Pt with ESLD and acute renal failure for ERCP

[GasForLife]

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How would you proceed at Endoscopy center that is part of the larger hospital.
Pt in her 20s with primary sclerosing cholingitis now with ESLD with high MELD who is admitted for abdominal pain and suspected malpositioned billiary stent. While in the hospital developed ileus with fecal vomiting and acute renal failure due to hypovolemia and now hyperkalemic with K =5.7. On exam moderate ascitis, NG tube and groggy secondary to disease exacerbation.
Whats the best way to proceed with ERCP on this patient and not to land her in ICU for a week?😕

 

[urge]

pent sux tube

 

[BobBarker]

You have to have a tube... I don't really understand any hand wringing with this case.

 

[caligas]

He is asking roc vs sux for the rsi. Sux probably safe with k 5.7. Pt may warrant icu and intubation anyway in which case roc is fine too.

 

[BobBarker]

Sux will be fine. If you are a scaredy pants give her an albuterol neb or some insulin if there is room with her native blood glucose.

 

[sevoflurane]

Fecal vomiting makes me think something distal. I'd review the CT with radiology and make sure it's not due to something else besides a malpositioned biliary stent.

If his main issue is an acute large bowel obstruction, ERCP is only getting in the way of his main issue.

Fecal vomitus is not the usual presentation of acute cholangitis.

I'd be looking elsewhere and take care of the primary insult first. Either way, Urge hit the nail on the head. I'd skip the sux and hit him up with cis.

 

[caligas]

Fecal vomiting makes me think something distal. I'd review the CT with radiology and make sure it's not due to something else besides a malpositioned biliary stent.

If his main issue is an acute large bowel obstruction, ERCP is only getting in the way of his main issue.

Fecal vomitus is not the usual presentation of acute cholangitis.

I'd be looking elsewhere and take care of the primary insult first. Either way, Urge hit the nail on the head. I'd skip the sux and hit him up with cis.

My concern with cis is slower onset, slower intubation, more seconds for fecal vomitus to go into the lungs.

Sometimes patients simply require post op vent.

 

[G-Man82]

So I take it you're trying to avoid placing the patient in the ICU because of an impaired ability to metabolize Roc due to her ESLD, and that you're trying to avoid Sux because of hyperkalemia. Yet she requires RSI. I realize that RSI is traditionally induction agent of choice plus sux or roc, but wouldn't an alternative to paralytics be a high dose of a rapid onset/offset opioid? Remifentanil for example. That may provide good intubating conditions pretty fast. It's not textbook but can probably be considered. Anyway, the tradition at my institution for floor/ICU airways is to go with sedation alone without paralytic most of the time. I don't agree, and when I'm called to an airway and am alone, I don't do it, but I've seen that you can still pass the tube in time that way.

 

[Idiopathic]

this patient needs to spend a week in the ICU

 

[KLPM]

pent sux tube

Are the anaesthetists on here over retrograde?

 

[PMPMD]

Fecal vomitus is not the usual presentation of acute cholangitis.

Charcot's triad, Reynold's pentad... Sevo's hexad?

 

[TrustMe]

Someone should look at fecal vomitus as a prognostic factor and long term outcomes. Sounds like a great publication.

Why don't they just replace her stent when they do her OLT? Save you the headache of admitting her to the ICU from the GI suite.

No matter what you do, she's likely heading to the ICU after this procedure. If she truly had cholangitis then she may get sicker when they manipulate her stent. Or from the ARDS after she aspirates poop.

 

[Bostonredsox]

Fecal vomiting makes me think something distal. I'd review the CT with radiology and make sure it's not due to something else besides a malpositioned biliary stent.

If his main issue is an acute large bowel obstruction, ERCP is only getting in the way of his main issue.

Fecal vomitus is not the usual presentation of acute cholangitis.

I'd be looking elsewhere and take care of the primary insult first. Either way, Urge hit the nail on the head. I'd skip the sux and hit him up with cis.

Im assuming that since Cis is Hoffman elimination and thus the safest for hepatorenal syndrome pts , this is why your using it? I use cis for continuous paralysis for my therapeutic hypothermias but my understanding is the half life is quite long. Do you guys use it for induction and/or maintenance paralysis in the OR? You'd think I'd have done an anesthesia rotation at some point in my training but I never did so I've never seen you guys at work.

And how high is the meld? Mid 20s with PBC as her source of elsd and I presume a nondrinker...she should be on a transplant list.

