paralytic first?

[doctor712]

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Hi Gang!!! Been working and in class of late, all going well with the premed stuff! Watched a case the other day and I have a question.

So, I get invited in by a CT surgeon to watch a few cases, this one is a MVR + CABG. This is about the nicest, (from my POV) CT surgeon anyone could ever want to watch. Well known guy in his field, friendly as can be, just amazing.

i check the board and see my fave Anesthesiologist, our kids play soccer against each other, is on the case too, FUN DAY!

Anyway, fave Anesthesiologist tells me he's in a "teaching mood" today. great. he's pre-oxygenating the patient, maybe there's some anesthesia in there, but im pretty sure there wasn't. i could SWEAR the patient isn't quite sleeping yet (certainly not intubated) and i see the doc push vecuronium. maybe a CC or two. not all that's in the syringe, just 1cc or 2ccs. with that, he follows with etomidate. i ask about the drug (im used to seeing propofol), and he says that's the induction agent. i ask why he doesn't use propofol, with a respectful curiosity, and he explains that a) it burns when it goes in (evidence the guy was given vecuronium awake) and b) its a heart case and he wants to keep the pressure up at first...etc etc. he gives me the long explanation, but you get it.

well, i say to myself, why is my pal putting in a paralytic before the induction agent? so, i ask you, as I didn't want to ask this anesthesiologist... does it take vecuronium a while to act? more so than etomidate? and IF not, what gives?!! also, after he gave the etomidate, he waited a minute and gave the "rest" of the vecuronium. then he intubates after showing me good cords (and asks if I want to put in the central line. i tell him i'd love 👍👍 to, but as an observer, i can't - yet. he thought i'd started med school.) so, doc shows me a quick jugular, tells me that its VERY superficial, never to push to hard or youll cut off flow, shows me how close it is to the jugular artery on screen, great. gets two large bore IVs in, everything hanging from IVs. time to step over the curtain to surgeon. to my dismay. 🙂

so, is this typical (safe) practice? a dab of vecuronium before etomidate? or more generically, ANY paralytic before your patient is induced and sleepy sleeping? what IF you paralyze and you thought you pushed etomidate and you mislabeled and push ANYTHING ELSE THAT DOESNT MAKE PATIENT GO TO SLEEP right away, and you have a paralyzed awake patient, be it until you realize you've screwed up.

thanks all, look forward to hearing,
D712

 

[BobBarker]

"jugular artery"=internal carotid. Yes, it take the vec some time to work. Some anesthesiolists give a "defasiculating dose" of rocuronium and then fully paralyze with succinylcholine a few moments later.

 

[Trisomy13]

most likely he was giving a small "priming" dose of vecuronium. about 1/10 of usual dose. it speeds up time of onset once the rest of the dose is given after induction.

one example of a study looking at this (albeit rocuronium rather than vec):

http://www.cja-jca.org/cgi/content/abstract/54/7/538

 

[doctor712]

thanks for the answer!

ah, maybe it was the jugular vein he was dealing with. there were swans going in, A-lines, central lines...i might have been confused!

 

[BobBarker]

He put the central line in the internal jugular vein which is just lateral to the internal carotid artery. Anesthesioligists tend to put central lines in the internal jugular vein and the subclavian vein just under the collar bone. You can put a regular IV in the external jugular vein if needed.

 

[Jeff05]

etomidate burns much more than propofol. he gave etomidate for the hemodynamic stability.

vec was likely given to prevent the rigidity associated with high dose narcotic induction (which i'm sure he did for mvr/cabg).

 

[Trisomy13]

vec was likely given to prevent the rigidity associated with high dose narcotic induction (which i'm sure he did for mvr/cabg).

this wouldn't be my first answer for why i am giving a NMB for surgery, even if the induction was high dose opioid.

narcotic is a legal term...

 

[Jeff05]

right. so nitrous/narcotic technique described in miller's anesthesia is purely a legal thing. you should write to miller and tell him to switch it to the more appropriate nitrous/opioid technique (next you're gonna teach me the difference between opioids and opiates - can't wait for the clinically relevant discussion that will ensue).

clearly, there are multiple roles for NMB in this case. however, the only 2 reasons for a small dose upfront is 1. speed up onset of second large dose 2. attempt to decrease chest wall rigidity associated with high dose fentanyl.

this wouldn't be my first answer for why i am giving a NMB for surgery, even if the induction was high dose opioid.

narcotic is a legal term...

