind us.

2kg newborn with severe tetrology, g-tube, hx of difficult intubation yesterday, lines all over the place, being sloppily bag/mask ventilated by RT. Extubated by staff for complete obliteration of the whopper 3.5 ETT with "goobers."

Note in chart said the team previously got the tube in yesterday on the second try. No problems mask/ventilating.

OK, here we go.

Give nothing but atropine first. Keep the baby SV. We take a look. Oropharynx filled with white tube feeds and mucus. Great. Inflamed bulbous Arytenoids visualized through the white bubbling goo that keeps comming no matter how much we suction. Tube in, we think. Hook up CO2 thingy. No co2, no chest rise. Strike one.

Same thing happens on the second attempt and 3rd attempt. What the hell! We called for the NICU attending after the 1st attempt BTW. So some more experienced hands were on the way.

All of a sudden masking becomes IMPOSSIBLE, even with the oral-airway. Christ....there go the sats...FAST. I ask for sux, maybe its a laryngo-spasm. Boom its in. I tell them to grab some pedi LMA. Can't find one. I tell them to start pushing atropine and epinephrine. We Look. Almost (too much white crap back there to be sure) positive the tube is in but NOTHING IS HAPPENING. We are completely second guessing ourselves now about tube placement. I'm too scared to waste anymore time futzing around with placing a tube when the sats are flyin in the toilet. I MUST ventilate, not just intubate. It seems like the ETT its getting hung up at 6 cm too.

Anyways we start coding the kid as soon as the NICU guy gets there. I feel like I'm gonna vomit.

Whats goen on?

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[Be a Pro]

TE Fistula?

 

[Planktonmd]

Anesthesia on-call overhead.

Walk in with one of my anes buddies to tackle this one. Attending right behind us.

2kg newborn with severe tetrology, g-tube, hx of difficult intubation yesterday, lines all over the place, being sloppily bag/mask ventilated by RT. Extubated by staff for complete obliteration of the whopper 3.5 ETT with "goobers."

Note in chart said the team previously got the tube in yesterday on the second try. No problems mask/ventilating.

OK, here we go.

Give nothing but atropine first. Keep the baby SV. We take a look. Oropharynx filled with white tube feeds and mucus. Great. Inflamed bulbous Arytenoids visualized through the white bubbling goo that keeps comming no matter how much we suction. Tube in, we think. Hook up CO2 thingy. No co2, no chest rise. Strike one.

Same thing happens on the second attempt and 3rd attempt. What the hell! We called for the NICU attending after the 1st attempt BTW. So some more experienced hands were on the way.

All of a sudden masking becomes IMPOSSIBLE, even with the oral-airway. Christ....there go the sats...FAST. I ask for sux, maybe its a laryngo-spasm. Boom its in. I tell them to grab some pedi LMA. Can't find one. I tell them to start pushing atropine and epinephrine. We Look. Almost (too much white crap back there to be sure) positive the tube is in but NOTHING IS HAPPENING. We are completely second guessing ourselves now about tube placement. I'm too scared to waste anymore time futzing around with placing a tube when the sats are flyin in the toilet. I MUST ventilate, not just intubate. It seems like the ETT its getting hung up at 6 cm too.

Anyways we start coding the kid as soon as the NICU guy gets there. I feel like I'm gonna vomit.

Whats goen on?

2 things to R/O:
1- Tension Pneumothorax.
2- Tracheoesophageal fistula.

Most likely # 2 but you have to R/O # 1

I know you thought about these things didn't you?

 

[VentdependenT]

2 things to R/O:
1- Tension Pneumothorax.
2- Tracheoesophageal fistula.

Most likely # 2 but you have to R/O # 1

I know you thought about these things didn't you?

Tension had crossed my mind, but I must admit, not up front. I couldn't move squat, I couldn't hear squat, and now the sats AND HR are completely in the pooper. Should I have done a bilateral needle thorocotomy on a 2kg PICU kid. Christ. I ain't that smart yet.

No hx of TE Fistula.

The NICU attending gets there and tubes the kid. Same problem we had. Not moving squat, no CO2. So he takes the blade, hoists the head up, and makes my buddy look with him. He's like "ok my friend, that tube is THROUGH the cords right? RIGHT?"

They are baggin like mofo's. The guy gets the special "baby safe" bag, which I should have asked for. Still baggin like CRAZY. Nothing. By now about 3-4 rounds of epi/atropine have gone in with chest compressions. HR in 100's. No BP. No sats. NICU attending asks what we think about epi in the tube. I'm like "hell ya, lets do it." How much? I say, double the IV dose. Kaboom it goes down there. Then he's like, how bout some albuterol nebs? RT dude is like, OK here it comes!

