Paralytic failure?

[Apollyon]

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Hey folks, I have a what I believe is an interesting case (along with some clinical goofs).

Had a guy last night, 39, otherwise healthy, doesn't speak one word of English (Chinese). In US for at least past 5 years. Looks good/nontoxic. RA sat 93%. Moist cough, productive of yellow sputum. Daughter recently had "flu like syndrome". Afebrile now, but was febrile at home and took APAP.

CXR shows a mild, diffuse infiltrate, R>L. I'm thinking viral pneumonia.

WBC 9.9, segs 45%, bands 45%, lymphs 7%. K+ is 4.2. Mag is 1.7.

I figured best to cover for bacterial, so ceftriaxone and azithromycin.

He crumps - SaO2 drops to 87%, spikes up to 102+, and gets a little wheezy. Pressure drops to 77/40, and HR up to 115. At the same time, when I get back to the bedside, he says something and his brother (who speaks English) and a friend start laughing. I ask what the pt said, and the brother tells me that the pt said "I feel comfortable". Hm.

Second line is started on the left, in the AC. I do not know what was the BP when that IV was started.

He is agitated - with NC on, SaO2 at 98%, good waveform. However, pulling stuff off. Nurse tells me, I order 1mg Ativan IV. She also says (and she is of Japanese descent) that he looks yellow. I say "that's racist!" but add on the hepatic panel.

About 15 minutes later, his RR just drops, until he's agonal. When RR got to 10, nurse had BVM out, and started bagging, and I got there, and the RR had already tanked. HR dropped to around 40, but still had pulses. However, nothing else - no seizure, no tetany, no vomiting, nothing focal. Have good BLS bagging going on. HR rebounds to 100.

Decide to tube the guy, as he still has no ventilatory effort. Into 2nd IV, 10mg vec and 20mg etomidate (that's what I got - all I got). Nothing. Tight jaw and moving tongue. For some reason, someone wonders if the IV is intra-arterial. The fluids are unhooked, and the blood RUSHES back. Hm.

Abx are in, so the first line on the right is used. Figure we need more meds. Somehow, now, there's roc. He gets 50mg roc IV (I estimated him at 70Kg, but, later, actual weight 56kg), and 10 more mg etomidate. Nothing. Tight jaw and moving tongue. 10 more mg vec. Nothing. Not heating up, no clonus, no tetany. The line is good. The biceps and triceps have good muscle tone. Still good BVM ventilation. I have not put the blade in the mouth - not mucked with the airway. 100mg sux IV. No defasciculating wave. Jaw still tight, but I can pry it open a bit, and he sticks out his tongue a bit. I have called for the intensivist and for him to bring the fiberoptic endoscope. Instead, the Glidescope comes down. The intensivist (IM-Pulm/CC) puts on a Mac 3 and slides it in, despite the tight jaw. He can't pass an 8.0 tube. Moves down to a 7.0, and he gets it in with difficulty. He says the epiglottis was soft and loose, but the cords were edematous and nearly closed. Even so, as stated, the BLS bagging was working.

Cr of 1.3. Not hypercalcemic. TBil 2.4, DB 2.1 (on his way to yellow, cultural differences notwithstanding). Good pulses in L arm that got IA meds (also, ABG by RT was actually venous - score!). Blood pressure holding at 90-100mmHg systolic.

Pt then to ICU. Didn't get an update in the ensuing 6hrs of my shift.

Any insight into failure of depolarizing and nondepolarizing paralytic agents?

(Not a theoretical case - actual case in a Chinese male in a tropical, first world community emergency department.)

 

[geogil]

Were the meds flushed in?

 

[Apollyon]

Were the meds flushed in?

Bolused in, then flushed (if that's what you mean - rapid injection - not dripped in).

 

[dhb]

I can only see a couple of reason for this:
-the patient didn't get the meds: or the wrong meds were given or they pushed up towards the bag.
-there was a problem with the paralytics : degradation , faulty lot which is very unrealistic considering the different meds used unless they were all kept in a very warm storage place.

