RSI and myasthenia gravis, induction drugs?

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morepatience

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78yo male with moderately severe myesthenia gravis and end stage renal disease fell off a tractor and has some limb injury. He's in the ED. Ortho wants to go now otherwise they say the guy will lose his foot. The patient is combative and drunk. A spot-check K is okay and he had HD yesterday.

The surgeon thinks he'll take about 45minutes.

How do you induce this guy? How do you paralyze him? Lots of succinylcholine? How much is enough? Rocuronium? How much?
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How's his airway exam? If it's normal I'd do it with no nmb. With severe MG he's prob weak anyway. Funny he was on a tractor.
 
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JobsFan said:
Prop remi tube
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I once did a lap chole on a mysthenic with just prop/remi induction and sevo/remi maintenance. Sometimes these people don't need paralytics at all, and this surgery sounds like it won't require paralytics anyway.
 
He's drunk and combative now and in 45 minutes when the surgeon's done, if you're dumb enough to wake him up and extubate him, he'll still be drunk and combative. Does it matter what you use or don't use, or what you do or don't reverse him with, if you just drop him off in the ICU and walk away when no one's looking?
 
pgg said:
He's drunk and combative now and in 45 minutes when the surgeon's done, if you're dumb enough to wake him up and extubate him, he'll still be drunk and combative. Does it matter what you use or don't use, or what you do or don't reverse him with, if you just drop him off in the ICU and walk away when no one's looking?
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:ninja:
 
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If he wasn't drunk and combative I'd assume everyone would spinal him?
 
zippy2u said:
Last day of residency was ,without a doubt, one of the best days of my life... I was on call, 3AM get a call from burn unit to emergently intubate a big guy that had been 50% burned upper torso with smoke inhalation. Half a stick of STP and 100 o' sux-- all edema. I told myself I wasn't goin' out like this. Just rammed a 7.5 where I thought it should be and it slid in. BS bilateral and PCXR was solid. O2 sats golden and RT lady all happy. No procedure note, no charge sheet. Beeper left at OR board when no one was lookin'. Slid out hospital at 0645 with no goodby's, thank you's or gonna miss you's. Got to the apt. and loaded up U-Haul with 100% VA disability, 100% SS disability uncle( Vietnam, agent orange, PTSD--you know the bogus gig). Letter and keys in an envelope dropped in the apt. night box. No change or forwarding of address with post office, no cares about apt. or electric deposits. ZIPPY DONE EVAPORATED! Roll on out at 1700 with floorboard boom box playin' "Comfortably Numb", and a bottle of chilled Wild Turkey in the ice chest. Uncle drivin' and on outskirts of town we light up a big fat doober. I told him not to shut off the old biitch until we were home. Ole Hunter Thompson didn't have a thing on us that night... Regards, ---Zip
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Since it just needed to be posted.
 
Just something to think about. It is well known that inducing without muscle relaxants, propofol and remi alone, can make an airway more difficult. The dose of remi is important.

I almost always give relaxants to pts in ICU, ER, or the floor when called to intubate. I want the best shot the first time.

This case is different, I understand.
 
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when did he eat last and is he obese?

It’s below the belt so why not LMA and titrate to respiratory rate?

Edit:
Missed the drunk part....so that assumes not NPO so would probably pass on the LMA. I’d probably prop, nimbex, tube him and make sure someone holds cric. If he’s drunk and combative, he needs to go to sleep because even if you’re able to get the spinal, now you have a drunk guy to deal with who’s awake in the OR. I guess you could MAYBE sedate him, but it sounds the level of sedation he’d need, now you’d have an aspiration risk on your hands.
 
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Noyac said:
Just something to think about. It is well known that inducing without muscle relaxants, propofol and remi alone, will make an airway more difficult. The dose of remi is important.

I almost always give relaxants to pts in ICU, ER, or the floor when called to intubate. I want the best shot the first time.

This case is different, I understand.
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Your first look should be your best look.

I try and talk with our pulm/ccm fellows about this when they call us to come rescue an airway. The medicine ccm docs here don't like NMBs of any flavor so they frequently tell their fellows not to use them. So they struggle. And they struggle with airways that shouldn't be struggle. So after the tube is in and the patient is safe, I pull the fellow aside and say "I know you have a boss and the boss said no paralytics but there is data that shows that it helps and is better for patients." It's up to them to make the decision when they are the attending, but I'd much rather them put the tube in the first time and minimize hypoxemia in the patient than have to come rescue a bad situation that could have been easy.
 