 

[Idiopathic]

Im assuming that since Cis is Hoffman elimination and thus the safest for hepatorenal syndrome pts , this is why your using it? I use cis for continuous paralysis for my therapeutic hypothermias but my understanding is the half life is quite long. Do you guys use it for induction and/or maintenance paralysis in the OR? You'd think I'd have done an anesthesia rotation at some point in my training but I never did so I've never seen you guys at work.

And how high is the meld? Mid 20s with PBC as her source of elsd and I presume a nondrinker...she should be on a transplant list.

i cant conceptualize people wanting to RSI with nimbex. whats your dose? are you that concerned with chronic hyperkalemia in an ESRD patient that you wont use sux here? i would think that if this patient doesnt look toxic and like she would need an ICU bed up front (which it sounds like she does) then i could see myself using sux. otherwise RSI with roc and go up tubed. some of the sickest patients ive ever seen in the ICU were post ERCP cholangitis and this patient sounds like a complete setup.

 

[Oggg]

I saw one senior resident and attending at my old place use 3x ED95 dose of Cisatra for a RSI.

Did you know that the Hoffman elimination thing with CIS is not completely correct? Hoffman elimination is a zero order process, meaning clearance is independent of the concentration of drug. Theoretically, if you give 10mg, and it takes 1 h to eliminate itself, 10mg should also take 1h. But clearly if you give 100mg you are going to have problems, and that is because the clearance of CIS is not completely by Hoffman elimination.

I would use sux. If she were 92, I might go with no paralytic.

 

[OB1🤙]

Not to dork out too much here, but 3x ED95 isn't enough in this situation.

We call the "usual" intubating doses 2x the ED95. I.e., the usual dose of roc, 0.6mg/kg, is 2 ED95s.

The RSI dose, 1.2mg/kg, is 4 ED95s.

The ED95 of cis is 0.05mg/kg. Our usual dose of 0.1mg/kg is 2 ED95s. And that dose takes forevvvvvvverrrrrrr to work.

0.15mg/kg of cis ain't gonna cut it to RSI a patient barfing poop.

If it was the only drug left in the hospital and I was faced with this patient, I'd just give the whole 20 mg.

 

[Bostonredsox]

i cant conceptualize people wanting to RSI with nimbex. whats your dose? are you that concerned with chronic hyperkalemia in an ESRD patient that you wont use sux here? i would think that if this patient doesnt look toxic and like she would need an ICU bed up front (which it sounds like she does) then i could see myself using sux. otherwise RSI with roc and go up tubed. some of the sickest patients ive ever seen in the ICU were post ERCP cholangitis and this patient sounds like a complete setup.

You misunderstand me. I use cis for continued paralysis to control shivering in therapeutic hypothermias. I induce with etomidate and suc.

 

[Oggg]

Not to dork out too much here, but 3x ED95 isn't enough in this situation.

We call the "usual" intubating doses 2x the ED95. I.e., the usual dose of roc, 0.6mg/kg, is 2 ED95s.

The RSI dose, 1.2mg/kg, is 4 ED95s.

The ED95 of cis is 0.05mg/kg. Our usual dose of 0.1mg/kg is 2 ED95s. And that dose takes forevvvvvvverrrrrrr to work.

0.15mg/kg of cis ain't gonna cut it to RSI a patient barfing poop.

If it was the only drug left in the hospital and I was faced with this patient, I'd just give the whole 20 mg.

Thanks for the correction. I agree 0.15mg/kg of Cisatra is too slow. Perhaps they used 3x the intubation dose, so 0.3mg/kg. that would be 21mg of Cisatra for a 70kg pt, meaning a second vial. Totally wasteful, but I think I remember them using a second vial.

 

[Idiopathic]

You misunderstand me. I use cis for continued paralysis to control shivering in therapeutic hypothermias. I induce with etomidate and suc.

no it wasnt in reference to you, but rather those who did recommend inducing this patient with cis. i just quoted your post for convenience.

 

[Bostonredsox]

no it wasnt in reference to you, but rather those who did recommend inducing this patient with cis. i just quoted your post for convenience.

Gotcha. I guess I just don't understand cisatras use in an or case. It's long onset and long half life. So I guess a lengthy spine case or something for maintenance paralysis, but still not for induction.