Even if given intra-arterial the paralytics should still work.

 

[Apollyon]

I said the same thing - IA should still work.

As for degradation, the meds (after the first vec bottle) were from the Pyxis, and not out of date. Our pharmacy is very diligent (unlike other areas of the hospital). At the same time, vec, roc, AND sux ALL degraded at the same time? And there have been no complaints from anesthesia about non-activity in the ORs.

And I watched the crisis nurse (from the ICU) push the meds. There were no IV fluids on the line. The antibiotics had finished, and the site was locked. He used the preloaded flushes after pushing the meds.

edit: also, to note something funny, there are 4 responses, and, right now, 69 views. If anyone remember ECW, Francine had a t-shirt that was on the same lines of the "Austin 3:16" theme, which said "Francine 4:69".

Also, not arguing with DHB - I agree. Still perplexed.

 

[IN2B8R]

The guy told you that he "feels comfortable," why did you start fuggin' around with his airway? No respect for patient feelings? IV not working is my best guess.... Why didn't push sux IM if you had doubts?....

 

[jetproppilot]

I dunno man. That's pretty bizarre. Never seen anything like that. I can see one vial of paralytic potentially being nonfunctional for whatever reason but Three?

Were the meds pulled from a crash cart that hasn't been opened in ten years or something?

 

[Apollyon]

The guy told you that he "feels comfortable," why did you start fuggin' around with his airway? No respect for patient feelings? IV not working is my best guess.... Why didn't push sux IM if you had doubts?....

I mentioned that aloud, about going IM with the sux, but the IV was clean. I mean, if it had infiltrated, there would have been 30 or 40 mL of fluid there, and been boggy, and we were looking at the site continuously.

 

[Apollyon]

I dunno man. That's pretty bizarre. Never seen anything like that. I can see one vial of paralytic potentially being nonfunctional for whatever reason but Three?

Were the meds pulled from a crash cart that hasn't been opened in ten years or something?

The first bottle of vec was in the airway kit. I had looked at it myself last week, and it was current, and stored out of the light. It hadn't been used between then and now.

All the other meds were directly, straight out of the Pyxis.

And they weren't leaking out of a line - like I said above, it was "saline lock --> patient".

Along with the IM, I was thinking that, if the meds even went subQ, they would still absorb in. Then, conversely, I am trying to think of things on the patient end, and not on the medication end, that would/could make this happen. The nondepol vs depol NMB, though, should have evened the odds.

They were going to keep him down in the unit (as if he needed it) with the milk of amnesia. I saw on the chart that a new IV had been started, also in the AC on the Right, in the unit. If I get in a little early, I'll cruise up to the ICU to see if the brother is still alive. Family was angry after and thought that the Ativan did it (all 1 milligram).

The intensivist was also perplexed. If I can find a solution, I may have a publishable case here!

 

[urge]

Hey folks, I have a what I believe is an interesting case (along with some clinical goofs).

Had a guy last night, 39, otherwise healthy, doesn't speak one word of English (Chinese). In US for at least past 5 years. Looks good/nontoxic. RA sat 93%. Moist cough, productive of yellow sputum. Daughter recently had "flu like syndrome". Afebrile now, but was febrile at home and took APAP.

CXR shows a mild, diffuse infiltrate, R>L. I'm thinking viral pneumonia.

WBC 9.9, segs 45%, bands 45%, lymphs 7%. K+ is 4.2. Mag is 1.7.

I figured best to cover for bacterial, so ceftriaxone and azithromycin.

He crumps - SaO2 drops to 87%, spikes up to 102+, and gets a little wheezy. Pressure drops to 77/40, and HR up to 115. At the same time, when I get back to the bedside, he says something and his brother (who speaks English) and a friend start laughing. I ask what the pt said, and the brother tells me that the pt said "I feel comfortable". Hm.

Second line is started on the left, in the AC. I do not know what was the BP when that IV was started.