 

[jetproppilot]

Tension had crossed my mind, but I must admit, not up front. I couldn't move squat, I couldn't hear squat, and now the sats AND HR are completely in the pooper. Should I have done a bilateral needle thorocotomy on a 2kg PICU kid. Christ. I ain't that smart yet.

No hx of TE Fistula.

The NICU attending gets there and tubes the kid. Same problem we had. Not moving squat, no CO2. So he takes the blade, hoists the head up, and makes my buddy look with him. He's like "ok my friend, that tube is THROUGH the cords right? RIGHT?"

They are baggin like mofo's. The guy gets the special "baby safe" bag, which I should have asked for. Still baggin like CRAZY. Nothing. By now about 3-4 rounds of epi/atropine have gone in with chest compressions. HR in 100's. No BP. No sats. NICU attending asks what we think about epi in the tube. I'm like "hell ya, lets do it." How much? I say, double the IV dose. Kaboom it goes down there. Then he's like, how bout some albuterol nebs? RT dude is like, OK here it comes!

Maybe its something simple.

Maybe the stomach is so full of air from the aggressive mask ventilation that the intra abdominal pressure is reducing those little lungs to zippo.

Put a little sucky tube down into the belly.

 

[VentdependenT]

We opened the g-tube from the start....at least I think we did. For sure it was opened and then suctioned at some point during this whole mess.

We dumped more epi down the tube and FINALLY the lungs started moving. Not great, but moving. Sats pop up. BP pops up. Seems like the kid aspirated, had a whopper bronchospasm, and shunted all his blood through his big ol tet VSD.

We gave phenylephrine too. Once the sats came up we gave some HCO3. Continued nebs. Sats never got above 75 though.

We looked at the CXR later. Massive tension pneumothorax. Was it there before? Did we cause it? Who the hell knows. But it didnt help the bronchospasm.

Man....I don't wanna do any more NICU kids.....at least this month.

 

[VentdependenT]

If I had to do it again I'd have tension pneumo and bronchospasm higher on my DDX. I think I was just seriously panicked. Never been in that position before. But my attending and the NICU dude thought we did just fine considering.

What size needle do you use on a 2KG baby for a thoracotomy? When nothings moving do you just g'head and stick both lungs?

I would also go with my gut and instead of just yanking the tube right away I'd stick that blade in for just a few seconds and confirm placement. At the time I just didn't want to waste time bagging a stomach when those sats started plummeting. Ventilate should ALWAYS come first, when rubber meets road, but there is nothing wrong with taking a quick look to reconfirm.

 

[Planktonmd]

If I had to do it again I'd have tension pneumo and bronchospasm higher on my DDX. I think I was just seriously panicked. Never been in that position before. But my attending and the NICU dude thought we did just fine considering.

What size needle do you use on a 2KG baby for a thoracotomy? When nothings moving do you just g'head and stick both lungs?

I would also go with my gut and instead of reaching yanking the tube right away I'd stick that blade in for just a few seconds and confirm placement. At the time I just didn't want to waste time bagging a stomach when those sats started plummeting. Ventilate should ALWAYS come first, when rubber meets road, but Ithere is nothing wrong with taking a quick look to reconfirm.

I think you did your best and that's what matters.
About the needles in the chest I wouldn't do it if there is a neonatologist around, they fix infants all day long, If It was only me then I would go with 2 # 18 angiocatheters bilaterally to the upper anterior chest.

 

[jetproppilot]

We opened the g-tube from the start....at least I think we did. For sure it was opened and then suctioned at some point during this whole mess.

We dumped more epi down the tube and FINALLY the lungs started moving. Not great, but moving. Sats pop up. BP pops up. Seems like the kid aspirated, had a whopper bronchospasm, and shunted all his blood through his big ol tet VSD.

We gave phenylephrine too. Once the sats came up we gave some HCO3. Continued nebs. Sats never got above 75 though.

We looked at the CXR later. Massive tension pneumothorax. Was it there before? Did we cause it? Who the hell knows. But it didnt help the bronchospasm.

Man....I don't wanna do any more NICU kids.....at least this month.

Rough case, bro.

You learned a sheaat load from it though.

So did we.

 

[milrisome]

Yeah, tough one, man. Those babies are scary and they desat at the drop of a hat.

 

[Arch Guillotti]

Healthy kids drop their sats like a rock as well. I have had a few cases of unrelenting laryngospasm in kids this year, a couple of them w/no IV. Everything turned out fine w/sux and atropine but it sure can be puckering when that pulse ox sounds like a foghorn.