Noyac said:
Just something to think about. It is well known that inducing without muscle relaxants, propofol and remi alone, will make an airway more difficult. The dose of remi is important.

I almost always give relaxants to pts in ICU, ER, or the floor when called to intubate. I want the best shot the first time.

This case is different, I understand.
Click to expand...

I think every student, resident, and new attending should soak this line in because he’s correct. Give yourself the best opportunity to win when called to intubate. CC-IM docs and ER docs shy away from relaxants because they’re afraid of the point of no return, but we’re airway experts and live our lives at the point of no return. Make it easy and relax these people (unless they’re a difficult airway and in that case be smart)
 
Physio Doc 2 Be said:
Your first look should be your best look.

I try and talk with our pulm/ccm fellows about this when they call us to come rescue an airway. The medicine ccm docs here don't like NMBs of any flavor so they frequently tell their fellows not to use them. So they struggle. And they struggle with airways that shouldn't be struggle. So after the tube is in and the patient is safe, I pull the fellow aside and say "I know you have a boss and the boss said no paralytics but there is data that shows that it helps and is better for patients." It's up to them to make the decision when they are the attending, but I'd much rather them put the tube in the first time and minimize hypoxemia in the patient than have to come rescue a bad situation that could have been easy.
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This. Just secure the airway. Make sure that is your highest priority. Then have a plan to deal with any chemical imbalances you may have created.
 
I used to do about a lot of intubation without relaxant on the floor, until an HIV positive GI bleed patient coughed blood in my face while I was putting the tube in.
 
caligas said:
facted said:
Seconded. Remi and prop provide phenomenal intubating conditions.
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...Due to the full cardiac arrest
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Larnygnospasm aka "chest wall rigidity" from a big slug of remi isn't helpful either. 🙂

I miss having alfentanil available. I used to use propofol + alfentanil + atropine a lot for eyeball cases with retrobulbar blocks, or for other super brief stimulating procedures. Patients get well stunned for just a couple minutes and you can do near anything to them without much hemodynamic response.


But honestly, we're not really arguing that RSI dose succinylcholine or rocuronium aren't the gold standard for optimal intubating conditions ASAP, are we?
 
I agree remi isn’t a good choice for relaxation in cardiac cripples.
I’ve used both alfentanil and remi, and both work but in my experience remi gives better conditions, and is shorter duration if that matters.

Nmba’s probably giver better conditions still and generally give better cvs stability (except anaphylaxis).

This isn’t a technique for airway dabblers, and if you’re a trainee you should practice this in healthy folk before you need to do it emergently.
 
Noyac said:
I almost always give relaxants to pts in ICU, ER, or the floor when called to intubate. I want the best shot the first time.
Click to expand...
Why?
I almost never do and haven't had a problem yet.
 
Most patients can be intubated without muscle relaxants on the first attempt. The conditions may not be optimal as with NMB but it is still consistently and reliably doable. You have good reason to avoid NMB in a patient with MG. If the airway exam is benign, I say just go for it using whatever cocktail you like without NMB. You can always paralyze if you need to but more than likely it won't be necessary.
 
I agree with the previous posters, I'd probably use a normal propofol induction dose and be a bit heavy handed with remi and intubate without NMB. If you didn't need to do an RSI, masking with sevo would make him nice and relaxed but alas.

If you are determined to use a NMB:

I'd avoid succs for obvious reasons, even though this patient is likely to have less than the typical 0.5 meq/L K bump despite ESRD (especially if they take AchE inhibitor). But if the surgeons think they can keep the leg but don't perfuse it well enough or there is a crush component - something that causes a K bump, surgery will blame it on the succs.

Roc is a reasonable option if you have sugammadex. Typically roc will be 2-4x more potent in MG patients (per stoelting I think), but that gets muddled if they're on AchE inhibitors, big/prolonged doses of steroids can also balance the scales. Either way I'd give a baby dose of roc. ESRD will make the sugammadex reversal of roc a bit slower than normal, +MG = even slower.

I guess those are my thoughts. What did you end up doing/how did it go?
 
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Twiggidy said:
I think every student, resident, and new attending should soak this line in because he’s correct. Give yourself the best opportunity to win when called to intubate. CC-IM docs and ER docs shy away from relaxants because they’re afraid of the point of no return, but we’re airway experts and live our lives at the point of no return. Make it easy and relax these people (unless they’re a difficult airway and in that case be smart)
Click to expand...

I don't know what to say to this.
 
JobsFan said:
I believe Noyac’s second sentence already tells you the answer
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We must live in different worlds then.

