RSI for ALS

[WholeLottaGame7]

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Interesting case on-call over the weekend.

Relatively young guy w/ moderately advanced ALS (some bulbar symptoms, UE>LE weakness), CAD (70% occlusion of LAD s/p PCI), on BiPAP at night, comes in with several days worth of nausea/vomiting/abd pain. Acute appendicitis on imaging, posted level 3 (in OR within 6 hours).

Plan for induction/airway? Intraop? Postop?

Curious to see other's thoughts, then will post how we handled it. Seemed to go pretty well.

 

[gasp]

Interesting case on-call over the weekend.

Relatively young guy w/ moderately advanced ALS (some bulbar symptoms, UE>LE weakness), CAD (70% occlusion of LAD s/p PCI), on BiPAP at night, comes in with several days worth of nausea/vomiting/abd pain. Acute appendicitis on imaging, posted level 3 (in OR within 6 hours).

Plan for induction/airway? Intraop? Postop?

Curious to see other's thoughts, then will post how we handled it. Seemed to go pretty well.

Lap or open?
My initial thought was epidural placement. Although I wouldn't do that for a lap procedure..

 

[sevoflurane]

Interesting case on-call over the weekend.

Relatively young guy w/ moderately advanced ALS (some bulbar symptoms, UE>LE weakness), CAD (70% occlusion of LAD s/p PCI), on BiPAP at night, comes in with several days worth of nausea/vomiting/abd pain. Acute appendicitis on imaging, posted level 3 (in OR within 6 hours).

Plan for induction/airway? Intraop? Postop?

Curious to see other's thoughts, then will post how we handled it. Seemed to go pretty well.

If he's pretty weak and a favorable airway: Low dose Prop +/- pressor of choice depending on vitals.
If he get's wiggly, titrate a whiff of roc. 5-10mg at a time.

Acute appendicitis rarely means small bowel full of fecal material ready to come out and hit you in the face. Look at the CT thouogh, ALS can mean megalocolon ready for lift off.

 

[WholeLottaGame7]

Lap or open?
My initial thought was epidural placement. Although I wouldn't do that for a lap procedure..

Lap. So, can't use succs, didn't want to use high-dose roc for a short procedure in a guy with ALS. I wasn't super concerned about aspiration but we still wanted to do the RSI since he'd been nauseated/vomiting for several days.

 

[lushmd]

My (admittedly limited) experience with these pts is that paralytic isn't necessary. I suppose one alternative would be a bolus of remifentanil.

 

[GhostTree]

Interesting case on-call over the weekend.

Relatively young guy w/ moderately advanced ALS (some bulbar symptoms, UE>LE weakness), CAD (70% occlusion of LAD s/p PCI), on BiPAP at night, comes in with several days worth of nausea/vomiting/abd pain. Acute appendicitis on imaging, posted level 3 (in OR within 6 hours).

Plan for induction/airway? Intraop? Postop?

Curious to see other's thoughts, then will post how we handled it. Seemed to go pretty well.

I'm a resident, here are my thoughts. Planning for a general anesthetic.

Induction: Presuming straghtforward airway, would proceed with low dose propofol chased with pressors. since he's weak already will probably not need paralysis for intubation. If something is needed then would use a remi bolus 50-100 mcg. Clearly avoiding sux in this pt. Regarding his CAD, I would investigate for any red flags (new angina, new arrhythmia, etc) and manage appropriately.

Intraop: No paralytics unless surgeons start complaining, then would use cisatracurium. Could probably get away with a reduced dose of any NMB but I like the Hoffman degradation of Cis so as to minimize postop weakness.

Postop: Respiratory insufficiency postop my primary concern so I would extubate to bipap. For pain control would use IV tylenol, toradol, minimal narcotics. tap block for pain relief if they open.

 

[WholeLottaGame7]

I'm a resident, here are my thoughts. Planning for a general anesthetic.

Induction: Presuming straghtforward airway, would proceed with low dose propofol chased with pressors. since he's weak already will probably not need paralysis for intubation. If something is needed then would use a remi bolus 50-100 mcg. Clearly avoiding sux in this pt. Regarding his CAD, I would investigate for any red flags (new angina, new arrhythmia, etc) and manage appropriately.

Intraop: No paralytics unless surgeons start complaining, then would use cisatracurium. Could probably get away with a reduced dose of any NMB but I like the Hoffman degradation of Cis so as to minimize postop weakness.