 

[Trisomy13]

right. so nitrous/narcotic technique described in miller's anesthesia is purely a legal thing. you should write to miller and tell him to switch it to the more appropriate nitrous/opioid technique (next you're gonna teach me the difference between opioids and opiates - can't wait for the clinically relevant discussion that will ensue).

clearly, there are multiple roles for NMB in this case. however, the only 2 reasons for a small dose upfront is 1. speed up onset of second large dose 2. attempt to decrease chest wall rigidity associated with high dose fentanyl.

sure, but looking at the first post, we already know induction is with etomidate, not high dose opioids. hence my response about the priming dose probably not being for rigidity. we aren't talking about nitrous/narcotic here, and for that matter, yes, it should be properly called nitrous/opiods. "narcotic" is a historical term used to lump marijuana with opium and other controlled substances. am i going to bother Dr. Miller about it? no. it's much easier to bother you about it here. 😉

 

[Idiopathic]

jeffs being a little antagonistic

i would argue that non depolarizing relaxants have not been proven to be great pretreatment for an opioid induction since the induction invariably needs to happen before the paralysis and the rigidity can happen at any time during the sequence.

the 'priming' dose of vec is a technique that i do not advocate, especially in cardiac patients. i think its valuable to have these patients as comfortable as possible for laryngoscopy, which includes having a small amount of anesthetic vapor on board as well as a full 3-5 minutes for the opiate to take effect. Is it worth the 45 seconds that a priming dose might save you if your patient is light and gets tachycardic, etc. on laryngoscopy?

also what if your airway is difficult?

so it isnt part of my practice routinely

 

[dhb]

First of all thoracic rigidity is a MYTH as proven elegantly here and here.

I often use a small dose of muscle relaxant just before pushing propofol to speed up the time til intubation. The delay of action of the muscle relaxant being greater than the induction agent you don't have to fear having an awake/paralyzed patient.

 

[thegasman]

clearly, there are multiple roles for NMB in this case. however, the only 2 reasons for a small dose upfront is 1. speed up onset of second large dose 2. attempt to decrease chest wall rigidity associated with high dose fentanyl.

Reason 3. defasiculating dose (although roc is much better for this)

I often give vecuronium prior to propofol (i don't use much etomidate) for intubation on easy airways. Onset of vec is much longer than the prop. I also use relatively low doses of vec to intubate because my surgeons are mostly pretty quick. All that being said I prefer roc. And if the airway looks at all tricky or aspiration risk is increased I go with the sux.

 

[BLADEMDA]

Reason 3. defasiculating dose (although roc is much better for this)

I often give vecuronium prior to propofol (i don't use much etomidate) for intubation on easy airways. Onset of vec is much longer than the prop. I also use relatively low doses of vec to intubate because my surgeons are mostly pretty quick. All that being said I prefer roc. And if the airway looks at all tricky or aspiration risk is increased I go with the sux.

Go with Rocuronium now for intubation then switch to vecuronium if desired. Roc is generic and only about $2.00 more than Vec these days especially if you use the 5ml vials. I bet Roc will be only a $1.00 more in about 6-12 months. Roc has a faster onset and is more predictable for good intubating conditions after 90-120 seconds.

I believe there are several manufacturers of generic rocuronium these days.

Blade

 

[deleted126335]

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[Jeff05]

interesting articles. a dose of paralytic would help here as well, by keeping the cords abducted.

also, even though the OP didn't mention it, i would imagine the anesthesiologist gave a large dose of opioid as a part of the induction.

First of all thoracic rigidity is a MYTH as proven elegantly here and here.

I often use a small dose of muscle relaxant just before pushing propofol to speed up the time til intubation. The delay of action of the muscle relaxant being greater than the induction agent you don't have to fear having an awake/paralyzed patient.

 

[starsop93]

also what if your airway is difficult?

I would argue that if you give a large dose of fentanyl or sufentanil to a cardiac patient on induction, you are essentially putting yourself in a position that you WILL be intubating the patient no matter what. I think a "test ventilation" is pointless in this scenario. I think if you get into trouble with ventilating the patient you won't be giving narcan, but instead you'll give muscle relaxant.

For that reason, I usually give my relaxant on induction at the same time I give my etomidate. It will take a few minutes for the vec to work and I'm not turning around at this point to wake the patient up if I can't ventilate. On the other hand if I suspect a difficult intubation, I either do a standard induction with low dose opiates and sux (if the patient can handle it clinically), or I do it awake with LOTS of lido.

