Peri-intubation levophed

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watermanMD

watermanMD

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Got to thinking last night…have noticed some evolution in my practice lately. I seem to be starting Levophed routinely prior to intubation to stave off hypotension and of course the feared post intubation arrest. Anecdotally less hypotension following. No post-intubation arrests that I can recall as of late. What dose you say? Something low—usually just a whiff—whatever my gut tells me. Very scientific, I know.

Haven’t a clue if there’s literature on this, and it certainly wasn’t how I trained unless the patient was obviously hypotensive. Perhaps this is a bad habit? Of note I have also largely switched to ketamine for induction, so I don’t know if this is absolutely necessary since I’ve made that move…but why isn’t this (Levo/norepi) routine or commonplace? Seems starting norepi at a low or moderate dose, particularly if it’s only for a transient time and the patient can be weaned off, has pretty minimal risks in the grand scheme of things. Came across some anesthesiologists discussing it in what sounded like the heterogenous critically ill pt population, which prompted me to consider it
 
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When I was in practice I would occasionally use a neostick for soft BP tubes

Didn't do this routinely just when BP was iffy heading into it
 
watermanMD said:
Got to thinking last night…have noticed some evolution in my practice lately. I seem to be starting Levophed routinely prior to intubation to stave off hypotension and of course the feared post intubation arrest. Anecdotally less hypotension following. No post-intubation arrests that I can recall as of late. What dose you say? Something low—usually just a whiff—whatever my gut tells me. Very scientific, I know.

Haven’t a clue if there’s literature on this, and it certainly wasn’t how I trained unless the patient was obviously hypotensive. Perhaps this is a bad habit? Of note I have also largely switched to ketamine for induction, so I don’t know if this is absolutely necessary since I’ve made that move…but why isn’t this (Lego/norepi) routine or commonplace? Seems starting norepi at a low or moderate dose, particularly if it’s only for a transient time and the patient can be weaned off, has pretty minimal risks in the grand scheme of things. Came across some anesthesiologists discussing it in what sounded like the heterogenous critically ill pt population, which prompted me to consider it
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It’s probably just overkill. It’s a good idea for gomer severe sepsis that will inevitably become septic shock once you introduce positive pressure, but random stroke/neuro trauma patient is probably going to hold their pressure.

Regarding ketamine, all of the database and RCTs that I’ve seen show either more hemodynamic instability or no difference compared to etomidate. It obviously has a role in delayed sequence intubation and ‘awake’/breathing intubations, but again not something that I’m doing routinely.

But you do you. There are no wrong answers here.
 
Phenylephrine is a good choice.. almost pure BP with minimal if any cardiac effect.
 
Phenyl stick is my go to for pre and intra intubation hypotension. I'll ask to start levo at the same time, but by the time it gets pulled from the Pyxis/Omnicell, the pump gets sorted out, gets started, and circulates a bit, I can give multiple 2-300mcg doses of phenylephrine/neosynephrine to ward off the bad spirits.
 
I'll start norepi for hypotension prior to intubation. Not really a phenylephrine fan because if they have hypotension before intubation, my sedatives and PPV aren't going to make it better, might as well have the norepi going. Only takes a couple of minutes to start.
 
CopaceticOne said:
Honest question - is it typical in EM to decrease your dose of induction med (prop, keta, etomidate, etc) for patients who are in the verge of hemodynamic instability?
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If anything I increase the dose as decreased perfusion = decreased clinical effect. This is well described particularly with NMBAs.
 
CopaceticOne said:
Honest question - is it typical in EM to decrease your dose of induction med (prop, keta, etomidate, etc) for patients who are in the verge of hemodynamic instability?
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I decrease for poor mentation only. I also don’t do large doses that my residents currently seem to be training in (I routinely use roc at 0.6mg/kg and etomidate at 0.2 mg/kg, my residents seem to jump to 100mg roc [50mg aliquots make this necessary for the 1.2mg/kg dose] and 30mg etomidate, a dose I’ve never needed in my entire career). I use propofol but not for hemodynamically tenuous cases.