Postop: Respiratory insufficiency postop my primary concern so I would extubate to bipap. For pain control would use IV tylenol, toradol, minimal narcotics. tap block for pain relief if they open.

Yeah y'all are getting pretty close. We used prop/phenyl and 100mcg remi. Cords were partially abducted, put an LTA through and topicalized and then were able to pass the tube through no problems.

During the case, we did run a remi infusion to avoid paralysis and some des (I did laugh about the irony of running a remi infusion for an appy after that previous thread). Phenylephrine infusion to keep the pressures up.

IV tylenol at the end of the case. Our institution doesn't have a great tradition about extubating to BiPAP and sometimes it takes awhile to get it setup in PACU, also. But for this case I did call RT and give them a heads-up that we might require their services.

As it turns out, we sat him upright at the end and he was pulling 500mL off the vent, awake and calm with the tube in, so we just extubated him. Did fantastic. Biggest complaint was a weird feeling in his throat from the LTA.

 

[pgg]

Very nice 👍

 

[Sonny Crocket]

Modified RSI with prop, fent, roc, cricoid pressure. Esmolol and NTG drawn up. Limit laryngoscopy to less than 10 sec. Then TAP block before incision. Intravenous Tylenol. Dilaudid as needed post op.

 

[sevoflurane]

My (admittedly limited) experience with these pts is that paralytic isn't necessary. I suppose one alternative would be a bolus of remifentanil.

+1 👍

I would avoid paralytics if at all possible. Remi or Alfenta would give you pretty good intubating conditions (along with prop).

So who here would use sux? Is it contraindicated? Why or why not? 🙄

How long will a MRSI dose of Roc last in this guy?

 

[sevoflurane]

Interesting case on-call over the weekend.

Relatively young guy w/ moderately advanced ALS (some bulbar symptoms, UE>LE weakness)...

Any fasciculations or atrophy? When I see fasciculations and muscle wasting = careful with paralytics for short procedures. Nice case.

 

[WholeLottaGame7]

Any fasciculations or atrophy? When I see fasciculations and muscle wasting = careful with paralytics for short procedures. Nice case.

He did, on both counts. He had atrophy particularly in his upper extremities for some reason, and some crazy tongue fasciculations.

He was super pleased with the anesthetic, I think in part because everybody scared the crap out of him talking about ventilators and ICU post-op. I'm definitely chalking this one up as a win.

 

[cincincyreds]

He did, on both counts. He had atrophy particularly in his upper extremities for some reason, and some crazy tongue fasciculations.

He was super pleased with the anesthetic, I think in part because everybody scared the crap out of him talking about ventilators and ICU post-op. I'm definitely chalking this one up as a win.

Nice job with the case. I'll put a note to reference this thread if I find myself in a similar situation. Never have I used remi as a bolus in my life, so thanks for sharing.

This is actually a pretty good oral board stem also so you residents should practice your responses on this one.

 

[Idiopathic]

Nice job with the case. I'll put a note to reference this thread if I find myself in a similar situation. Never have I used remi as a bolus in my life, so thanks for sharing.

This is actually a pretty good oral board stem also so you residents should practice your responses on this one.

the bradycardia can be a beast especially in someone who is likely to have autonomic dysfunction. also, have seen rigid chest from it more than once...could actually make things a little worse. just be on the lookout for those two

 

[pgg]

the bradycardia can be a beast especially in someone who is likely to have autonomic dysfunction. also, have seen rigid chest from it more than once...could actually make things a little worse. just be on the lookout for those two

Yeah, rigid chest aka vocal cord closure from a remi bolus isn't uncommon. Treatment, succ? 🙂 That would be a fun corner to back into.

 

[sevoflurane]

Alfenta...

 

[BobBarker]

Treat the vocal cord closure with LTA. At least that's what their paid speaker told me while I dined on a delicious steak.

 

[cincincyreds]

Treat the vocal cord closure with LTA. At least that's what their paid speaker told me while I dined on a delicious steak.

Hope the steak was good.

So that is an interesting dilemna. I've never bolused remifentanil, so it is nice to know the real world badness of doing so.

 

[ketap]

the bradycardia can be a beast especially in someone who is likely to have autonomic dysfunction. also, have seen rigid chest from it more than once...could actually make things a little worse. just be on the lookout for those two

Idiopathic: so, can we reduce the incidence by giving a diluted remifentanyl more slowly?