 

[OB1🤙]

Gotcha. I guess I just don't understand cisatras use in an or case. It's long onset and long half life. So I guess a lengthy spine case or something for maintenance paralysis, but still not for induction.

Nimbex is just fine for induction and maintenance of any case that doesn't require RSI. You just have to wait a couple minutes extra for optimal intubating conditions. And its half-life is intermediate, not long.

 

[Bostonredsox]

Nimbex is just fine for induction and maintenance of any case that doesn't require RSI. You just have to wait a couple minutes extra for optimal intubating conditions. And its half-life is intermediate, not long.

Ah ok. Thanks for the info.

 

[OB1🤙]

It also doesn't sting the way roc does going in, so I give it before the induction agents, provided I have a reliable IV.

 

[deleted9493]

So I take it you're trying to avoid placing the patient in the ICU because of an impaired ability to metabolize Roc due to her ESLD, and that you're trying to avoid Sux because of hyperkalemia. Yet she requires RSI. I realize that RSI is traditionally induction agent of choice plus sux or roc, but wouldn't an alternative to paralytics be a high dose of a rapid onset/offset opioid? Remifentanil for example. That may provide good intubating conditions pretty fast. It's not textbook but can probably be considered. Anyway, the tradition at my institution for floor/ICU airways is to go with sedation alone without paralytic most of the time. I don't agree, and when I'm called to an airway and am alone, I don't do it, but I've seen that you can still pass the tube in time that way.

I generally agree with your comment re: remifentanil for intubation. It is in my mind an alternative for those patients that you don't care to leave intubated but have risk factors for hyperkalemia from succinylcholine. That being said, in cases like these where the patient probably should remain intubated postoperatively, it's 1.2mg/kg of Rocuronium and to the MICU after.

 

[TrustMe]

I have only used remifentanil in lieu of muscle relaxant for induction and intubation once, but it worked great gave the remi (I think 2mcg/kg) over 30 seconds and chased it with propofol and the patient was very relaxed. Just make sure you pre-treat with some ephedrine and/or glyco. I'm looking for another good case to try it on. Would like to get more comfortable with that option.

 

[Idiopathic]

I have only used remifentanil in lieu of muscle relaxant for induction and intubation once, but it worked great gave the remi (I think 2mcg/kg) over 30 seconds and chased it with propofol and the patient was very relaxed. Just make sure you pre-treat with some ephedrine and/or glyco. I'm looking for another good case to try it on. Would like to get more comfortable with that option.

works great until they get rigid

 

[Arch Guillotti]

I have only used remifentanil in lieu of muscle relaxant for induction and intubation once, but it worked great gave the remi (I think 2mcg/kg) over 30 seconds and chased it with propofol and the patient was very relaxed. Just make sure you pre-treat with some ephedrine and/or glyco. I'm looking for another good case to try it on. Would like to get more comfortable with that option.

I do this every now and then with 2-4 cc of remi. Can really cause some hypotension (especially in sick and elderly) if you aren't careful. Alfentanil (~1000 mcgs) works as well.

works great until they get rigid

Have you seen this much? I think I saw it once although I wasn't sure.

 

[Idiopathic]

Have you seen this much? I think I saw it once although I wasn't sure.

more than i ever thought i would. ive seen it with doses of fentanyl that were pretty low, like 150-200 mcg preparing for induction, but that always seemed questionable. i have seen it more than a few times with higher dose remi - the last time was trying to intubate someone who i would have rather not paralyzed for a procedure, stiffened up completely with 1.5 mcg/kg of remi, had to go ahead and paralyze 2/2 difficulty bagging. it happens.

 

[urge]

How would you proceed at Endoscopy center that is part of the larger hospital.
Pt in her 20s with primary sclerosing cholingitis now with ESLD with high MELD who is admitted for abdominal pain and suspected malpositioned billiary stent. While in the hospital developed ileus with fecal vomiting and acute renal failure due to hypovolemia and now hyperkalemic with K =5.7. On exam moderate ascitis, NG tube and groggy secondary to disease exacerbation.
Whats the best way to proceed with ERCP on this patient and not to land her in ICU for a week?😕

So, what did you do, and what happened?

 

[deleted9493]

I guess we're all pointing to the obvious fact that there's no perfect rapid intubating relaxant in the U.S....muscle rigidity, masseter spasm, hyperkalemia, relaxation in excess of the procedure...pick yer' poison. As rarely as I really want it, it's too bad that Sugammadex is still being shelved.