 

[Noyac]

Great case. Are should I say awful case.

But don't be discouraged about these neonates. **** happens really fast with them but they can be very rewarding at times as well. I feel like they can be some of the most rewarding cases we do.

 

[fval28]

If I had to do it again I'd have tension pneumo and bronchospasm higher on my DDX. I think I was just seriously panicked. Never been in that position before. But my attending and the NICU dude thought we did just fine considering.

What size needle do you use on a 2KG baby for a thoracotomy? When nothings moving do you just g'head and stick both lungs?

I would also go with my gut and instead of reaching yanking the tube right away I'd stick that blade in for just a few seconds and confirm placement. At the time I just didn't want to waste time bagging a stomach when those sats started plummeting. Ventilate should ALWAYS come first, when rubber meets road, but Ithere is nothing wrong with taking a quick look to reconfirm.

tough case vent, sounds like you did everything right, don't be too hard on yourself- thanks for sharing with us.

one thing i thought of when reading your case is when you put the 1st tube in the goose, leave it there and let the tube feeds and air drain out of it as well as leaving the g-tube open, then try to reintubate, may help with keeping some of the crap out of the hypopharynx- this idea may help as long as you still have enough room in the mouth to fit the laryngoscope and another 3.5 oett, monday morning quarterbacking but really the only thing i could think of off hand after reading your post.

 

[Noyac]

tough case vent, sounds like you did everything right, don't be too hard on yourself- thanks for sharing with us.

one thing i thought of when reading your case is when you put the 1st tube in the goose, leave it there and let the tube feeds and air drain out of it as well as leaving the g-tube open, then try to reintubate, may help with keeping some of the crap out of the hypopharynx- this idea may help as long as you still have enough room in the mouth to fit the laryngoscope and another 3.5 oett, monday morning quarterbacking but really the only thing i could think of off hand after reading your post.

I don't think the first tube was in the goose. Am I right Venti?

 

[VentdependenT]

I don't think the first tube was in the goose. Am I right Venti?

Correct Noy.

I have heard of leaving the tube in the goose on adults and letting em spray out of it but that just wasn't the case here. I suppose we could have done that though. At worst it would have reconfirmed tube placement.

Like I said before, once those sats are in the gutter and the HR is clearly gonna head in the gutter, I want to VENTILATE and not screw around with the tube anymore.

 

[Noyac]

Correct Noy.

I have heard of leaving the tube in the goose on adults and letting em spray out of it but that just wasn't the case here. I suppose we could have done that though. At worst it would have reconfirmed tube placement.

Like I said before, once those sats are in the gutter and the HR is clearly gonna head in the gutter, I want to VENTILATE and not screw around with the tube anymore.

I had a very similar case yesterday but it was never stressful and much easier. So I am not taking anything away from your nightmare Venti.

Here it is. First time this has happened to me to this degree. Very obese 240# female for FESS (endoscopic sinus surgery). H/O nasal polyps with chronic sinusitis, asthma, NSAID allergy (it makes my chest tight and i can't breath), Sz disorder, HTN, GERD, OSA. ASC case so she is going home postop (I know but another topic). I induce her with 100mcg fent, 200mg Prop, 50 mg Roc. Easy to mask but some stiffness. Circulating nurse is talking to me about another case. I ventilate her for around 1 1/2 minutes I notice that it isn't real easy but I am successful nontheless. Feels like ventilating an obese pt. During DL I get a wide open grade one view and I pass the tube. Hook it up still talking with the nurse and start to ventilate. It really tight and no CO2. I think aw **** how did i put that in the goose. I pull the tube and mask aain. Now she is really tight. Sats low 90's. Now 80's No Co2 with mask, 70's. I feel air exchange but no CO2. 60's and finally some blips of CO2 on the scene. I'm not worried caus eI know I'm ventilating her by the feel and chest rise but the CO2 is concerning. I mask her back up to 99%. All is well, right? DL again huge wide open cords, still talikng with nurse about other case. The nurse notices but I am calm so she keeps talking. I really watch the tube pass thru the cords this time. Hook it up and start to ventilate. NOTHING! What the bleep. I listen over the chest, NOTHING. I pull the tube again, wrong thing to do, and mask her. 80, 70 80 90 99%. OK what's up.

 

[Planktonmd]

I had a very similar case yesterday but it was never stressful and much easier. So I am not taking anything away from your nightmare Venti.