He is agitated - with NC on, SaO2 at 98%, good waveform. However, pulling stuff off. Nurse tells me, I order 1mg Ativan IV. She also says (and she is of Japanese descent) that he looks yellow. I say "that's racist!" but add on the hepatic panel.

About 15 minutes later, his RR just drops, until he's agonal. When RR got to 10, nurse had BVM out, and started bagging, and I got there, and the RR had already tanked. HR dropped to around 40, but still had pulses. However, nothing else - no seizure, no tetany, no vomiting, nothing focal. Have good BLS bagging going on. HR rebounds to 100.

Decide to tube the guy, as he still has no ventilatory effort. Into 2nd IV, 10mg vec and 20mg etomidate (that's what I got - all I got). Nothing. Tight jaw and moving tongue. For some reason, someone wonders if the IV is intra-arterial. The fluids are unhooked, and the blood RUSHES back. Hm.

Abx are in, so the first line on the right is used. Figure we need more meds. Somehow, now, there's roc. He gets 50mg roc IV (I estimated him at 70Kg, but, later, actual weight 56kg), and 10 more mg etomidate. Nothing. Tight jaw and moving tongue. 10 more mg vec. Nothing. Not heating up, no clonus, no tetany. The line is good. The biceps and triceps have good muscle tone. Still good BVM ventilation. I have not put the blade in the mouth - not mucked with the airway. 100mg sux IV. No defasciculating wave. Jaw still tight, but I can pry it open a bit, and he sticks out his tongue a bit. I have called for the intensivist and for him to bring the fiberoptic endoscope. Instead, the Glidescope comes down. The intensivist (IM-Pulm/CC) puts on a Mac 3 and slides it in, despite the tight jaw. He can't pass an 8.0 tube. Moves down to a 7.0, and he gets it in with difficulty. He says the epiglottis was soft and loose, but the cords were edematous and nearly closed. Even so, as stated, the BLS bagging was working.

Cr of 1.3. Not hypercalcemic. TBil 2.4, DB 2.1 (on his way to yellow, cultural differences notwithstanding). Good pulses in L arm that got IA meds (also, ABG by RT was actually venous - score!). Blood pressure holding at 90-100mmHg systolic.

Pt then to ICU. Didn't get an update in the ensuing 6hrs of my shift.

Any insight into failure of depolarizing and nondepolarizing paralytic agents?

(Not a theoretical case - actual case in a Chinese male in a tropical, first world community emergency department.)

I got a headache reading that.

So you are telling us you have a superb team that places iv's in arteries, gets arterial blood gases from veins, and have muscle relaxants that do not work? Makes me wonder why!

 

[proman]

if the meds even went subQ, they would still absorb in.

SubQ absorption of paralytics takes a long time. That was one of the death penalty cases that the Supreme Court reviewed re: cruelty.

The only inductions that I've had not work involved an infiltrated IV.

 

[wine thief]

honestly i didn't read your entire post. tldr.

but if you're asking why 3 different paralytics "didn't work," the answer is...nonfunctioning IV.

the upper arm can hide a lot of fluid before an inexperienced practitioner will recognize an infiltrated AC IV.

you're welcome.

 

[IlDestriero]

honestly i didn't read your entire post. tldr.

but if you're asking why 3 different paralytics "didn't work," the answer is...nonfunctioning IV.

the upper arm can hide a lot of fluid before an inexperienced practitioner will recognize an infiltrated AC IV.

you're welcome.

Yeah, that's the only reasonable answer in my mind. I would have given the Sux in a new IV, that I placed, if the airway was stable. IM if not.
BTW, when you say that blood rushed out of the other IV, do you mean jetted out of the large catheter in a pulsatile manner onto the floor like an a line or rushed out like draining a hematoma under some pressure? An a line is pretty distinct.
I don't think either line was in.

 

[pgg]

Why on earth are you using vecuronium for an emergent intubation? Couldn't find the D-tubocurare?