In 10+ years I think I’ve used a pressor once or twice preintubation and out of the handful of post intubation arrests I’ve had, none were due to pre-existing hypotension. So no, I don’t think routine use of peri-intubation pressors is warranted. I think caution and maximum resuscitation with hypotensive, hypoxic, acidotic, and asthmatic patients is more important than the trend of push dose pressors.
 
Thank you for the replies. The reason I asked is the trauma bay can be a very different setting than the OR and ICU settings I’m more used to being in. And NPO status is even more of a variable in the ED setting.

Where I trained and where I work now the approach from anesthesia people was small doses and be patient. Less abrupt loss of sympathetic tone as a result.

Obviously, urgent intubations with high chance for aspiration or difficulty changes the above equation somewhat.
 
CopaceticOne said:
Thank you for the replies. The reason I asked is the trauma bay can be a very different setting than the OR and ICU settings I’m more used to being in. And NPO status is even more of a variable in the ED setting.

Where I trained and where I work now the approach from anesthesia people was small doses and be patient. Less abrupt loss of sympathetic tone as a result.

Obviously, urgent intubations with high chance for aspiration or difficulty changes the above equation somewhat.
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Virtually every trauma patient that I have taken care of in my career eats a full Big Mac meal + refried beans right before they get shot/stabbed/fall off a ladder/drive into a tree.
 
And none of them aspirate two patties with RSI. Anesthesia is appropriately conservative for elective surgery, but hopefully they understand that the risk of aspiration is very low and outweighed by the benefit of emergent airway control. Admittedly, we also overestimate the need to control some airways.
 
Mount Asclepius said:
And none of them aspirate two patties with RSI. Anesthesia is appropriately conservative for elective surgery, but hopefully they understand that the risk of aspiration is very low and outweighed by the benefit of emergent airway control. Admittedly, we also overestimate the need to control some airways.
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I don't anymore. Atraumatically being totally gorked is not a hard indication in my world.

Traumatically being totally gorked? Also probably means patient is elderly and actually has sepsis. Resuscitation for a bit and see what happens.
 
Yeah. I just don’t intubate hypotensive patients if there is any alternative ?

“a is for airway” means airway occlusion to me now

As long as they are breathing and OK on a 100% NRB I can prop them up a bit, get good access, get a couple liters infusing, and sure start levophed if needed.

I’m not into self inflicted post intubation arrests / severe hypotension.

(Severe trauma being a bit of a different beast)
 
Janders said:
Yeah. I just don’t intubate hypotensive patients if there is any alternative ?

“a is for airway” means airway occlusion to me now

As long as they are breathing and OK on a 100% NRB I can prop them up a bit, get good access, get a couple liters infusing, and sure start levophed if needed.

I’m not into self inflicted post intubation arrests / severe hypotension.

(Severe trauma being a bit of a different beast)
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Is anyone into it? 😆 I always resuscitate before, where able. That occasional post-intubation drop in BP is, I guess, what I’m getting at here (and seeing less of) since starting levo before induction and continuing after. Maybe overkill
 
Etomidate you only need 10-20ish. If they're really sick I just give a little versed or nothing if they are near arrest.

Push dose pressors are great. Phenylephrine 100-200 mcg on induction or 8-16 mcg of norepi. I mix it all in a 30 cc syringe and push at once, some prop lido roc decadron.
 
Etomidate puts people in comas. I’m always surprised by how quick and deep the sedation is when I give 0.1 mg/kg dosing for cardioversions. I truly doubt that 0.3 mg/kg is even necessary for RSI particularly for encephalopathic patients.
 
Jabbed said:
Etomidate puts people in comas. I’m always surprised by how quick and deep the sedation is when I give 0.1 mg/kg dosing for cardioversions. I truly doubt that 0.3 mg/kg is even necessary for RSI particularly for encephalopathic patients.
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Yea and the dose required for deep sedation decreases as patients get more critically ill, so 10-20 of etomidate is usually plenty.

