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RSI and myasthenia gravis, induction drugs?

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

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  1. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    I’m surprised that we have all of these comments and nobody has asked (unless I missed it)if this pt takes anticholinesterase medications and if he took it today?

    How might this effect succinylcholine and NMB meds?
    -succ action can be prolonged
    - NMB possibly could be antagonized but I haven’t seen this.

    What if he is non-compliant?
    -profound responses to NMB can be found.
     
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  3. Arch Guillotti

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

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    Why is the airway more difficult? Please provide a reference or something other than anecdote.:)

    For you it may be a poorly chosen induction. Not for me. Never had to resuscitate a patient with this induction.

    The point of discussion is that intubation can be safely and reliably done without muscle relaxant, not just "prop and a nmb".
     
  4. Arch Guillotti

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

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    Have you ever seen ""larnygnospasm aka "chest wall rigidity"" from alfentanil (or remi for that matter)?
     
  5. Arch Guillotti

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

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    Mostly they can but mostly it is sort of ugly a lot of the time and not a good situation if they are a full stomach.
     
  6. vector2

    vector2 ASA Member 10+ Year Member

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    Drunk, combative, full stomach takes precedence over MG here. Prop + roc 20mg Rsi here. Switch him to dex infusion at end of case. Let ICU attending know to keep him sedated for another etoh half life and to give him some sugammadex if his NIF is still piss poor when trying to extubate
     
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  7. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    Can someone explain the rationale for remi during airway management?

    I never encountered any attending using remi for airway management as a resident or as an attending. It seems like overkill to me, or at the very least a waste of remi.
     
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  8. pgg

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

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    No.

    But enough people have told me that they have seen it after boluses of the synthetic fents that I'm reluctant to dismiss it as complete dogma.
     
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  9. Arch Guillotti

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

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    Maybe not. I think that if it exists it is pretty doggone rare though.
     
  10. BeatriZZ

    BeatriZZ

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    I'm enjoying this thread...I heard of using remi for intubation during residency but never have tried it myself or seen it used

    But please explain why you are all so hesitant to use sux in this patient. So hesitant to use it that you prefer expensive remi. I genuinely want to know because I don't understand why
     
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  11. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Statement: 4th National Audit Project (NAP4): investigated complications of airway management in United Kingdom for 1 yr; suggested early use of additional anesthetic agent and/or NMB if anesthesia by face or laryngeal mask complicated by failed ventilation; “no anaesthetist should allow airway obstruction and hypoxia to develop to the stage where emergency surgical airway is necessary without having administered a muscle relaxant“.
    Most of the literature I’ve read on this comes from Britain.
    If you look at image#2 plan C you will see that the recommendation a difficult mask ventilation is to paralyze. I know this isn’t exactly saying that remi will make things more difficult but what I am saying is that the dose of remi rally matters and that the way to fix the problem isn’t remi but paralysis. Therefore, paralysis gives us the best opportunity at the airway.
    So having an administrator of this site state that this is nonsense should actually concern the others on this site about the agenda of said administrator. You of all people should be educated on the things to admonish.
     
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  12. Newtwo

    Newtwo 2+ Year Member

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    Mate what was nap4?
    A self reported email survey.

    It's good info but not exactly level 1 evidence for anything.

    And as for their recommendations, you are assuming this will be a difficult airway.

    And as for rigidity or Brady's with remi I've done quite a bit of intubations with it and usually 40 or 50 mcg boluses don't cause this.

    I have seen some spectacular rigidities but only with much higher doses over 150 to 200mcg quickly.


    I don't think anyone argues that 100 or roc or sux gives you best conditions, but best conditions are rarely needed. Especially with a glidescope.

    Now this guy is drunk so it's a definite RSI with roc and then ICU post-op. But if it was elective, I wouldn't paralyse him
     
  13. Fluffhead87

    Fluffhead87 5+ Year Member

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    I couldn’t find the specific image you referenced, but I do find the contrast between what you mentioned and the ASA Diffcult Airway Algorithm interesting. Nowhere in the ASA’s are NMBDs mentioned but they are here to facilitate difficulty with mask ventilation and then intubation.
     
  14. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    I forgot the link.
    PubMed Central Image Viewer.
     
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  15. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    No. I was not talking about this case. It was a general statement.

    The dose you describe has an even lower chance of giving an adequate view. Some studies describe an 80% chance. This is improved with 3-5mcg/kg bolus of remi. I would agree that 80% is a pretty good chance but in that means 20% of the time you are not getting a good view. If I didn’t get a good view this frequently then I’d change what I was doing.
    Now, with this large of a dose of remi you will need to address other issues from time to time. So I ask why deal with all of this when in this guy you could get by with a small dose of roc and prop and call it good?
     
  16. SaltyDog

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

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    Can you please elaborate on your statement that those that did not get Roc "do better mostly". I'm geuinely curious but also wildly skeptical that a single intubating dose of NMB has any negative clinical significance.
     