My $'s on a nonfunctional IV. I've seen a surprising amount of IV fluids easily drip into a patient's subq tissue and only get recognized when drugs didn't work.


Was he unconscious because he was hypoxic and obtunded or do you think your etomidate worked? I bet it went subq too.

100mg sux IV. No defasciculating wave.

Did the succ go into the same IV as the other drugs?

If (big if) your succ actually got into a vessel, it's possible that one reason it didn't produce any fasiculations is because you'd just given a couple big ass defasciculating doses of nondepolarizers. Even if the NDNMBDs went subq, you gave enough of them that perhaps 1/10th was absorbed ... not enough to relax the patient but enough to serve as defasciculating doses.

 

[IN2B8R]

I mentioned that aloud, about going IM with the sux, but the IV was clean. I mean, if it had infiltrated, there would have been 30 or 40 mL of fluid there, and been boggy, and we were looking at the site continuously.

Ummm, look a little closer next time.👍 More importantly, use good 'ol common sense: in humans, based on what I know, there has not been a reported case of "resistance" to all the agents that you claim were administered IV. You Rock'ed, Vec'ed and Vomidat'ed this little Asian fella to oblivion--he does not poses a super virus that makes him resistant to these agents, only a non-functional IV!

 

[medical geek5]

Maybe the line clotted if any of the drugs pushed were incompatible(IV incompatibility)and clogged it up?

 

[Apollyon]

Updates from last night...guy is still alive. Overbreathing the vent. Still not sure what is going on. The "IA" line was placed by a PACU nurse that was in the ED (not sure why she was there). One line had 2 liters go through it; the other, about 1300mL. If there was an extra 2 to 4 pounds in those arms, that would be hard to hide (even for the "inexperienced", which I am not).

As for the vec, that's what they give me, because it doesn't have to be refrigerated, and we don't need it so frequently that we could use roc before 60 days at room temperature was up.

Occam's razor...bummer. But for the actuality of the meds not working, I would defy anyone here, were they where I was, to believe that the IV lines were not effective and functioning. Oh well, lesson learned.

edit: and I checked - not incompatible meds through the lines. Good thought.

 

[jwk]

honestly i didn't read your entire post. tldr.

but if you're asking why 3 different paralytics "didn't work," the answer is...nonfunctioning IV.

the upper arm can hide a lot of fluid before an inexperienced practitioner will recognize an infiltrated AC IV.

you're welcome.

Ditto to all those voting for non-functioning/infiltrated IV. It's the only reasonable explanation. If it walks like a duck, quacks like a duck...

You've already shown that someone had lousy IV skills, so that skews the whole scenario in favor of that. If they can screw it up once, they can certainly screw it up again.

Three different paralytics not working? Not a chance. Not even close. We occasionally get bad lots of Roc, but even then they still work some, just not great or not for long.

 

[dhb]

Oh well, lesson learned.

edit: and I checked - not incompatible meds through the lines. Good thought.

So what do you think happened?
Did they try paralyzing him in the ICU?

 

[Apollyon]

So what do you think happened?
Did they try paralyzing him in the ICU?

A new peripheral was placed, and he's sedated on propofol, but not paralyzed. I don't think paralytics were needed after he was tubed, and, at that time, he was gorked and not needing sedation right at that moment.

 

[drccw]

I got called for an intubation recently in the ICU.

It was a locums intensivist, who apparently didn't feel comfortable managing airways (fine, especially having the good sense to call before screwing things up).

78 yo M with worsening respiratory failure likely secondary to CHF. Just transferred in. Lots of unknowns, but what is know is EF is 25%.

I ask the nurse for Etomidate 16 mg, Rocuronium 100 mg. She pushes both. About 5 seconds later the patient increases his respiratory rate and is breathing deeper. This continues for another minute...

I think to myself.. he should definitely not be breathing more.. but continue to wait because perhaps slow circulation time secondary to poor cardiac function. At about 1 min 30 secs no signs of abating, so I feel his arm... lots of laxity but definitely appears that the IV has infiltrated....

