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RSI and myasthenia gravis, induction drugs?

Discussion in 'Anesthesiology' started by morepatience, Oct 2, 2017.

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  1. morepatience

    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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  3. nimbus

    nimbus Member 10+ Year Member

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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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  4. JobsFan

    JobsFan 10+ Year Member

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    Prop remi tube
     
  5. Psai

    Psai Account on Hold Physician 2+ Year Member

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    Haldol ketafol igel
     
  6. facted

    facted ASA Member 7+ Year Member

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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.
     
  7. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    You don't.
     
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  8. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Agree...no NMB needed....even for intubation
     
  9. Lecithin5

    Lecithin5 2+ Year Member

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    Alfentanil, if available at your hospital, works like a charm in lieu of a paralytic
     
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  10. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

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    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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  11. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    Closer to Mexico
    :ninja:
     
  12. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    Zippy style
     
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  13. Physio Doc 2 Be

    Physio Doc 2 Be Supratentorial problems Physician 10+ Year Member

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    I haven't read the zippy post in a while, thanks for the reminder.
     
  14. dchz

    dchz Avoiding the Dunning-Kruger 5+ Year Member

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    If he wasn't drunk and combative I'd assume everyone would spinal him?
     
  15. JobsFan

    JobsFan 10+ Year Member

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    probably, but he should do fine with a non relaxant GA
     
  16. Physio Doc 2 Be

    Physio Doc 2 Be Supratentorial problems Physician 10+ Year Member

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    Since it just needed to be posted.
     
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  17. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    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.
     
    Last edited: Oct 10, 2017
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  18. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    Well known? By whom?
     
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  19. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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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.
     
    Last edited: Oct 8, 2017
  20. Physio Doc 2 Be

    Physio Doc 2 Be Supratentorial problems Physician 10+ Year Member

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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.
     
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  21. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    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)
     
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  22. skypilot

    skypilot 2K Member 10+ Year Member

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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.
     
  23. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    This is nonsense.
     
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  24. facted

    facted ASA Member 7+ Year Member

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    Seconded. Remi and prop provide phenomenal intubating conditions.
     
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  25. caligas

    caligas ASA Member 5+ Year Member

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    ...Due to the full cardiac arrest
     
  26. caligas

    caligas ASA Member 5+ Year Member

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    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.
     
  27. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    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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  28. pgg

    pgg Laugh at me, will they? Moderator 10+ Year Member

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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?
     
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  29. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    If this isn’t a myth, it’s mythical;)
     
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  30. facted

    facted ASA Member 7+ Year Member

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    We did remi/prop on TONS of patients in residency. Not smart for cardiac cripple, but otherwise you'll be just fine.
     
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  31. Physio Doc 2 Be

    Physio Doc 2 Be Supratentorial problems Physician 10+ Year Member

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    It seems like it.
     
  32. JobsFan

    JobsFan 10+ Year Member

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    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.
     
  33. Newtwo

    Newtwo 2+ Year Member

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    Why?
    I almost never do and haven't had a problem yet.
     
  34. nimbus

    nimbus Member 10+ Year Member

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    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.
     
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  35. JobsFan

    JobsFan 10+ Year Member

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    I believe Noyac’s second sentence already tells you the answer
     
  36. Ronin786

    Ronin786 ASA Member 5+ Year Member

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  37. GeorgiaPhDCRNA

    GeorgiaPhDCRNA Banned Banned Account on Hold

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    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?
     
    Last edited: Oct 8, 2017
  38. Newtwo

    Newtwo 2+ Year Member

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    I don't know what to say to this.
     
  39. Newtwo

    Newtwo 2+ Year Member

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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
     
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  40. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Troll
     
  41. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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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.
     
  42. BeatriZZ

    BeatriZZ

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    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?
     
  43. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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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?
     
  44. GeorgiaPhDCRNA

    GeorgiaPhDCRNA Banned Banned Account on Hold

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    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.
     
  45. caligas

    caligas ASA Member 5+ Year Member

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    Another point is that not EVERY patient has to be extubated in the O.R.

    Obviously we try, but a trauma patient with MG sometimes might need to be extubated in the PACU/ICU.
     
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  46. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    Narcan
     
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  47. JobsFan

    JobsFan 10+ Year Member

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    Huh? I have no idea what you’re getting at
     
  48. JobsFan

    JobsFan 10+ Year Member

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    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.
     
  49. caligas

    caligas ASA Member 5+ Year Member

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    Has any experienced attending here, since the glidescope, had a floor patient that they were unable to intubate?
     
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  50. JobsFan

    JobsFan 10+ Year Member

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    Jetpearl Number 5

    I may not be that good with a miller 2, but I can intubate a gravid fire ant with the glidescope.
     

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