My (admittedly limited) experience with these pts is that paralytic isn't necessary. I suppose one alternative would be a bolus of remifentanil

sorry for being a dumb, but i can't really understand this..
i do understand why this patient didn't need a paralytic because of ALS, but how can an opioid replaces a paralytic ?

thx u

 

[sevoflurane]

Alfenta and Remi are not like succinylcholine or ROC, but in the right patient they still are able to provide excellent intubating conditions. Do a literature search and you will see what I mean. The Attached PDF is a recent article that addresses them both.

And FWIW, on certain OR days with rapid turnover I dilute 1mg of remi in 100cc bag and have ten 10 cc syringes of 10 mcg/ml for quick cases. I have seen regidity, but its easily overcomed. Very useful for a variety of applications.

 

[Idiopathic]

Idiopathic: so, can we reduce the incidence by giving a diluted remifentanyl more slowly?


sorry for being a dumb, but i can't really understand this..
i do understand why this patient didn't need a paralytic because of ALS, but how can an opioid replaces a paralytic ?

thx u

a high dose opioid given relatively quickly can provide blunting of involuntary response to stimulation, which is essentially why you cough or close your cords when someone is trying to pass a tube through them. the benefit of remi is that its gone so quickly, you could do the same thing with a gram or two of fentanyl, obviously that will have its own downsides.

if you give remi slowly you may not get the wanted benefit, which is the intense desensitization that allows you intubate someone without paralytics. the densitization goes hand in hand with the vagotonic effects. if done right, it looks like you have sux on board, easy DL, good view, cords open. doesnt always work perfectly. bradycardia->asystole is reported and i have seen it. obviously it shoudl respond to things like laryngoscopy, atropine, CPR, but its pretty annoying when it happens

 

[sevoflurane]

a high dose opioid given relatively quickly can provide blunting of involuntary response to stimulation, which is essentially why you cough or close your cords when someone is trying to pass a tube through them. the benefit of remi is that its gone so quickly, you could do the same thing with a gram or two of fentanyl, obviously that will have its own downsides.

if you give remi slowly you may not get the wanted benefit, which is the intense desensitization that allows you intubate someone without paralytics. the densitization goes hand in hand with the vagotonic effects. if done right, it looks like you have sux on board, easy DL, good view, cords open. doesnt always work perfectly. bradycardia->asystole is reported and i have seen it. obviously it shoudl respond to things like laryngoscopy, atropine, CPR, but its pretty annoying when it happens

👍

This is a very accurate description. 50-100mcgs IVP with proporol bolus.
I have not seen asystole however. Bradycardia is common and responds to laryngophed.

Today happens to be a call day, so I have my stash ready to go.

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[Idiopathic]

yeah in my experience most asystole is just bradycardia that got bored while waiting to be treated. if given prompt attention, this should respond, but obviously people that wont tolerate extreme bradycardia (some heart failure/valve types, patients with shock in general, etc.) should cause some heightened awareness

 

[dhb]

I've used remi for intubations extensively patient will frequently cough upon induction (vc closure) i don't ventilate, chest wall rigidity is a myth. Intubation in 60 seconds so it's awesome for fast turnover cases that need a tube. I've never had severe bradycardia but it should be reserved for ASA 1 or 2 patients or patients with myopathies.
The only criticism i've heard about the technique was from people who have never tried it (= talking out if their a....)

 

[dhb]

👍

This is a very accurate description. 50-100mcgs IVP with proporol bolus.
I have not seen asystole however. Bradycardia is common and responds to laryngophed.

The sweet spot for optimal conditions is 4mcg/kg so you are underdosing which is evidenced by the sympathetic reaction to intubation: ideally you should see no reaction to intubation.

 

[sevoflurane]

The sweet spot for optimal conditions is 4mcg/kg so you are underdosing which is evidenced by the sympathetic reaction to intubation: ideally you should see no reaction to intubation.

Yeah.. you are right. I start with 50-100 IVP. If I'm placing an lma, I don't need anymore. If I'm placing an ETT, then yeah, you need to use a bigger dose.

 

[Idiopathic]

i usually dose 200mcg as a max for intubating. I definitely see bradycardia with that dose. Usually not an issue. Have seen rigidity a few times as well

 

[WholeLottaGame7]

We also use it to blunt the sympathetic response to Mayfield pinning and it seems to work pretty well. Still usually bolus 1mcg/kg (100mcg). Tell the neurosurgery to place the pin when I hear the heart rate dropping. I haven't really seen the HR go below 50 with the 1mcg/kg bolus.