Great.... another nurse pipes up that he's a difficult stick and they had to use the US to put the IV in on the floor...

Great... Finally about at 4 minutes his breathing slows, and probably at about 5-6 minutes ceases completely, upon which I intubate him...

It was awesome... but now I know how long SQ Rocuronium takes to act.. I think that his upstroke in breathing was likely secondary to the etomidate irritating the his SC.

drccw

 

[IN2B8R]

That's why the first question to always be asked is: do we have a functioning IV.

I got called for an intubation recently in the ICU.

It was a locums intensivist, who apparently didn't feel comfortable managing airways (fine, especially having the good sense to call before screwing things up).

78 yo M with worsening respiratory failure likely secondary to CHF. Just transferred in. Lots of unknowns, but what is know is EF is 25%.

I ask the nurse for Etomidate 16 mg, Rocuronium 100 mg. She pushes both. About 5 seconds later the patient increases his respiratory rate and is breathing deeper. This continues for another minute...

I think to myself.. he should definitely not be breathing more.. but continue to wait because perhaps slow circulation time secondary to poor cardiac function. At about 1 min 30 secs no signs of abating, so I feel his arm... lots of laxity but definitely appears that the IV has infiltrated....

Great.... another nurse pipes up that he's a difficult stick and they had to use the US to put the IV in on the floor...

Great... Finally about at 4 minutes his breathing slows, and probably at about 5-6 minutes ceases completely, upon which I intubate him...

It was awesome... but now I know how long SQ Rocuronium takes to act.. I think that his upstroke in breathing was likely secondary to the etomidate irritating the his SC.

drccw

 

[drccw]

That's why the first question to always be asked is: do we have a functioning IV.

yeah I asked..
and the answer I got was yes....

Just because it flushes easily doesn't mean that it's in a vessel that connects to the heart...

We don't get called to the ICU to often.. I had forgotten how much of an idiot squad they are...

drccw

 

[Bertelman]

My $'s on a nonfunctional IV. I've seen a surprising amount of IV fluids easily drip into a patient's subq tissue and only get recognized when drugs didn't work.

Hung a new bag pre-op on an existing AC IV, pushed 20 cc propfol and 6 cc sux, 1 minute later this guy was staring at me like..."When am I going to sleep?"

Absolutely no evidence in this non-obese (and muscular) guy's antecubital that his IV was infiltrated.

 

[urge]

A new peripheral was placed, and he's sedated on propofol, but not paralyzed. I don't think paralytics were needed after he was tubed, and, at that time, he was gorked and not needing sedation right at that moment.

Did you investigate why a new peripheral was needed?

 

[Apollyon]

Did you investigate why a new peripheral was needed?

I didn't get up to the unit until the next night, and, although the same intensivist was on, I didn't get to speak with him. However, after all that had been said and done, without information, I would think that it seemed prudent. There was nothing in the note stating a need (as CERNER, as we have in in the hospital, isn't really amenable to freetexting and doesn't require a prompt for indication of an IV), but, at the same time, Occam's razor.

 

[Idiopathic]

ive seen this before where i gave a 75 year old lady 350mg pentothal and 10 of vec and she continued to talk to me for 5 minutes. IV ran great. I put in a second IV and gave propofol and she slowly drifted off to sleep and I ended up intubating her. I dont have an answer. However, you were able to draw a gas off your IV that was venous, suggesting its in a vein.

 

[Mac4]

A somewhat similar case??
http://journals.lww.com/anesthesiol...ent_cross_resistance_to_neuromuscular.43.aspx

 

[Apollyon]

So it DOES happen (resistance to NMB's)! I am not saying that it happened in this case (and the kid got a depolarizer after 2 nondepols), and he was/is septic (but improving, I was told this evening).