Here it is. First time this has happened to me to this degree. Very obese 240# female for FESS (endoscopic sinus surgery). H/O nasal polyps with chronic sinusitis, asthma, NSAID allergy (it makes my chest tight and i can't breath), Sz disorder, HTN, GERD, OSA. ASC case so she is going home postop (I know but another topic). I induce her with 100mcg fent, 200mg Prop, 50 mg Roc. Easy to mask but some stiffness. Circulating nurse is talking to me about another case. I ventilate her for around 1 1/2 minutes I notice that it isn't real easy but I am successful nontheless. Feels like ventilating an obese pt. During DL I get a wide open grade one view and I pass the tube. Hook it up still talking with the nurse and start to ventilate. It really tight and no CO2. I think aw **** how did i put that in the goose. I pull the tube and mask aain. Now she is really tight. Sats low 90's. Now 80's No Co2 with mask, 70's. I feel air exchange but no CO2. 60's and finally some blips of CO2 on the scene. I'm not worried caus eI know I'm ventilating her by the feel and chest rise but the CO2 is concerning. I mask her back up to 99%. All is well, right? DL again huge wide open cords, still talikng with nurse about other case. The nurse notices but I am calm so she keeps talking. I really watch the tube pass thru the cords this time. Hook it up and start to ventilate. NOTHING! What the bleep. I listen over the chest, NOTHING. I pull the tube again, wrong thing to do, and mask her. 80, 70 80 90 99%. OK what's up.

Bad bronchospasm and severely hyper-reactive airway.
I would take her down deep with Vapor before attempting to intubate again.

 

[Noyac]

Bad bronchospasm and severely hyper-reactive airway.
I would take her down deep with Vapor before attempting to intubate again.

Yep.

What caused it?

How you gonna treat it?

How you gonna wake her up?

Starting to look like I hijacked this thread, sorry.

 

[Planktonmd]

Yep.

What caused it?

How you gonna treat it?

How you gonna wake her up?

Starting to look like I hijacked this thread, sorry.

well,
She has Samter's syndrome: Nasal polyps, Asthma and aspirin allergy.
Her bronchospasm could have been at least accelerated by your 50 mg of Rocuronium if not triggered by it.
The passage of the ETT is making it worse every time so she is not deep enough.
So:
You can give an Antihistamine, Lidocaine IV, deepen the anesthetic with Sevo, and you intubate when she has > 2 mac on board.

At the end you extubate deep after a dose of lidocaine IV.

 

[jeesapeesa]

Incoming MS-I slash RT. I was called to the same exact situation by the anesthesiologist about a month ago to give some albuterol/atrovent neb. I came in the OR and the pt was already extubated but he had trouble ventilating her. All I knew that she was asthmatic and I think it was post-op appy (sorry guys for the lack of more info). He was panicking since her sats were 80/79. Never used the MDI but all he did was kept a tight seal and bagged her with 100% O2 the whole time about 15 minutes then decided to intubate her again. She had a thick neck and the doc looked so relieved when the tube was in. Placed on vent -- sats came back up -- stayed around 90% for about an hour, gave more MDI tx. Extubated the next day.

 

[Noyac]

well,
She has Samter's syndrome: Nasal polyps, Asthma and aspirin allergy.
Her bronchospasm could have been at least accelerated by your 50 mg of Rocuronium if not triggered by it.
The passage of the ETT is making it worse every time so she is not deep enough.
So:
You can give an Antihistamine, Lidocaine IV, deepen the anesthetic with Sevo, and you intubate when she has > 2 mac on board.

At the end you extubate deep after a dose of lidocaine IV.

Exactly.

I had the sevo at 6% while masking and once the tube was in. I gave decadron 8mg and she was improving pretty quickly. PIP's 45 at time of bronchoconst. and down to 24 in about 15-20 minutes. She received more fentanyl and propofol during the case so the most likely aggravator was the Roc and airway manipulation. At the end of the case we extubated her deep : and put a face mask with neb albuterol on her to let her wake up with. She did fine.

 

[VentdependenT]

Friggen nice noy!

Beware ye of the BRONCHOSPASM!

Do you give 100ucg epi ever for that kind of bronchospasm? My reasoning is that if the lungs are that friggen tight how do you know that the vapor/albuterol is getting to where its needed? It does, eventually get there, as we can see from these case examples.

 

[VentdependenT]

I hope I never get hamsters syndrome

 

[Gern Blansten]

I hope I never get hamsters syndrome

Poor little Lemmiwinks!

 

[Noyac]

Friggen nice noy!

Beware ye of the BRONCHOSPASM!

Do you give 100ucg epi ever for that kind of bronchospasm? My reasoning is that if the lungs are that friggen tight how do you know that the vapor/albuterol is getting to where its needed? It does, eventually get there, as we can see from these case examples.

