RSI in ESRD patient going for AVF

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Elderly patient with CKD 5 not on HD going for AVF. Cr 10, K 5.7. Patient also has severe gastroparesis, and has constant nausea.

Assuming block isn't available for the discussion sake, what NMB agents would you use for RSI?

Would you cancel the case?
Would you still use sux even though K is > 5.5? How about if K was 6.2?
Would you use cis at higher dose for RSI and reverse with neostigmine at the end of case? If so, what dose of cis and what does neo?
Would you use RSI dose Roc with suggamadex reveral at the end of the case?

Thanks in advance.
 
If no block, then just local. Otherwise rsi with roc if you were so inclined for a GA. No sux. The potassium issue is a classic oral board question-at what point is the absolute cut off? Judgment call based on several factors...
 
prop sux tube. if concerned, give some insulin sometime before to drop the K and then induce. this isn't an emergent case by any means, so can wait a few minutes before going. ESRD patients are chronic hyperkalemics. a 6.2 in ESRD is not the same as 6.2 in patient with acute RF. nephrologists i talk to aren't even concerned until K >6.5 in esrds.

or can play it safe and induce with DD roc and reverse w neo/glyc

sug is not approved for ESRD patients but who knows if it actually causes harm

and yes if local is an option then go local
 
Man who cares about the absolute k? Is there ecg changes

Do they have risk factors? Burn, muscular disease, spinal cord transection, serious intraabdominal infection, been in bed for days, etc.

If not then prop sux tube

Id rather treat hyperkalemia anyway over aspiration pneumonitis
 
There is a study from 2003 where they lighted the renal artery of cats and reversed RSI doses of Roc with sugammadex and didn’t have any evidence of recurarization even 24 hours later.
 
Out of left field, I’m guessing if diabetic and sugar is high, hit them with some IV insulin, drop the K, and then prop sux tube, if you're really worried.
 
If you do a quick search of the literature there are an increasing number of studies and cases being reported of safe reversal of roc with sugammadex in patients with varying degrees of renal impairment. I have also done it ~5 times with no issues. The first and third are of more use.

Efficacy and safety of sugammadex in the reversal of deep neuromuscular blockade induced by rocuronium in patients with end-stage renal disease: A ... - PubMed - NCBI

Case Report: Sugammadex rescue following prolonged rocuronium neuromuscular blockade with ‘recurarisation’ in a patient with severe renal failure

Sugammadex in patients with chronic renal failure: two case reports | Yeo | Advances in Bioscience and Clinical Medicine
 
With double dose roc you get intubating conditions almost as quick as sux ( maybe 10 second difference). I definitely don’t consider that a enough of a benefit to screw around with hyperkalemia. Agree on reversing with suggamadex. We do it all the time on ESRD patients with no issues.
 
An awful lot of ppl are saying they’d use sux on this forum, but I bet that if you asked the average anesthesiologist, they wouldn’t.
 
anbuitachi said:
or can play it safe and induce with DD roc and reverse w neo/glyc
Click to expand...

What practice setting do you work in that an AVF takes long enough that you can reverse an RSI dose of rocuronium with neostigmine?! 😵

In our practice these are all done under local/MAC and take a hair over 20 min skin to skin...
 
Lecithin5 said:
An awful lot of ppl are saying they’d use sux on this forum, but I bet that if you asked the average anesthesiologist, they wouldn’t.
Click to expand...

The average anesthesiologist is holding cricoid, running sevo at 2 L and giving NS in ESRD patients against the evidence as well
 
Psai said:
The average anesthesiologist is holding cricoid, running sevo at 2 L and giving NS in ESRD patients against the evidence as well
Click to expand...

I get what you’re saying, so how about I only speak about my group of over 100 docs: Most would NOT use cricoid pressure for rsi cuz most of us realize it’s bogus (and I may be wrong, but I thought that evidence actually does not support cricoid). But I think the prospect of using sux is much more devastating than using cricoid or normal saline or sevo in a renal patient. You can cause, and I have seen, hyperkalemic arrest, from sux. Why be cavalier about it and risk it when you have a pretty good alternative in roc?
 