On rereading, no one has mentioned a resistance to NMBs (save for IN2B8R broaching the topic), and I did not know that it was possible. I could have theorized, but didn't have data. That some people are SO dogmatic is interesting, although, again, Occam's razor. The line into which the sux went had 1 liter of fluid, 1g ceftriaxone, 500mg azithromycin, 10 of vec, 50 of roc, and 10 of etomidate before the sux (the other vec and etomidate went into the other line). Most likely is a line failure, with less common being a medication problem (degraded), then a combination of those, then a patient idiosyncratic reaction.

Is that a common written board question? "These conditions will cause failure of nondepolarizing NMBs:
a. cerebral palsy, tetanus, sepsis, burns
b. blah blah blah
c. etc."

I mean, is it routine knowledge that septic patients might not respond to NDNMBs? That is an honest question.

(And I did do a lit search before posting this thread.)

 

[mghanesres]

I mean, is it routine knowledge that septic patients might not respond to NDNMBs? That is an honest question.

(And I did do a lit search before posting this thread.)

I'm a CA-1 and I know about certain patients needing more NDNMBs than other patients so I'd say it's pretty common anesthesia knowledge and does come up on boards, etc.

 

[IN2B8R]

I think that every self respecting practicing anesthesiologist on here is well aware that there are "conditions" that alter the way paralytics/sedatives work. That is what we covered in our residencies.... What is characterized as "dogmatic" is perhaps a little unfair to those receiving that criticism: these drugs are pushed on a daily by all practicing anesthesiologists. One thing they will for certain be dogmatic about is the fact that multiple agents went down a questionable IV line in a thin, relatively previously healthy patient (that was clearly stated in your initial post).... If your initial question/post was "can there be any conditions that may lead to paralytics failure," then I think that you may have had different responses and perhaps less "dogma" from the responders.... Nontheless, to answer your inquery, written and oral boards do ask such questions....

Regards!

So it DOES happen (resistance to NMB's)! I am not saying that it happened in this case (and the kid got a depolarizer after 2 nondepols), and he was/is septic (but improving, I was told this evening).

On rereading, no one has mentioned a resistance to NMBs (save for IN2B8R broaching the topic), and I did not know that it was possible. I could have theorized, but didn't have data. That some people are SO dogmatic is interesting, although, again, Occam's razor. The line into which the sux went had 1 liter of fluid, 1g ceftriaxone, 500mg azithromycin, 10 of vec, 50 of roc, and 10 of etomidate before the sux (the other vec and etomidate went into the other line). Most likely is a line failure, with less common being a medication problem (degraded), then a combination of those, then a patient idiosyncratic reaction.

Is that a common written board question? "These conditions will cause failure of nondepolarizing NMBs:
a. cerebral palsy, tetanus, sepsis, burns
b. blah blah blah
c. etc."

I mean, is it routine knowledge that septic patients might not respond to NDNMBs? That is an honest question.

(And I did do a lit search before posting this thread.)

 

[Apollyon]

Actually, the "dogmatic" referred to only one; I guess the "some people" qualifier was misleading.

As most of you know, I hold no animus towards anesthesia or anesthesiologists, and consider them, rightly, colleagues (although, just as in my field, as in life in general, there is an ******* or two, but not more than that). I even helped out the first anesthesiologist I've ever seen in my ED (pre-op for a patient) - he was a white guy with a Hawai'ian middle name (like James Kuakini Jones) - who didn't have a clue as to where ANYTHING was, and needed to be walked through everything (despite assurances that everyone had been trained in CPOE, because, if they didn't, they wouldn't be working).

However, dogma does work - I mean, you don't re-invent the wheel every time; at the same time, there can be idiosyncratic situations.

This evening, I'll talk with the intensivist, and see if they can do a test of NMBs on the pt, since he is intubated, to see if he has train-of-four.

 

[IN2B8R]

Could not agree more: nothing in life is so sacrosanct that it cannot be questioned!👍

Actually, the "dogmatic" referred to only one; I guess the "some people" qualifier was misleading.