Never had to give the SQ epi but i wouldn't hesitate.

 

[sdn1977]

Never had to give the SQ epi but i wouldn't hesitate.

Could you have given the epi down the tube when you knew you were in for sure the second time?

 

[Noyac]

Could you have given the epi down the tube when you knew you were in for sure the second time?

Absolutely.

By the way SDN, what do you think of the albuterol wakeup? I remember our discussion of albuterol a few weeks back but I am foggy on the details.

 

[Enrico81]

I don't think the first tube was in the goose. Am I right Venti?

sorry for the silly question, but what do you mean by goose? esophagus or trachea? I can't find it anywhere, not even in the urban dictionary

 

[Planktonmd]

sorry for the silly question, but what do you mean by goose? esophagus or trachea? I can't find it anywhere, not even in the urban dictionary

Esophagus.

 

[Enrico81]

So, please correct me if I haven't understood the situation properly, if the first intubation attempt had probably been successful, and the baby couldn't be ventilated just because of bronchospasm - then why was it still possible to ventilate him via a face mask? ventdependent, did you feel much resistance while trying to bag air through the ETT? or was bagging possible, but the chest didn't expand?

I, too, remember having experienced a bronchospasm case - 3 or 4-yrs-old girl, scheduled for adenotonsillectomy. Easy to ventilate after induction, but once the tube was placed, when I tried bagging, the bag was as hard as wood the attending, who was in the OR, pulled out the tube and reintubated her, but it was pretty much the same as before. Meanwhile, the child was blue, of course :S Luckily, the spasm subsided quickly with albuterol. Really scary though - vent, I can understand you :S

Anyway, sorry for butting in so abruptly, I like this forum a lot

 

[Noyac]

So, please correct me if I haven't understood the situation properly, if the first intubation attempt had probably been successful, and the baby couldn't be ventilated just because of bronchospasm - then why was it still possible to ventilate him via a face mask? ventdependent, did you feel much resistance while trying to bag air through the ETT? or was bagging possible, but the chest didn't expand?

I, too, remember having experienced a bronchospasm case - 3 or 4-yrs-old girl, scheduled for adenotonsillectomy. Easy to ventilate after induction, but once the tube was placed, when I tried bagging, the bag was as hard as wood the attending, who was in the OR, pulled out the tube and reintubated her, but it was pretty much the same as before. Meanwhile, the child was blue, of course :S Luckily, the spasm subsided quickly with albuterol. Really scary though - vent, I can understand you :S

Anyway, sorry for butting in so abruptly, I like this forum a lot

I think what happens (not trying to speak for Venti here) is you find the bagging to be a little difficult but instead of really trying to figure out why you just proceed with intubation and when it is difficult to ventilate through the ETT you think that you must have placed the tube wrongly. First instinct is to pull it and bag again. Then the bagging is difficult again and you realize that you were most likely in the right place the first time and something else is going on. This is what happened in my case at least. I was clued in early in my case b/c at this point in my career I rarely have difficulty masking a pt unless they are just extremely large men with stiff short necks and a beard. You know the type. When I noticed that I wasn't getting much ETCO2 with masking then I realized that the tube was really in in the first place and I put it back in and waited for the lungs to loosen up.

 

[VentdependenT]

I think what happens (not trying to speak for Venti here) is you find the bagging to be a little difficult but instead of really trying to figure out why you just proceed with intubation and when it is difficult to ventilate through the ETT you think that you must have placed the tube wrongly. First instinct is to pull it and bag again. Then the bagging is difficult again and you realize that you were most likely in the right place the first time and something else is going on. This is what happened in my case at least. I was clued in early in my case b/c at this point in my career I rarely have difficulty masking a pt unless they are just extremely large men with stiff short necks and a beard. You know the type. When I noticed that I wasn't getting much ETCO2 with masking then I realized that the tube was really in in the first place and I put it back in and waited for the lungs to loosen up.

Ka-ching.

I was able to bag after the first 2 attempts. But I bet I was getting more and more air in the stomach and less and less in the lung. But it was just enough to oxygenate the kid.

The Tetrology didn't help the sats much because any increase in pulm pressure leads to MASSIVE shunt.

Is Epi down the tube any better than IM epi or IV epi? All I know is that it can cause more cardiac dysrhythmias (from what I've read),

 

[oldbearprofessor]

Current evidence supports a much greater efficacy of IV compared to ETT epi and the new (2006) NRP guidelines reflect this and the need for higher epi doses than were previously recommended.

http://pediatrics.aappublications.org/cgi/content/abstract/118/3/1028

I expect that little of the ETT epi ever gets into the baby in this circumstance leading to its lack of much effect in the few available studies.