Heh, we were joking about how the whole situation sounded like an oral board scenario.

 

[TrustMe]

I'm using remi+propofol more and more in pts with neuromuscular disorders for induction. Depending on baseline HR I usually pre-treat with 10mg of ephedrine or 0.2mg glyco. I typically use 2mcg/kg of remi over 30 seconds followed by propofol. Have had good incubating conditions. May decrease remi to 1mcg/kg if old. I just don't like guessing some of these pts responses to paralytics.

 

[fakin' the funk]

Propofol 2-3 mg/kg
Alfentanil 30 mcg/kg
Who needs a paralytic to intubate? (especially in a neuromusc pt)

Agree with the need/preference for HR treatment w/ glyco etc.

 

[RedAnesthesia]

Pre induction after pre oxygenated:
Glyco 0.2mg
Ephedrine 10-15mg
Then
Prop 2-3mg/kg
Remi 3mcg/kg bolus
Tube

I have never done this for ALS patients but have done it for patients with pseudocholinesterase deficiency with short procedure. It has worked well and provided good intubating conditions.
Red

 

[Sonny Crocket]

I've used remi for intubations extensively patient will frequently cough upon induction (vc closure) i don't ventilate, chest wall rigidity is a myth. Intubation in 60 seconds so it's awesome for fast turnover cases that need a tube. I've never had severe bradycardia but it should be reserved for ASA 1 or 2 patients or patients with myopathies.
The only criticism i've heard about the technique was from people who have never tried it (= talking out if their a....)

Chest wall rigidity is not a myth bro. Do a lot of TIVA over here in Scandinavia. Intubating without relaxant, no prob. Had a lady for a distal radius fracture. Difficult to ventilate/stiff the whole case. Got by. In The PACU, still stiff. Naloxone IV stiffness gone immediately.

Stiffness and bradycardia def have to watch out for.

 

[painstop]

Pre induction after pre oxygenated:
Glyco 0.2mg
Ephedrine 10-15mg
Then
Prop 2-3mg/kg
Remi 3mcg/kg bolus
Tube

I have never done this for ALS patients but have done it for patients with pseudocholinesterase deficiency with short procedure. It has worked well and provided good intubating conditions.
Red

So are you skipping the lidocaine since you have the remi to blunt the sympathetic surge due to laryngoscopy? Or are you just not a fan of lidocaine for intubations in general?

 

[RedAnesthesia]

So are you skipping the lidocaine since you have the remi to blunt the sympathetic surge due to laryngoscopy? Or are you just not a fan of lidocaine for intubations in general?

I am a fan of lidocaine but with that dose of remi you are often fighting the bradycardia and sympathetics are blunted just fine. You have less to muddy the waters. Each to their own.
Red

 

[pgg]

Chest wall rigidity is not a myth bro.

It's vocal cord closure, not chest wall rigidity. Semantics? Maybe not, but close to it. It's not like anyone can tell the difference when squeezing the bag and air isn't going in.

 

[Idiopathic]

It's vocal cord closure, not chest wall rigidity. Semantics? Maybe not, but close to it. It's not like anyone can tell the difference when squeezing the bag and air isn't going in.

certainly you can have laryngospasm, but thats not the same thing as the muscle rigidity that can come with high dose opiates, although a component of the rigidity can be pharyngeal and laryngeal muscle spasm

 

[lakersbaby]

why not etomidate for induction for more hemodynamic stability given some LAD occlusion and a bolus of sufentanil for intubation. good to see all the diff ways people would do things

 

[WholeLottaGame7]

why not etomidate for induction for more hemodynamic stability given some LAD occlusion and a bolus of sufentanil for intubation. good to see all the diff ways people would do things

Didn't want to add adrenal suppression to the list of problems that guy had, plus you can maintain hemodynamics with prop/phenyl just as well if you're careful.

 

[RedAnesthesia]

Didn't want to add adrenal suppression to the list of problems that guy had, plus you can maintain hemodynamics with prop/phenyl just as well if you're careful.

Agree completely plus I think propofol is better at manipulating airway and blunting airway reflexes.
Red

 

[Scotty_G]

I have never did this as a resident but will bring it up next time I encounter one of these patients. Many muscular dystrophy pts have bad hearts. You guys aren't concerned about giving propofol to these patients?