Another trick that works well is giving a push of calcium shortly after intubation. It’s a natural vasopressor and will last around 15 minutes. A single push of Ca never hurt anyone and depending on the etiology of their illness it may well be beneficial
 
The Knife & Gun Club said:
Yea and the dose required for deep sedation decreases as patients get more critically ill, so 10-20 of etomidate is usually plenty.

Another trick that works well is giving a push of calcium shortly after intubation. It’s a natural vasopressor and will last around 15 minutes. A single push of Ca never hurt anyone and depending on the etiology of their illness it may well be beneficial
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I love EM docs that do CC and should have done it. Keep bringing the knowledge to this forum. I use Calcium a lot in codes and traumas due to the pressor effects, but just never really have in the peri-intubation period. Might start trying.

I reached out to several EM/CC physicians (residency program alumni) in private practice (never wanted to do academics) during residency and they all either worked a ton - week on week off, moonlighting in the ED during their off weeks - or gradually gave up EM. The private practice half and half split is tough. I couldn’t see working like a resident forever doing both. I really liked EM then and couldn’t imagine giving it up. That didn’t age as well. I thought I’d give EM a chance and go back if I hated it. It was tolerable and the SDG partner pay eventually became golden handcuffs. I still haven’t gone back as the two year opportunity cost doesn’t seem worth it now that mid career and pursuing other job-related interests. If choosing over I may have done IM->PCCM instead…

Instead might just have to live vicariously through you EM/CC folks.
 
watermanMD said:
Is anyone into it? 😆 I always resuscitate before, where able. That occasional post-intubation drop in BP is, I guess, what I’m getting at here (and seeing less of) since starting levo before induction and continuing after. Maybe overkill
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I feel that training 15+yr ago it was extremely common to be instructed immediately intubate ASAP with one peripheral IV, the first pinch of fluid going in, no pressor around, and a starting BP of 90/40.

Now I never do that unless they very much aren’t breathing, and then I’m push-dosing them as we tube.


Also agree w/ above on meds. 20mg of etomidate + sux/roc will rsi anyone and 10mg works if they are already half-gone.
 
We used to do this routinely in residency on those patients that had soft pressures prior to intubation. Post intubation arrest is real. I seem to remember using Neo back then most of the time.

These days, I do the same thing though not as often and in general I can't remember an ED that stocked Neo post residency so I usually have the nurses draw up pulse dose epi which is easy...you just squirt out 1cc of a 10cc flush and draw up one cc of code dose epi, shake and voila...each cc is 10mcg epi. I usually give 20 mcg boluses. I'm honestly not sure on the literature to support this but anecdotally it definitely helps IMO. Sometimes I also give IV calcium for the pressor effect. I also will usually pay more attention to what vent settings respiratory is punching in to make sure it's not some crazy TV/PEEP/RR/PIP, etc..
 
I'm sticking with (assuming we've all done the right thing and resuscitated the patient as best as possible before intubation):

Norepi gtt or, rarely, dirty epi gtt. You do need an ED pharmacist or nurse with a lot of experience because the new ones don't know what to do to make the epi.
Most of the time, ketamine and rocuronium RSI. If hemodynamics are bad, lower dose ketamine and higher dose rocuronium. Video assisted. Always with non-video, bougie, and supraglottic devices by my side.
Post-intubation pain and sedation plan with meds pulled prior to intubation.
Always know where the BVM PEEP valves are because you might some day find that nobody in your ED that day other than you knows what that is.

For anyone newly out of residency:
Nurses may get antsy or bored when you do this in a controlled, methodical fashion. Don't let them rush you.
 
Groove said:
We used to do this routinely in residency on those patients that had soft pressures prior to intubation. Post intubation arrest is real. I seem to remember using Neo back then most of the time.