As most of you know, I hold no animus towards anesthesia or anesthesiologists, and consider them, rightly, colleagues (although, just as in my field, as in life in general, there is an ******* or two, but not more than that). I even helped out the first anesthesiologist I've ever seen in my ED (pre-op for a patient) - he was a white guy with a Hawai'ian middle name (like James Kuakini Jones) - who didn't have a clue as to where ANYTHING was, and needed to be walked through everything (despite assurances that everyone had been trained in CPOE, because, if they didn't, they wouldn't be working).

However, dogma does work - I mean, you don't re-invent the wheel every time; at the same time, there can be idiosyncratic situations.

This evening, I'll talk with the intensivist, and see if they can do a test of NMBs on the pt, since he is intubated, to see if he has train-of-four.

 

[medical geek5]

to use the drug(s)categories?? See genetech.com; I know it's not a very medically-based site as it is more of a sales pitch with a chart.

 

[PMPMD]

to use the drug(s)categories?? See genetech.com; I know it's not a very medically-based site as it is more of a sales pitch with a chart.

Huh?

 

[drccw]

Not really related... but I had a patient the other day tell me that she

"is allergic to succinycholine. They had to give me some sort of antidote to reverse it."

Okay dokey... no suxey....

I love antidotes.. reminds me of "medieval times."

drccw

 

[bullard]

Sure, people on certain antiepileptics, septic folks, etc can be a little resistant to NMB. But I've found that to be more of an issue with maintenance dosing. For induction, if I given a reasonable dose of rocuronium as you did, you should see an effect. So again, it was probably bad/no IV access.

My personal rule used to be that all IVs inherited from the ER are infiltrated until proven otherwise (after doing a couple of appys as a first year resident where god knows how much or how little propofol and succ went intravascular). No surprise as the few ERs I am familiar with are notorious for placing 20g IVs in the AC. But then I've had one or two preop IVs infiltrate as well. I do my own cases, and now my rule is: all IVs that I have not placed myself are infiltrated until proven otherwise (i.e. check the IV in preop or in ICU, flush, make sure it runs well, check the IV site before using). I am less vigilant about it before placing labor epidurals, but I shouldn't be. I've been burned there once as well.

 

[btbam]

Sure, people on certain antiepileptics, septic folks, etc can be a little resistant to NMB. But I've found that to be more of an issue with maintenance dosing. For induction, if I given a reasonable dose of rocuronium as you did, you should see an effect. So again, it was probably bad/no IV access.

Exactly, someone on Dilantin might chew through a nmb faster than the average person, but it's simply not possible for 10mg of vec, 100mg of roc, and 100mg of sux to have NO effect on induction.

 

[Idiopathic]

Not really related... but I had a patient the other day tell me that she

"is allergic to succinycholine. They had to give me some sort of antidote to reverse it."

Okay dokey... no suxey....

I love antidotes.. reminds me of "medieval times."

drccw

"it was called 'dantro...something'"

 

[epidural man]

When I was a resident, I had a similar case. The surgery guys brought a guy from the unit in extremis with his "working" right sided central line - which I couldn't draw back on. Fine...that happens sometimes. I double check with the surgery folks - is this working? Sure, they say, we have been giving him a ton of fluid all day.

30 vec - no effect. Guys - i say - this isn't working. We need a new line. They continue muckin' in the belly and tell me not to put a line in. I continue to struggle - non of my meds seem to work...and i can't ventilate the guy. Finally, I say screw it and stick a subclavian line in (that was a challenge on this fat and extremely edematous dude). Things improve after that (oh, also improved after a CXR and subsequent chest tube on right drained about 6 litters of fluid from the chest).

It's hard to do anesthesia on a guy without being able to give drugs.

My vote for your case is the same - non functioning IV. Sometimes you can look with an ultrasound to see if the catheter is in the vein.

Hey folks, I have a what I believe is an interesting case (along with some clinical goofs).

Had a guy last night, 39, otherwise healthy, doesn't speak one word of English (Chinese). In US for at least past 5 years. Looks good/nontoxic. RA sat 93%. Moist cough, productive of yellow sputum. Daughter recently had "flu like syndrome". Afebrile now, but was febrile at home and took APAP.