 

[Trisomy13]

also, even though the OP didn't mention it, i would imagine the anesthesiologist gave a large dose of opioid as a part of the induction.

he gave etomidate for induction. i'm guessing the OP didn't mention a large dose of opioid because it didn't happen. not trying to be too antagonistic here, but i think the answer to the OP is just a simple priming dose...

if it was an etomidate induction, opioids could be given after securing the airway. i'm assuming you're thinking of opioids for sternotomy. we have attendings here who prefer the high dose opioid induction, and those who prefer etomidate with judicious use of fentanyl, usually in those we plan on fast-tracking and extubating in the OR or shortly after arriving in the unit.

 

[Gern Blansten]

It seems silly to theorize what may or may not have been given in this case described. There are about an infinite number of ways to do a cardiac induction. It appears that the most common techniques involve at least a modest amount of non canabis narcotics. Just because a lay person observer did not see it administered does not mean it did not happen. It doesn't really matter anyway.
The reason for the vec up front is not that important either. The fact that you could give 1 mg to a person and have little to no clinical symptoms noticed by the patient is the important point for the OP. This is a perfectly normal technique and was not a "screw up."
If you have used etomidate much, you know that patients complain of pain with injection just like they do with propofol, just as Jeff noted.

 

[dhb]

I would argue that if you give a large dose of fentanyl or sufentanil to a cardiac patient on induction, you are essentially putting yourself in a position that you WILL be intubating the patient no matter what.

If you give sufenta very slowly you can actually keep a spontaneous ventilation even at fairly high doses, i've personally witnessed 50 mcg but you can even go higher.

 

[doctor712]

i believe only etomidate was given. i could be wrong of course...though I like to think of myself as a step above a lay person!!! 😀

interesting articles. a dose of paralytic would help here as well, by keeping the cords abducted.

also, even though the OP didn't mention it, i would imagine the anesthesiologist gave a large dose of opioid as a part of the induction.

 

[coprolalia]

(1) It's also called "precurarization" and it works.

(2) Muscle rigidity is most certainly not a myth, and has been copiously described in the literature. As well, I've seen it both with fentanyl and remifentanil. If you want me to tell you specifically when and how, including most recently about two weeks ago in a non-paralyzed toddler undergoing a Ladd's procedure whose peak pressures went up immediately after each dose of fentanyl I gave until I finally realized what was happening (and, no, it wasn't an anaphylactoid reaction).

-copro

 

[OB1🤙]

It appears that the most common techniques involve at least a modest amount of non cannabis narcotics.

LOL. Well played, sir.

Does make you wonder how well Marinol would work as a premed.

 

[dhb]

(2) Muscle rigidity is most certainly not a myth,
-copro

Not the same as Thoracic rigidity at induction of anesthesia

 

[soonerfrog]

Was talking with some of the docs today on this very topic and even mentioned dhb's articles and the jury seems split. A couple of our guys trained at places like Emory and John Hopkins where high dose fent/sufent are staples of anesthesia. A few still use 200mcg/kg with pedi hearts. Point is, they have mixed experiences with truncal rigidity. Some never saw it (usually those who titrated it in) and the few who "slugged em up front" seemed to lend the matter more credence. What was ironic is that none had ever given thought to the notion that most of the difficulty ventilating/elevated PIP, ect had to do cord closure or supraglottic phenomena. Just curious what everyone's thoughts were on the MOA for the rigidity seen. Thoughts? I know those articles were from mid-late 90's, but haven't really seen much recently on the matter.

 

[coprolalia]

Was talking with some of the docs today on this very topic and even mentioned dhb's articles and the jury seems split. A couple of our guys trained at places like Emory and John Hopkins where high dose fent/sufent are staples of anesthesia. A few still use 200mcg/kg with pedi hearts. Point is, they have mixed experiences with truncal rigidity. Some never saw it (usually those who titrated it in) and the few who "slugged em up front" seemed to lend the matter more credence. What was ironic is that none had ever given thought to the notion that most of the difficulty ventilating/elevated PIP, ect had to do cord closure or supraglottic phenomena. Just curious what everyone's thoughts were on the MOA for the rigidity seen. Thoughts? I know those articles were from mid-late 90's, but haven't really seen much recently on the matter.

The kid I was referring to was intubated but not paralyzed. It happened after every dose. No change in BP or heart rate.

People believe the bolded portion of this statement is true because it doesn't happen to everyone. We don't see it more because a majority patients are relaxed during the parts of surgery where we're giving it.

-copro

 

[Arch Guillotti]

A few still use 200mcg/kg with pedi hearts.

That is a very large dose. Not too conducive to fast tracking but then again kids can tolerate and chew through some narcotics sometimes.