These days, I do the same thing though not as often and in general I can't remember an ED that stocked Neo post residency so I usually have the nurses draw up pulse dose epi which is easy...you just squirt out 1cc of a 10cc flush and draw up one cc of code dose epi, shake and voila...each cc is 10mcg epi. I usually give 20 mcg boluses. I'm honestly not sure on the literature to support this but anecdotally it definitely helps IMO. Sometimes I also give IV calcium for the pressor effect. I also will usually pay more attention to what vent settings respiratory is punching in to make sure it's not some crazy TV/PEEP/RR/PIP, etc..
Click to expand...

Thats good because positive pressure may decrease your venous return and the epi will help the right heart
 
Great thread!

I'm a nurse anesthetist far removed from US politics, though I do intubations/inductions in the ED every other week or so. We use NE infusions and/or fluid resus pre induction every single time, unless there's active vomiting AND a GCS warranting an immediate tube. They'll probably get NE at some point anyway.

Drugs of choice are most often a balanced fentanyl and propofol sedation, then either rocuronium or sux depending on what we want to achieve. Not rocket science.

Esketamine if shock.

So, do you have nurses administering your drugs for induction, or do you do it yourselves?
 
norski said:
Great thread!

I'm a nurse anesthetist far removed from US politics, though I do intubations/inductions in the ED every other week or so. We use NE infusions and/or fluid resus pre induction every single time, unless there's active vomiting AND a GCS warranting an immediate tube. They'll probably get NE at some point anyway.

Drugs of choice are most often a balanced fentanyl and propofol sedation, then either rocuronium or sux depending on what we want to achieve. Not rocket science.

Esketamine if shock.

So, do you have nurses administering your drugs for induction, or do you do it yourselves?
Click to expand...
Nurses push all meds. I don't know how and have other things to manage.
 
TooMuchResearch said:
Nurses push all meds. I don't know how and have other things to manage.
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Except first wave of COVID when we didn’t have enough PPE! I had to chose an RT or an RN a few times, and I took the RT so they could set the vent up as it’s pretty easy for me to push ketamine and sux…
 
Janders said:
Yeah. I just don’t intubate hypotensive patients if there is any alternative ?

“a is for airway” means airway occlusion to me now

As long as they are breathing and OK on a 100% NRB I can prop them up a bit, get good access, get a couple liters infusing, and sure start levophed if needed.

I’m not into self inflicted post intubation arrests / severe hypotension.

(Severe trauma being a bit of a different beast)
Click to expand...
Yeah, I think that you’re correct. How we approach airways in the ICU is very different than in the ED, and I must flip a switch when changing hats. Today, I have a much greater appreciation for the “physiologically difficult” airway than when I finished EM residency almost 20 years ago. I would not go rushing into an anatomically difficult airway with RSI 20 years ago, and I don’t go doing that now with the physiologically difficult ones. That is because I’ve come to accept that RSI is great for rapidly placing a tube, but has some intolerable physiologic trade offs in some patients - especially those who are sick enough to be in the ICU.

My basic approach is this. If they’re physiologically difficult due to hypotension, then I simultaneously start NE while I perform a RUSH exam while my airway equipment is prepped. I’m basically making sure that I don’t turn a laryngoscope blade into a murder weapon by attempting to RSI tamponade, RV failure, etc. Virtually all of my intubations have NE hanging if not started because most of my patients are in shock or at high risk for peri-intubation cardiovascular collapse. I tailor my vasoactives +/- fluids to what I saw on the RUSH exam.
 
thegenius said:
Remember phenyl ain't good if you have low EF or otherwise a very weak heart. I wouldn't use it if you are tubing someone with EF 20%
Click to expand...
ShockIndex said:
Yeah, I think that you’re correct. How we approach airways in the ICU is very different than in the ED, and I must flip a switch when changing hats. Today, I have a much greater appreciation for the “physiologically difficult” airway than when I finished EM residency almost 20 years ago. I would not go rushing into an anatomically difficult airway with RSI 20 years ago, and I don’t go doing that now with the physiologically difficult ones. That is because I’ve come to accept that RSI is great for rapidly placing a tube, but has some intolerable physiologic trade offs in some patients - especially those who are sick enough to be in the ICU.