Psai said:
Man who cares about the absolute k? Is there ecg changes

Do they have risk factors? Burn, muscular disease, spinal cord transection, serious intraabdominal infection, been in bed for days, etc.

If not then prop sux tube

Id rather treat hyperkalemia anyway over aspiration pneumonitis
Click to expand...
I completely disagree. I had an attending back in training that told the resident (not me thanks goodness) this same thing. The pt then proceeded to show the attending that he was wrong.
 
Urzuz said:
What practice setting do you work in that an AVF takes long enough that you can reverse an RSI dose of rocuronium with neostigmine?! 😵

In our practice these are all done under local/MAC and take a hair over 20 min skin to skin...
Click to expand...

About 90min to 2 hrs here. Also roc barely works these days.
 
anbuitachi said:
sug is not approved for ESRD patients but who knows if it actually causes harm
Click to expand...

My understanding is that it is contraindicated in ESRD because the 1/2 is so greatly increased (from 2hrs to 19hrs) since 95% of sug is excreted unchanged in the urine. Therefore, if for some reason there was a need to reintubate or give roc then it would be unpredictable. I think most of us wouldn’t really concern ourselves with that.
 
Noyac said:
I completely disagree. I had an attending back in training that told the resident (not me thanks goodness) this same thing. The pt then proceeded to show the attending that he was wrong.
Click to expand...

What happened
 
You experienced an anecdotal case that supports your presuppositions when it could have easily gone the other way with aspiration, a prolonged trip to the icu and eventual death?
 
anbuitachi said:
Well n is pretty low and how long did you follow them for? But anyway I doubt there are any issues as well.
Click to expand...

About 24 hrs. Most of them got dialysis the day after surgery. No one ever bounced back to PACU or went to icu for hypoxia or respiratory distress. Talking to the rep, he tells me that even in delayed HD (or HD that’s relatively poor at clearing the complex), the complex dissociation amount is so low that no recurarization occurs.
 
Psai said:
You experienced an anecdotal case that supports your presuppositions when it could have easily gone the other way with aspiration, a prolonged trip to the icu and eventual death?
Click to expand...
Are you talking to me?
I was the first to respond to the code.
He gave the pt sux for induction with a K of 5.something. The pt promptly coded and we never got him back. Insulin, albuterol, calcium all given. Nothing got him back. I never forgot this. The attending was one of our best. So it shocked me. Antecdotal? Maybe but it was pretty clear what happened to everyone there.
Btw, thanks for your condescending reply. And to answer that part of the question, he died. And it wasn’t from aspiration.
 
It wasn't meant to sound condescending. What were the circumstances? What were the risk factors? So far your story is patient had a k of 5. got sux. they died. It's not clear to me that this is attributable to hyperkalemic arrest from sux without other risk factors. I don't think the absolute k matters.

The first link I posted:
We retrospectively reviewed more than 40,000 general anesthetics administered over 70 mo in which succinylcholine was given at the induction. This search yielded 38 patients with a preoperative potassium of 5.6 mEq/L or greater. Survival of the anesthetic was 100%, and no dysrhythmias or other major morbidity were documented upon manual review of the intraoperative automated record keeper charts or the patient medical records.
 
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I've started using remi for RSI cases in kids that aren't projected to be that long- supracondylars and stuff. Do people have experience using on the adult side for the same? Other than the musculoskeletal effects and bradycardia- neither of which I have seen yet, any big adverse effects?
 
shepardsun said:
I've started using remi for RSI cases in kids that aren't projected to be that long- supracondylars and stuff. Do people have experience using on the adult side for the same? Other than the musculoskeletal effects and bradycardia- neither of which I have seen yet, any big adverse effects?
Click to expand...

brady, hypotension are most of what i see. though i do find patients to be more difficult to intubate with remi induction than paralytics. they just dont feel as relaxed..