In general, I have little to add to this discussion from a neonatologist perspective other than to note that we are expected in a "code" situation to needle both sides of the chest if the tube is visualized directly to be in place and air movement does not occur. We'd like to have the X-ray, but our babies don't have long to survive if they have a large tension pneumo, so we have to use clinical judgment and needle the chest sometimes. We will use any reasonably sized catheter, usually a 16 or 18 G angio will work. Butterfly needles can be used, but it is difficult to do this effectively. On occasion, especially if a central line which could have perforated into the pericardium and allowed it to fill with fluids is suspected, needling the pericardial space is indicated.

Atropine has little if any role in this situation in neonates. Severe bronchospasm causing a "code" is uncommon in preterm infants, but can occur and a bit older baby with a TEF might have some early chronic lung disease and be at risk. Using pressure limited and monitored bags helps lower the risk of a pneumo in this situation, but it is still a common complication even in the most experienced of folks doing the bagging.

Hope this is helpful.

 

[Noyac]

Maybe SDN can elaborate more on this but I was taught that epi SQ or IV was more effective than down the ETT. The only time I remember that it is warranted to give epi via the ETT is in a newborn without IV access who is coding. I probably shouldn't say "only" but thats all I can remember at this time. I still wouldn't hesitate to do it if I thought it might help.

Is that vague enough for you guys?

 

[sdn1977]

Maybe SDN can elaborate more on this but I was taught that epi SQ or IV was more effective than down the ETT. The only time I remember that it is warranted to give epi via the ETT is in a newborn without IV access who is coding. I probably shouldn't say "only" but thats all I can remember at this time. I still wouldn't hesitate to do it if I thought it might help.

Is that vague enough for you guys?

You really don't want me to "elaborate" - I can go on & on far tooo long about drugs Good thing I've got to get off to work!

In a short fashion - it depends on what you want the epi to do. Generally, yes, epi is most effective IV (its all right there in the blood right now) - but, you'll get all the "systemic" effects along with where you want it in this situation - the bronchi. SQ is slower due to the vasoconstriction, but it obviously works fast enough - we use it all the time in epipens for allergic outpts. But, they're not in this situation - yet!

Decades ago, when I first started in pharmacy (the 70's) nebulized epinephrine used to be used frequently - for this purpose & for the asthmatics & COPD's. However - it was in a more concentrated form - 1%. It had to be this high because absorption into the pulmonary circulation put the drug very fast at the liver which is where its metabolized by COMT & other enzymes, so it was deactivated rapidly. That made the effect rapid, but of short duration. Using it inhalationally brought all the other systemic effects too - HR, mydriasis, increased intracranial pressure, etc..

And, unfortunately, the inhalational epinephrine was often confused with the injectable product (inhalational was 1:100 & injectable was 1:1000). They were both put in what appeared to be multidose vials (there were very few single dose vials at that time) & more than one death was due to the injection of the inhalational product being given by mistake.

This was all before albuterol was manufactured. So, unless you were around in the 70's or 80's, you might never have seen epi used much thru an ETT or nebulizer. The only reason I thought about it in this case was you thought you had the tube in place & you had a bronchospasm & you always have epi with you (altho lower concentration). Those albuterol unit of use containers are hard to use without the actual nebulizer, but you could draw it up in a syringe & put it down the tube the same way......I don't think they're on our anesthesia trays - I'll have to look.

Inhalational epi (1%) was removed from the market after albuterol became the standard drug of choice.

 

[Planktonmd]

You really don't want me to "elaborate" - I can go on & on far tooo long about drugs Good thing I've got to get off to work!

In a short fashion - it depends on what you want the epi to do. Generally, yes, epi is most effective IV (its all right there in the blood right now) - but, you'll get all the "systemic" effects along with where you want it in this situation - the bronchi. SQ is slower due to the vasoconstriction, but it obviously works fast enough - we use it all the time in epipens for allergic outpts. But, they're not in this situation - yet!

Decades ago, when I first started in pharmacy (the 70's) nebulized epinephrine used to be used frequently - for this purpose & for the asthmatics & COPD's. However - it was in a more concentrated form - 1%. It had to be this high because absorption into the pulmonary circulation put the drug very fast at the liver which is where its metabolized by COMT & other enzymes, so it was deactivated rapidly. That made the effect rapid, but of short duration. Using it inhalationally brought all the other systemic effects too - HR, mydriasis, increased intracranial pressure, etc..