My basic approach is this. If they’re physiologically difficult due to hypotension, then I simultaneously start NE while I perform a RUSH exam while my airway equipment is prepped. I’m basically making sure that I don’t turn a laryngoscope blade into a murder weapon by attempting to RSI tamponade, RV failure, etc. Virtually all of my intubations have NE hanging if not started because most of my patients are in shock or at high risk for peri-intubation cardiovascular collapse. I tailor my vasoactives +/- fluids to what I saw on the RUSH exam.
Click to expand...
I love this thank you!!

Disclaimer: new EM grad, now CCM fellow.

Everyone that has spoken is more experienced and much smarter than I, but I am sitting in fellow orientation and eager to do literally anything else; especially, talk out some acute resuscitation.

Personal practice: Def pro pre-tube RUSH exam as intubation prep is occurring. This gets me the info I really want on LV+RV function and fluid status (and gives me a baseline before I put them on PPV, which I expect will alter the function/appearance of things), and will dictate how I go about getting the MAP up.

If they are hypotensive pre-intubation > “get the BP up,” my attendings mantra’d over and over.

Pressure-bagged liter if they are fluid down and not cardio shock. If I have time, and I think they will need the pressor after the intubation (e.g. elderly, septic) > Levophed GTT. I get them up to a MAP of 80 or so (?arbitrary, sure) as I anticipate them to go down with induction and PPV.

If I don’t have time > epi push-dose, or if I’m that desperate, phenyl. But for most of the shocks, you’re going to want the contractility bonus. (Could always draw from the Levo/neo bag and push-dose some of that.)

I’d almost rather bolus vasopressin before I’d rely on phenyl (at least this doesn’t increase PVR also), but I fully recognize that neo-sticks are much easier to come by. Times I’d more likely consider Phenyl push-dose: don’t have Levo or epi, maybe tachydysrhythmia until I get pads on to shock, or iatrogenic vasodilation (e.g. mod sed that I gave too much propofol).

Then I repeat my RUSH/triple scan after they are settled post-intubation.

Alright: thoughts? Critiques?
 
Doc Doc Doc Goose said:
I love this thank you!!

Disclaimer: new EM grad, now CCM fellow.

Everyone that has spoken is more experienced and much smarter than I, but I am sitting in fellow orientation and eager to do literally anything else; especially, talk out some acute resuscitation.

Personal practice: Def pro pre-tube RUSH exam as intubation prep is occurring. This gets me the info I really want on LV+RV function and fluid status (and gives me a baseline before I put them on PPV, which I expect will alter the function/appearance of things), and will dictate how I go about getting the MAP up.

If they are hypotensive pre-intubation > “get the BP up,” my attendings mantra’d over and over.

Pressure-bagged liter if they are fluid down and not cardio shock. If I have time, and I think they will need the pressor after the intubation (e.g. elderly, septic) > Levophed GTT. I get them up to a MAP of 80 or so (?arbitrary, sure) as I anticipate them to go down with induction and PPV.

If I don’t have time > epi push-dose, or if I’m that desperate, phenyl. But for most of the shocks, you’re going to want the contractility bonus. (Could always draw from the Levo/neo bag and push-dose some of that.)

I’d almost rather bolus vasopressin before I’d rely on phenyl (at least this doesn’t increase PVR also), but I fully recognize that neo-sticks are much easier to come by. Times I’d more likely consider Phenyl push-dose: don’t have Levo or epi, maybe tachydysrhythmia until I get pads on to shock, or iatrogenic vasodilation (e.g. mod sed that I gave too much propofol).

Then I repeat my RUSH/triple scan after they are settled post-intubation.

Alright: thoughts? Critiques?
Click to expand...
I skip both rush exams.
 
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