 

[psychbender]

Considering propofol's primary CV effect is to decrease SVR, giving a reduced dose, titrated slowly, and with support of an alpha agonist like phenylephrine you can make inducing with it just as safe (or safer, as there is no adrenal suppression) as etomidate. I hate it when I see someone give etomidate "because this guy is sick," then they just slam in 0.2-0.3mg/kg. I can only give the same speech so many times before I just push the drugs myself.

 

[sevoflurane]

Did someone say Vomidate?

I hate that stuff. Not good for apnea and they can get wiggly with it.

I might think of it with an emergent left main, but even then... it's usually 2nd to a slow IVP of the white stuff with some pressor behind it.

It's not about the drug... it's how you use it.

 

[Idiopathic]

Agree 100%. Does not provide optimal airway conditions unless you overdose with it - remember it actually can suppress myocardial function as well, especially in the hypovolemic , high-catecholamine state.

Adrenal suppression is about the 12th reason not to use it, honestly. If its all I have I will certainly give it, but they usually keep breathing and will definitely cough, etc. they will just have their eyes closed when they do it.

 

[dhb]

Chest wall rigidity is not a myth bro. Do a lot of TIVA over here in Scandinavia. Intubating without relaxant, no prob. Had a lady for a distal radius fracture. Difficult to ventilate/stiff the whole case. Got by. In The PACU, still stiff. Naloxone IV stiffness gone immediately.

Stiffness and bradycardia def have to watch out for.

I've seen some reports in children not in adults and have never experienced it myself, sorry but i'll have to see it to believe it.

 

[ketap]

hi, thx to Sevo and Idiopathic..very nice explanation indeed...👍
btw, sorry for bringing this up again and responded to it late..just want to ask some more,,

if given prompt attention, this should respond, but obviously people that wont tolerate extreme bradycardia (some heart failure/valve types, patients with shock in general, etc.) should cause some heightened awareness

Idiopathic: i am very interested with your last sentence...so, how would you treat an unstable patient like this? titrate the IVP of Remi and the Prop? or would you just add the glyco or atrop. at pre induction?

Quote:
Originally Posted by sevoflurane View Post


This is a very accurate description. 50-100mcgs IVP with proporol bolus.
I have not seen asystole however. Bradycardia is common and responds to laryngophed.

The sweet spot for optimal conditions is 4mcg/kg so you are underdosing which is evidenced by the sympathetic reaction to intubation: ideally you should see no reaction to intubation.

DHB: i cannot understand which sympathetic reaction that you meant on Sevo's posting there? oh, i am from outside of US so,i don't really know this: do you mean phenylephrine when you mentioned the laryngoped?

plus you can maintain hemodynamics with prop/phenyl just as well if you're careful.

👍 very true..titrate it if it is possible and just watch closely to the patient's response while also be prepared also for a drop BP..better than etomidate even for an unstable patient in emergency settings..
thx u🙂

 

[pgg]

Idiopathic: i am very interested with your last sentence...so, how would you treat an unstable patient like this? titrate the IVP of Remi and the Prop? or would you just add the glyco or atrop. at pre induction?

If I use remi for induction, I'll pre-treat with 0.2 of glyco and have atropine within arms reach.

DHB: i cannot understand which sympathetic reaction that you meant on Sevo's posting there? oh, i am from outside of US so,i don't really know this: do you mean phenylephrine when you mentioned the laryngoped?

Laryngophed is a slang term - it just means that sticking a laryngoscope in someone's mouth and performing laryngoscopy is stimulating and can raise HR and BP by way of the patient's own catecholamines. With 'enough' induction +/- opiate it may not be a reliable effect. I personally wouldn't count on it to overcome hypotension or bradycardia from a heavyhanded induction.

 

[Idiopathic]

if a patient is truly unstable, then they get paralytic, not remi, in my opinon. if a patient has a condition that could worsen if they get bradycardic, you should give serious thought to not giving them remi, or pretreating with an anticholinergic. keep in mind that tachycardia may be just as bad.

 

[deleted162650]

I've seen some reports in children not in adults and have never experienced it myself, sorry but i'll have to see it to believe it.

Rigidity from high dose opiates is definitely a real phenomenon. Standard induction for crani's where I trained was to titrate fentanyl to the point of borderline apnea prior propofol. We're talking usually somewhere in the 750-1250mcg range for an otherwise healthy normal pt. Not all the time but a significant proportion of pts would develop rigidity not just of the chest wall, but also arms/legs, etc. sometimes with involuntary contractions. Give enough of the blue drugs and you will certainly see it.

 

[ketap]

PGG and Idiopathic: thx u..great explanation..being helpful as always 🙂