  17. FFP

    FFP Grunt, cog, body, pompous ass Gold Donor Classifieds Approved 10+ Year Member

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    the opposite pole
    Give narcan?
     
  18. WholeLottaGame7

    WholeLottaGame7 10+ Year Member

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    Right here.
    At least in my training institution, ICUs did not use much NMB because non-anesthesia staffed ICUs couldn't give NMB without an attending or someone from anesthesia being present (or something like that). Apparently one too many etomidate/100 roc/no tube incidences. I'm sure that had something to do with the number of failed intubations (as well as poor positioning, suboptimal patient condition, lack of equipment, etc).

    I figured there were enough "muscle relaxation provides the best intubating condition/initial success rate" papers out there that it would be unnecessary to post some, but now I'm wondering.

    If this case were elective, prop/remi for sure. As is, prop/NMB/tube/ICU. Also, @Twiggidy, don't bring that cricoid pressure crap in here! I put my hand on the neck to help with the view and to say that I did it in the chart, not because it prevents aspiration.
     
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  19. vector2

    vector2 ASA Member 10+ Year Member

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    You're right, it's much sparser than what I would've imagined, but to be fair I didn't go looking back 20-30 years. Most of the papers are from ICU/ED/paramedic literature. Even the Canadian and American difficult airway papers give dosing/re-dosing NMB a weak recommendation / C level evidence.

    http://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-517OC

    Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents - ScienceDirect

    Paramedic-Administered Neuromuscular Blockade Improves... : Journal of Trauma and Acute Care Surgery

    The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient
     
  20. facted

    facted ASA Member 7+ Year Member

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    We used it VERY frequently in training and in lieu of paralytics (much of the time it was academic and clearly not necessary). Works very well. So any case where you don't want to paralyze for whatever reason, you could use remi in it's place for intubation.
     
  21. facted

    facted ASA Member 7+ Year Member

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    I gave 1mg of remi bolus to probably over 100 patients in residency for inductions (we had some attendings that were very fond of it). Didn't once see laryngospasm or chest wall rigidity. Can't recall any colleagues telling me any stories about their issues with it either.
     
  22. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    Cool. Never thought of the replacement for NMB aspect. Now I've learned something which makes this thread useful now. Cheers
     
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  23. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    [​IMG]
     
  24. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    This is the most important point, “any case that you don’t want to paralyze.”
     
  25. JobsFan

    JobsFan 10+ Year Member

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    1 mg? Really ?
    I dilute 1 mg in 20 ml (50mcg/ml) and give about 1-2 mcg/kg ie 1 -4 ml

    Otherwise my experience echoes yours ... works great as replacement for neuromuscular blockade for intubation. If you underdose you still get reasonable conditions, but they cough a bit on passing the tube into the trachea
     
  26. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    Last edited: Oct 10, 2017
  27. Ezekiel2517

    Ezekiel2517 Anesthesiologist Physician 10+ Year Member

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    Late to this thread but I actually did have a patient a couple months back who couldn't be tubed with any type of blade/glidescope/McGrath. Ankylosing spondylitis pt with cervical fusion, smallish mo. Grade 4 views with Mac 3, miller 2/3, glidescope, McGrath with every size blade. Attempts made by 3 different anesthesiologists including the chair of dept. Could barely even get a glimpse of epiglottis. Ultimately I went fiberoptic with scope thru ett already placed nasally. Would've went that route much sooner but took a while to get the scope at this particular hospital. Point is, there's airways out there that you can't get with any blade or glidescope
     
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  28. propadope

    propadope 2+ Year Member

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    I induce and intubate with propofol and remi %95 of the time for office based dental. Most of the time you get excellent intubating conditions provided that you give enough but not too much and not too fast. Definitely not as reliable as NMB and not as stable from a cardiovascular standpoint. I do see closed cords from time to time requiring a small dose of sux. Also sometimes coughing when the tube goes in or when the cuff is inflated. I usually give 2.5ug/kg of remi in divided doses. A small dose before the propofol and the balance after.
     
  29. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    This is pretty much the jest of my argument.
     
  30. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

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    Yes but originally we weren't talking about a potential difficult airway but a run of the mill MG patient.
     
  31. Newtwo

    Newtwo 2+ Year Member

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    I very much doubt I can prove any of this to you...

    But In my mind there is a difference between a medical ICU patient and a surgical ICU patient. (Maybe obvious)

    The classic medical patient is the one I'm thinking of who I've seen fall apart from roc. I don't know if it's the paralysis or the positive pressure ventilation that inevitably follows...

    A frail 70 to 80 yo ards neutropenic sepsis anuric patient. Failed bipap. I would prefer to avoid paralysis in that type of patient if I can

    There is a type of icu patient I would always paralyse to tube and another type I would try to avoid paralysis if I can...

    I don't have great evidence for it (I don't think there will ever be a decent trial on who to paralyse and who not to) so I can be shot down easily but it works well for me this last few years...
     
  32. pgg

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

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    What do you mean fall apart from roc?

    How are you avoiding PPV in patients you intubate without relaxant? Are you really doing spontaneous vent inductions in these floor patients?
     