Noyac said:
Are you talking to me?
I was the first to respond to the code.
He gave the pt sux for induction with a K of 5.something. The pt promptly coded and we never got him back. Insulin, albuterol, calcium all given. Nothing got him back. I never forgot this. The attending was one of our best. So it shocked me. Antecdotal? Maybe but it was pretty clear what happened to everyone there.
Btw, thanks for your condescending reply. And to answer that part of the question, he died. And it wasn’t from aspiration.
Click to expand...

while i dont give sux for hyperK, it's also hard to simply blame the sux.. unless this guy is a tetraplegic and hasnt' moved in years or something. could have undiagnosed stuff like severe AS or something. hard to say.
 
anbuitachi said:
About 90min to 2 hrs here. Also roc barely works these days.
Click to expand...
Roc works very well, except for the roc that's been sitting in the cart for a week, because the lazy resident did not bother to get fresh ones from the fridge (despite knowing he'll need them for RSI).
 
FFP said:
Roc works very well, except for the roc that's been sitting in the cart for a week, because the lazy resident did not bother to get fresh ones from the fridge (despite knowing he'll need them for RSI).
Click to expand...

well for it to have been given, it cant only be due to a lazy resident.. but also a lazy attending and probably lazy tech
 
Noyac said:
He gave the pt sux for induction with a K of 5.something. The pt promptly coded and we never got him back. Insulin, albuterol, calcium all given. Nothing got him back. I never forgot this. The attending was one of our best. So it shocked me. Antecdotal? Maybe but it was pretty clear what happened to everyone there.
Click to expand...

A K+ of 5.1 is "5.something," and I'd give an ESRD patient with a K+ of 5.1 sux every day of the week, and twice on Sundays. ESRD patients like to die, and they have lots of reasons to do it. Vascular disease, pulm hypertension, you name it.

We had an attending in residency who had an AVF patient code and die in the OR after getting like 0.5mg of midaz and 25mcg of fentanyl for sedation after a block (like 45min after the block). Probably 2/2 pulmonary hypertension.

Barring the attending saying he watched the QRS complex widen and then the patient coded from an arrhythmia, the story of a patient coding on induction and being not recoverable makes me think more pulmonary hypertensive crisis.

Not saying you're wrong, and I obviously wasn't there, but like @Psai I get the impression there was more to that story.

K of 5-5.5, almost always go, unless it's AKI. 5.5-6.0, would hesitate a little bit more but likely still go depending on the trend.
 
Agreed with above. ESRD patients Can have a handful of arrest on induction conditions that have nothing to do with potassium. I literally always do a TTE with my point of care device on all ESRD patients to screen for unknown pericardial effusion
 
WholeLottaGame7 said:
Barring the attending saying he watched the QRS complex widen and then the patient coded from an arrhythmia, t.
Click to expand...
Yes, that’s what happened. Obviously this pt wasn’t the picture of health. But the code was classic hyperkalemia. Classic enough that I never forgot it. The details are a bit fuzzy after 15+ yrs so you will either have to believe me or not.
I just don’t give these pts sux after this event. Too many good options.
 
Before the days of sugammadex I enjoyed the good ol remi “RSI”, the one downside I encountered in adults is a not infrequent occurrence of laryngospasm, but it’s a weak spasm that you can nudge past if you have a soft tipped stylette to start it.
 
DM27 said:
Before the days of sugammadex I enjoyed the good ol remi “RSI”, the one downside I encountered in adults is a not infrequent occurrence of laryngospasm, but it’s a weak spasm that you can nudge past if you have a soft tipped stylette to start it.
Click to expand...

What dose of remi? I just encountered this while looking at some old papers. Seems like 4 per kilo causes more hemodynamic effects and the intubating conditions are good with 2/kg but I've never tried it.

Also people here seem to disagree on whether remi induced chest rigidity actually exists and if it's just the laryngospasm that you're talking about
 
Alfenta 30/kg works great for this. And yes, high dose opiates can cause rigidity - all muscle groups can be involved. Seen it many times with big fentanyl loads - never seen it with remi but I’m sure it can happen.
 