And, unfortunately, the inhalational epinephrine was often confused with the injectable product (inhalational was 1:100 & injectable was 1:1000). They were both put in what appeared to be multidose vials (there were very few single dose vials at that time) & more than one death was due to the injection of the inhalational product being given by mistake.

This was all before albuterol was manufactured. So, unless you were around in the 70's or 80's, you might never have seen epi used much thru an ETT or nebulizer. The only reason I thought about it in this case was you thought you had the tube in place & you had a bronchospasm & you always have epi with you (altho lower concentration). Those albuterol unit of use containers are hard to use without the actual nebulizer, but you could draw it up in a syringe & put it down the tube the same way......I don't think they're on our anesthesia trays - I'll have to look.

Inhalational epi (1%) was removed from the market after albuterol became the standard drug of choice.

Since you are on this subject, how about Terbutaline injectable for this indication?
I think Terbutaline is a great drug that has been neglected because of marketing issues.

 

[dhb]

Hope this is helpful.

Yes thanks

 

[VentdependenT]

Just had an attending give sq terbutaline the other day to someone who was "refractory" to albuterol puffs in the vent. It worked.

The only thing I don't like about sq epi/or terbutaline (neither of which I have used for bronchospasm) is that it takes 15min or so to work. So yer twiddlen the thumbs for a while.

 

[Planktonmd]

Just had an attending give sq terbutaline the other day to someone who was "refractory" to albuterol puffs in the vent. It worked.

The only thing I don't like about sq epi/or terbutaline (neither of which I have used for bronchospasm) is that it takes 15min or so to work. So yer twiddlen the thumbs for a while.

Terbutaline can be given IV, just don't give too much.

 

[Noyac]

Terbutaline can be given IV, just don't give too much.

Its given SQ by our FP docs that do OB when they want to arrest contractions and by the midwives. I haven't seen the real OB's give that I can recall.

But when these momma's come to the OR for c/s they are taching away at 120-140 bpm. Tis is fine usually since they can tolerate this rate.

Mild adverse effects

Headache, dizziness, drowsiness, restlessness, insomnia (infrequent)
Rapid, pounding heartbeat; increased sweating; muscle cramps in arms and legs (infrequent to frequent)
Nausea, heartburn, vomiting (rare with oral form, frequent with IV)
Increased blood sugar (frequent- 40% abnormal one-hour glucose test)

Serious adverse effects
Rapid or irregular heart rhythm, intensification of angina, increased blood pressure (infrequent)
Lowered blood calcium or potassium (especially with intravenous use) (possible)
Liver toxicity (case reports)
Severe lowering of blood pressure (hypotension) (case reports)
Increased blood sugar (infrequent)
Seizures (rare reports)

Effects of overdosage
Nervousness, palpitation, rapid heart rate, sweating, headache, tremor, vomiting, chest pain

I hate when they use it. These girls are already really scared cause their baby isn't doing well and their belly is about to be sliced open and now I gotta deal with a basket case of nerves.

 

[Planktonmd]

Its given SQ by our FP docs that do OB when they want to arrest contractions and by the midwives. I haven't seen the real OB's give that I can recall.

But when these momma's come to the OR for c/s they are taching away at 120-140 bpm. Tis is fine usually since they can tolerate this rate.

Mild adverse effects

Headache, dizziness, drowsiness, restlessness, insomnia (infrequent)
Rapid, pounding heartbeat; increased sweating; muscle cramps in arms and legs (infrequent to frequent)
Nausea, heartburn, vomiting (rare with oral form, frequent with IV)
Increased blood sugar (frequent- 40% abnormal one-hour glucose test)

Serious adverse effects
Rapid or irregular heart rhythm, intensification of angina, increased blood pressure (infrequent)
Lowered blood calcium or potassium (especially with intravenous use) (possible)
Liver toxicity (case reports)
Severe lowering of blood pressure (hypotension) (case reports)
Increased blood sugar (infrequent)
Seizures (rare reports)

Effects of overdosage
Nervousness, palpitation, rapid heart rate, sweating, headache, tremor, vomiting, chest pain

I hate when they use it. These girls are already really scared cause their baby isn't doing well and their belly is about to be sliced open and now I gotta deal with a basket case of nerves.

These side effects are not specific to terbutaline, any beta agonist will do the same.
Actually in OB they use many dangerous drugs that they have very little knowledge of, examples include:
Methergine, Oxytocin, Butorphanol (Stadol)......
Do you think anyone in OB really knows anything about these drugs?