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  33. SaltyDog

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

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    You're not really making any sense here. PPV makes people who are teetering on the edge crump. That is well known fact. If someone has failed BiPAP, then the next step is PPV. You can avoid paralysis, but not the PP. There's a good study that shows equal rates of hypotension in ICU patients who were intubated with and without any drugs. It's not the Roc.
     
  34. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    Correction...OP had a run of the mill MG patient, alcoholic, with possible full stomach. I'm not liking the coughing potential in the OP situation.
     
  35. Newtwo

    Newtwo 2+ Year Member

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    Why not PS?
     
  36. pgg

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

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    What are you asking? Are you saying PS isn't PPV?
     
  37. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    If you read my post, I said, “This case is different, I understand”.
    Frequently, we go off topic or off scenario to make a point that still has some value to the original post.
     
  38. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    I find this to be subjective and not worthy of stating as fact.
     
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  39. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Well known by this guy:
    Michael A. Phelps, MD, Clinical Instructor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
     
  40. SaltyDog

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

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    And here I thought he was just a swimmer.
     
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  41. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Apparently he is a fast learner.
     
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  42. Arch Guillotti

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

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    What is your point?

    The original scenario involved a discussion of how to intubate a patient without using muscle relaxants, which can be easily accomplished if you know what you are doing. There is no mention of a potential difficult airway or potential difficult ventilation.

    Of course muscle relaxants provide the best intubating conditions. Nobody that I can tell is disputing this fact. A CA-1 learns this on the first day! Nothing in the study from the UK that you cited is news to anyone who is a decent anesthesiologist.

    Again, what about remi and propofol without muscle relaxant make the airway "more difficult"? The mythical laryngeal/chest wall rigidity? I have intubated without muscle relaxant many times and never had a problem. Sux is the "gold standard" (even though in a pt. with MG I wouldn't really know what the best dose is). Remi/prop may not be equal to prop/sux but if you do it right the chances of having crappy conditions is slim. What is my agenda anyway? I would love to know!o_O
     
  43. SaltyDog

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

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    I think the main question here is:

    Would you feel comfortable intubating this full stomach RSI worthy patient using any one of the "relaxant sparing" techniques?
     
  44. Arch Guillotti

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

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    Agree. I would have no issue intubating this patient without muscle relaxant.

    I might use muscle relaxant if the patient had a bad bowel obstruction, etc.
     
  45. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    You know what the point is. You are being obstinate.
    And no, it’s not the rigidity that I’m talking about.
     
  46. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    i mean, the reality is that in the hands of an experience anesthesiologist, if the airway is presumed easy, you can probably tube this gent with no relaxant AND avoid aspiration.

    if there was any presumed difficulty, ie "maybe i need the glide" then the guy get's NMB...that's just me. honestly, how long people sit in ERs before they actually make it to us and the OR, it's likely been a few hours so I'd probably still Nimbex the guy and slip the tube in, if he's easy.
     
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  47. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Why nimbex?
     
  48. Maverikk

    Maverikk ASA Member 2+ Year Member

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    Be practical, back to the OP...MG, full stomach (NDMB: can last longer, sometimes hours of weakness Sux: need a higher dose), either way RSI, no nimbex, no opioid, no funny stuff, KISS. This patient will go to ICU intubated postop, no reason not to for an emergent case like this, no reason to extubate this person until they're ready

    Edit: to be specific: 100mg lido, 100mg Roc, 160 prop, everything quick IVP
     
  49. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Finally, someone answers the question.
    My question to the OP (forum) earlier was, what meds does he take for MG? Did he take them recently?
    If he is on an anticholinesterase (pyridostigmine)? What Dose? More than 750mg/day?
    How long has he had MG? More than 6 yrs?

    I have taken care of many pts with MG and it isn’t that difficult. Monitor twitches closely.

    Personally, I would consider inducing without NMB if airway looked like a slam dunk. My only comment earlier was that Remi can make the airway more difficult especially when underdosed. I’d give about 4mcg/kg and chase it with 150mcg of neo. But his belly is probably full of beer so it better be a slam dunk. If not I would give 30mg of roc immediately before the propofol and do an RSI. this case will most definitely last longer than the NMB. Extubated at the end of the case.
     
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  50. vector2

    vector2 ASA Member 10+ Year Member

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    Damn dude, I'm pretty sure the difficult airway algorithm doesn't include calling in the chair to perform the 14th DL/video attempt. :p Was masking this guy difficult? If not, would've definitely stopped with the attempts after the glidescope fail and just hand ventilated/LMA until the scope arrived. Also makes me wonder, have you or anyone else had situations (excluding those where someone's mouth is so small you can't get the glidescope blade in) where someone was unglidescopable but yet the McGrath worked? It would not have occurred to me to try to use a video mac 3 after a conventional mac 3 and highly angulated video blade had already failed.
     
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  51. JobsFan

    JobsFan 10+ Year Member

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    This sounds a disturbingly like what happened here ...
     

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