I use
Lecithin5 said:
An awful lot of ppl are saying they’d use sux on this forum, but I bet that if you asked the average anesthesiologist, they wouldn’t.
Click to expand...
I use sux often when there’s no contraindications. The residents that rotate through apparently never use it back at their mother ship. It’s all about the sugammadex now.
 
IlDestriero said:
I use

I use sux often when there’s no contraindications. The residents that rotate through apparently never use it back at their mother ship. It’s all about the sugammadex now.
Click to expand...

I meant to say on this thread, not forum. I actually have less of an aversion to it than many of my colleagues, and use it with some regularity. But I won’t use it in a pt with a K of 5.7 or 6.2 as the OP was asking
 
Psai said:
What dose of remi? I just encountered this while looking at some old papers. Seems like 4 per kilo causes more hemodynamic effects and the intubating conditions are good with 2/kg but I've never tried it.

Also people here seem to disagree on whether remi induced chest rigidity actually exists and if it's just the laryngospasm that you're talking about
Click to expand...

depends on the patient. usually do 3-5 per kg. less for old sicker people. some people do 1 mg but lately theres a remi shortage and also you dont need that much.
agree with what someone said about cords being closed. ive seen this a bunch
 
Lecithin5 said:
I meant to say on this thread, not forum. I actually have less of an aversion to it than many of my colleagues, and use it with some regularity. But I won’t use it in a pt with a K of 5.7 or 6.2 as the OP was asking
Click to expand...

if it's 5.5 or less I have no qualms about giving sux. You start getting closer to or above 6 and I see no need to use it.
 
anbuitachi said:
depends on the patient. usually do 3-5 per kg. less for old sicker people. some people do 1 mg but lately theres a remi shortage and also you dont need that much.
agree with what someone said about cords being closed. ive seen this a bunch
Click to expand...

Someone else mentioned this, but are you seeing much rigidity with this? I’ve only used Remi a handful of times for intubations and encountered some very difficult ventilations (transient) as a result of it.

Back to the original post - a Cr of 10 and K of 5.7 in a very near ESRD probably can’t wait for the new AVF to mature prior to HD. The pt will almost certainly need a temporary HD cath anyway so I’d talk with the surgeon about that - dialysis could be done ahead of surgery to deal with the potassium load. Personally, 5.7 is about where I shy away from sux - hard to defend if something goes wrong and other agents are out there or the case can be delayed.
 
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Thank you very much for all the responses! It was very helpful and also interesting to see different perspectives.

Initially, the surgeon was very against blocks for whatever reason, but we were able to convince him eventually. We did the case under MAC after the block, and everything went well.
 
I've asked them and a lot of the time they're like oh the block takes too long. I'm like it will be 15 extra minutes max which is a good investment for the patient and their postoperative pain.
 
IlDestriero said:
I use sux often when there’s no contraindications. The residents that rotate through apparently never use it back at their mother ship. It’s all about the sugammadex now.
Click to expand...

Succinylcholine is a medieval barbaric drug. The myalgias are miserable. In a world with sugammadex, I limit its use to RSIs (it's better than high dose roc), laryngospasm, and rare cases where I really want optimal intubating conditions ASAP (like super morbid obese patients who are going to desat like falling rocks).
 
pgg said:
Succinylcholine is a medieval barbaric drug. The myalgias are miserable. In a world with sugammadex, I limit its use to RSIs (it's better than high dose roc), laryngospasm, and rare cases where I really want optimal intubating conditions ASAP (like super morbid obese patients who are going to desat like falling rocks).
Click to expand...
Agreed, there are good alternatives to six for most cases, but it’s still the fastest and safest in the super obese or true RSI.

WholeLottaGame7 said:
We had an attending in residency who had an AVF patient code and die in the OR after getting like 0.5mg of midaz and 25mcg of fentanyl for sedation after a block (like 45min after the block). Probably 2/2 pulmonary hypertension.
.
Click to expand...

I find this hard to believe, there must have been some clue in the patients history that they had some cardiac issues, or an old echo or something. Also, if it was really from pHTN and hypercarbia I would think there would have been a very good chance for rosc.
 
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