We probably do in that I don't 'call' people to my ICU to tube when I'm on call and I also dont leave to go back to the OR 5 mins later. I stay and look after them after them. And the ones without Roc do better mostly.

And the tube always goes in. First time. No big deal
 
Arch Guillotti said:
Precisely!

I am very cautious with this combo especially with the sick, frail or elderly. Always give some combo of glyco, ephedrine or neo.
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So you now need to give more meds to counter the effects of your poorly chosen induction.

Give me prop and a nmb and I’m done while you are resuscitating.
 
GeorgiaPhDCRNA said:
I agree with the previous posters, I'd probably use a normal propofol induction dose and be a bit heavy handed with remi and intubate without NMB. If you didn't need to do an RSI, masking with sevo would make him nice and relaxed but alas.

If you are determined to use a NMB:

I'd avoid succs for obvious reasons, even though this patient is likely to have less than the typical 0.5 meq/L K bump despite ESRD (especially if they take AchE inhibitor). But if the surgeons think they can keep the leg but don't perfuse it well enough or there is a crush component - something that causes a K bump, surgery will blame it on the succs.

Roc is a reasonable option if you have sugammadex. Typically roc will be 2-4x more potent in MG patients (per stoelting I think), but that gets muddled if they're on AchE inhibitors, big/prolonged doses of steroids can also balance the scales. Either way I'd give a baby dose of roc. ESRD will make the sugammadex reversal of roc a bit slower than normal, +MG = even slower.

I guess those are my thoughts. What did you end up doing/how did it go?
Click to expand...


1) What are the "obvious reasons" sux contraindicated if K is normal and he was dialyzed yesterday?
2) What dose of remi do you give for intubation, and do you push it or run it in over a minute?
 
BeatriZZ said:
1) What are the "obvious reasons" sux contraindicated if K is normal and he was dialyzed yesterday?
2) What dose of remi do you give for intubation, and do you push it or run it in over a minute?
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As I mentioned in my previous post, the dose of remi is important.
When someone calls it nonsense, they must be more clear. Don’t be an ass.

Let me ask this, if you are struggling to intubate and even mask the pt,what are you going to do. You just gave a 10min dose of remi. Is this pt going to start breathing and come back around in time? What are you going to do?
 
BeatriZZ said:
1) What are the "obvious reasons" sux contraindicated if K is normal and he was dialyzed yesterday?
2) What dose of remi do you give for intubation, and do you push it or run it in over a minute?
Click to expand...

1) I didn't say it was contraindicated, just that there were apparent reasons one might avoid succs here. Is there a crush component to his injury?Is there likely to be a potassium load from reperfusion? ESRD...when can he be dialyzed next if you do bump the K? is this happening in the evening? Are there HD nurses in house? Are the units staffed for CRRT if this is a community hospital? That stuff. I think you could probably get away with succs.

2) Depends on hemodynamics to some extent. I'd probably push it unless I thought it would make him crump. Even then I'd probably push it with some phenyl/ephedrine.

What would you do BeatriZZ?


Also I don't disagree that NMBs improve your first look. I'd just approach this airway (sans NMB) with a miller, with a glide or FO ready to go. As long as the patient is deep I'm not sure what advantage NMB would get me that I couldn't overcome with a glide/FO. Maybe I'm being silly but that's the way I see it.
 
Noyac said:
As I mentioned in my previous post, the dose of remi is important.
When someone calls it nonsense, they must be more clear. Don’t be an ass.

Let me ask this, if you are struggling to intubate and even mask the pt,what are you going to do. You just gave a 10min dose of remi. Is this pt going to start breathing and come back around in time? What are you going to do?
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Narcan
 
Newtwo said:
We must live in different worlds then.

We probably do in that I don't 'call' people to my ICU to tube when I'm on call and I also dont leave to go back to the OR 5 mins later. I stay and look after them after them. And the ones without Roc do better mostly.

And the tube always goes in. First time. No big deal
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Huh? I have no idea what you’re getting at
 
No one seems to have suggested a remi dose ...

So here’s what I do ...

Sick, crumbly, likely difficult tube — I don’t give remi

Healthy adult needs ett but has good reason not to use nmba = 50mcg increments ... likely 2 per kg (titrated to hr and to how obtunded they look)

Healthy adult but rsi with good reason not to give muscle relaxant = 1.5 mcg per kg push , have atropine handy

Kids need a bit more ... like 2-3 per kg
I have muscle relaxant drawn up in case I need better conditions, but I very rarely use it.
 
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