 

[Noyac]

These side effects are not specific to terbutaline, any beta agonist will do the same.
Actually in OB they use many dangerous drugs that they have very little knowledge of, examples include:
Methergine, Oxytocin, Butorphanol (Stadol)......
Do you think anyone in OB really knows anything about these drugs?

I know the midwives don't understand the drugs. That is apparent.

BTW, are you laughing at me or my post?

 

[Planktonmd]

I know the midwives don't understand the drugs. That is apparent.

BTW, are you laughing at me or my post?

I am not laughing at you, your description of the nervous pregnant woman who was treated with Terbutaline reminded of a similar situation not too long ago where the woman went really crazy and had a fully blown panic attack after terbutaline, it wasn't funny at that time !

 

[Noyac]

Don't you love how these threads take on a life of their own. They morph into something that is totally unrelated to the original post.

We went from a disaster airway in a neonate to a freaked out bundle of nerves in a c/s.

 

[jetproppilot]

Since you are on this subject, how about Terbutaline injectable for this indication?
I think Terbutaline is a great drug that has been neglected because of marketing issues.

Concur.

Still use it in the OR for mild-moderate bronchospasm refractory to albuterol down the ETT.

Usually .3mg terbutaling sq + IV methylprednisilone 125mg for an adult.

 

[sdn1977]

Yep - I like terbutaline & have seen it down the tube, but not often. I'm not sure its a marketing issue or just a practical issue of where to find it when you want it. If your OR doesn't have a pharmacist, the nurse or techs don't know where it is so have to call the central pharmacy....far too long a turn around for you. Since its been generic, it doesn't get "marketed" much.

Where I work, the few who use it down the tube, use it with dexamethasone .... same idea.

For OBs - yeah - I honestly feel they have a good handle on terbutaline (start it as soon as they can after a Mg drip, give 1 or 2 SQ doses & transition to po terbutaline & home...hopefully to term). We actually do a lot of adjusting of the po terbutaline in the outpt mom to keep them from getting admitted. They've got lots of side effects from it & lots of time to think about them since they're usually at bed rest. So...they call the pharmacy to ask. We get to know the terbutaline moms pretty well

I also think the OBs & OB nurses dose oxytocin pretty well. We don't see too much in M&M with any of these drugs (Mg, terbutaline or oxytocin). Standardizing drips & protocols has diminished drug errors a lot.

Now...butorphanol - I agree - no they don't know about that one. I also don't think narcotics are handled particularly well in that area (dosing I mean....either too much or too little when being given IV) & if you've got an addict in labor....the nurses just can't get past how much narcotic has to be given.

Methergine - the OB's know this one well too, but not the OB nurses. But, its really used after the girl has gone home, if they were even admitted at all. Most of the complete spontaneous abortions go home where I am right from the ER or doctor's office. If they need a d&c, they'll get admitted for that, then they go home from PACU with an rx for the methergine - we don't give it out of the pharmacy. I've not sent methergine to L&D, PACU or any of the medical units in 10 years. We never send these ladies to the post-partum unit even if they have to be followed for something else - uncontrolled htn or something. I think the OBs do a pretty good job of explaining to these ladies what to expect since by the time they come to get the rx filled, they know they'll cramp, etc..

My hospital has no midwives at all, but I've got lots of respect for the OBs. I've seen a few who've had trainwrecks - DIC, ruptured uterus, stroke during labor - many who've never had prenatal care & these women had to go from OR to ICU & some never went home. The OBs did great (who am I to even comment....) But...they handled the ICU situation very, very well. I guess I'm just lucky where I am.

I've got no idea what a midwife would do in those circumstances.

 

[sdn1977]

Just had an attending give sq terbutaline the other day to someone who was "refractory" to albuterol puffs in the vent. It worked.

The only thing I don't like about sq epi/or terbutaline (neither of which I have used for bronchospasm) is that it takes 15min or so to work. So yer twiddlen the thumbs for a while.

There used to be a product - Susphrine, which was an epinephrine suspension. It was designed to be used SQ - so it took a while to work, but the suspension formulation allowed it to work for a long time. It was dosed about q 4-6 h for the COPDs before the development of all the inhalationals we have now.

Bad stuff used to happen - it would get "mixed" up by nursing for regular epi & the suspension would be given IV. That caused pulmonary emboli from the oil - not good!

It think its been taken off the market now. We've come a long way!!

 

[tussionex]

sdn...we send more methergine to the floor than one would think they'd need. we must be admitting the same patient's ya'll are sending home

i second the motion on terbutaline. good stuff, definately not "marketed". it's annoying when inexpensive and effective get overlooked in favor of better promoted!