CXR shows a mild, diffuse infiltrate, R>L. I'm thinking viral pneumonia.

WBC 9.9, segs 45%, bands 45%, lymphs 7%. K+ is 4.2. Mag is 1.7.

I figured best to cover for bacterial, so ceftriaxone and azithromycin.

He crumps - SaO2 drops to 87%, spikes up to 102+, and gets a little wheezy. Pressure drops to 77/40, and HR up to 115. At the same time, when I get back to the bedside, he says something and his brother (who speaks English) and a friend start laughing. I ask what the pt said, and the brother tells me that the pt said "I feel comfortable". Hm.

Second line is started on the left, in the AC. I do not know what was the BP when that IV was started.

He is agitated - with NC on, SaO2 at 98%, good waveform. However, pulling stuff off. Nurse tells me, I order 1mg Ativan IV. She also says (and she is of Japanese descent) that he looks yellow. I say "that's racist!" but add on the hepatic panel.

About 15 minutes later, his RR just drops, until he's agonal. When RR got to 10, nurse had BVM out, and started bagging, and I got there, and the RR had already tanked. HR dropped to around 40, but still had pulses. However, nothing else - no seizure, no tetany, no vomiting, nothing focal. Have good BLS bagging going on. HR rebounds to 100.

Decide to tube the guy, as he still has no ventilatory effort. Into 2nd IV, 10mg vec and 20mg etomidate (that's what I got - all I got). Nothing. Tight jaw and moving tongue. For some reason, someone wonders if the IV is intra-arterial. The fluids are unhooked, and the blood RUSHES back. Hm.

Abx are in, so the first line on the right is used. Figure we need more meds. Somehow, now, there's roc. He gets 50mg roc IV (I estimated him at 70Kg, but, later, actual weight 56kg), and 10 more mg etomidate. Nothing. Tight jaw and moving tongue. 10 more mg vec. Nothing. Not heating up, no clonus, no tetany. The line is good. The biceps and triceps have good muscle tone. Still good BVM ventilation. I have not put the blade in the mouth - not mucked with the airway. 100mg sux IV. No defasciculating wave. Jaw still tight, but I can pry it open a bit, and he sticks out his tongue a bit. I have called for the intensivist and for him to bring the fiberoptic endoscope. Instead, the Glidescope comes down. The intensivist (IM-Pulm/CC) puts on a Mac 3 and slides it in, despite the tight jaw. He can't pass an 8.0 tube. Moves down to a 7.0, and he gets it in with difficulty. He says the epiglottis was soft and loose, but the cords were edematous and nearly closed. Even so, as stated, the BLS bagging was working.

Cr of 1.3. Not hypercalcemic. TBil 2.4, DB 2.1 (on his way to yellow, cultural differences notwithstanding). Good pulses in L arm that got IA meds (also, ABG by RT was actually venous - score!). Blood pressure holding at 90-100mmHg systolic.

Pt then to ICU. Didn't get an update in the ensuing 6hrs of my shift.

Any insight into failure of depolarizing and nondepolarizing paralytic agents?

(Not a theoretical case - actual case in a Chinese male in a tropical, first world community emergency department.)

 

[medical geek5]

dantrolene? then it's possible the patient had malignant hyperthermia.

 

[lane]

dantrolene? then it's possible the patient had malignant hyperthermia.

Nurse, get this man a cookie! Stat!

 

[nap$ter]

I can only see a couple of reason for this:
-the patient didn't get the meds: or the wrong meds were given or they pushed up towards the bag.
-there was a problem with the paralytics : degradation , faulty lot which is very unrealistic considering the different meds used unless they were all kept in a very warm storage place.

Even if given intra-arterial the paralytics should still work.

bingo.

 

[cincincyreds]

The famous "that old iv from the floor".

Let me ask, if you squeeze the arm of an IV that is infiltrated, will it stop dripping? If it is truly in a vein and you squeeze the arm, does it continue to drip?