RSI in ESRD patient going for AVF

[Noyac]

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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.

Blocks make his AVF more likely to succeed.

 

[DM27]

I typically did 4-5 mcg/kg for Remi. I put a fiberoptic once for resident teaching and we saw the cords go into spasm about 30 sec after the remi was given. So I am a believer in the spasm theory, especially having encountered the spasm before.

 

[IlDestriero]

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).

That’s when I’m using it. But I do those patients often. I wouldn’t be pushing sux with K much above 5. Case by case I suppose.

 

[anbuitachi]

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.

I don't ventilate after I give remi. I wait a bit and then intubate. I find it a bit harder to intubate with remi induction than paralytics and it feels harder to open the mouth

 

[dhb]

Your typical ESRD patient has way more chances of arresting with a remi induction than with sux.
I simply refuse to do anything more than a block for all those super sick patients for avf, amputations and the like. If they want a GA i'll direct them to another sucker.

 

[Mman]

Your typical ESRD patient has way more chances of arresting with a remi induction than with sux.
I simply refuse to do anything more than a block for all those super sick patients for avf, amputations and the like. If they want a GA i'll direct them to another sucker.

and what if they are going all the way up into the armpit and your block isn't a sufficient anesthetic?

 

[pgg]

Your typical ESRD patient has way more chances of arresting with a remi induction than with sux.
I simply refuse to do anything more than a block for all those super sick patients for avf, amputations and the like. If they want a GA i'll direct them to another sucker.

How odd.

 

[dhb]

and what if they are going all the way up into the armpit and your block isn't a sufficient anesthetic?

An av fistula in the armpit? Never seen one

 

[Arch Guillotti]

and what if they are going all the way up into the armpit and your block isn't a sufficient anesthetic?

Armpit fistula?

 

[Arch Guillotti]

Your typical ESRD patient has way more chances of arresting with a remi induction than with sux.
I simply refuse to do anything more than a block for all those super sick patients for avf, amputations and the like. If they want a GA i'll direct them to another sucker.

Depending on what you give with it, remi on induction can cause hypotension and bradycardia and you must be careful with it especially in old and sick patients. I agree with your premise there.

As for the rest of your post, punting management of a sick patient because you can’t choose the anesthetic simply would not fly in most practices.

 

[dhb]

As for the rest of your post, punting management of a sick patient because you can’t choose the anesthetic si

I'm just saying i don't give the sick cripples the choice: it's a block or nothing.

I had a specific scenario in mind when i wrote this: despite me recommending a block, a collegue decide to induce and surprise found himself with a patient with no pulse 🙄.

 

[Noyac]

I'm just saying i don't give the sick cripples the choice: it's a block or nothing.

I had a specific scenario in mind when i wrote this: despite me recommending a block, a collegue decide to induce and surprise found himself with a patient with no pulse 🙄.

Just a random comment here. I feel like we sometimes get too anxious to move forward with the case at our usual pace. If I have one of these super fragile ESRD pts that need a GA I might give 5cc of propofol (or even less) and wait for it to show its presence. Then muscle relaxant etc. These pts don’t need much.

 

[Mman]

An av fistula in the armpit? Never seen one

graft going up high, we see it plenty in the long term disaster ESRD patients that have nonfunctioning fistulas and grafts lower down their arm

 

[Mman]

Just a random comment here. I feel like we sometimes get too anxious to move forward with the case at our usual pace. If I have one of these super fragile ESRD pts that need a GA I might give 5cc of propofol (or even less) and wait for it to show its presence. Then muscle relaxant etc. These pts don’t need much.

the older and sicker the patient is, the slower the induction and the smaller the doses of meds required

 

[WholeLottaGame7]

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.

Oh they knew about it, they just didn't know how fragile they would be. I don't think any code in a patient with pulm HTN has a very good chance for ROSC, certainly not when there are no BPs documented for several minutes and the CRNA has been hitting the "Surgeon on Cuff" button to explain it...

 

[Noyac]

Your typical ESRD patient has way more chances of arresting with a remi induction than with sux.

I’m having a hard time wrapping my head around this comment.

 

[dhb]

I’m having a hard time wrapping my head around this comment.

If you give an intubation dose of remi to a cripple you're going to have some fun.

 

[Noyac]

If you give an intubation dose of remi to a cripple you're going to have some fun.

Ok I trust you. But since I don’t do this, could you elaborate more?

 

[dhb]

Ok I trust you. But since I don’t do this, could you elaborate more?

4mcg or more is fine in an ASA1 patient and gives you good intubating conditions in less than 60sec with minor hypotension if you don't crank the sevo up right after intubation.
The same dose or even half will result in profound hypotension and probably arrest in a ASA 3 or 4 patient.
It's great for intubating without NMB but just not in every patient.

 

[Noyac]

4mcg or more is fine in an ASA1 patient and gives you good intubating conditions in less than 60sec with minor hypotension if you don't crank the sevo up right after intubation.
The same dose or even half will result in profound hypotension and probably arrest in a ASA 3 or 4 patient.
It's great for intubating without NMB but just not in every patient.

So I guess this all goes back to my earlier post which described giving a little bit and waiting. Which is what I was getting at. Thanks for playng along. 😉

 

[dhb]

So I guess this all goes back to my earlier post which described giving a little bit and waiting. Which is what I was getting at. Thanks for playng along. 😉

Which goes back to doing a block and not having to wait 😉

 

[deleted162650]

Oh get a room you two.

 

[Noyac]

Oh get a room you two.

Jealous?

 

[deleted162650]

Jealous?

Yup. It’s always been a fantasy of mine to be the meat in and Old guy/Belgian sandwich.

 

[Planktonmd]

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).

Really???
I love it when people project their personal comprehension of an issue and make it sound like a fact!

 

[Planktonmd]

I’m having a hard time wrapping my head around this comment.

I have to say that I totally agree with Noyac here, I have seen a cardiac arrest after Sux on an ESRD patient with a potassium of 5.5 and it was very unfortunate!
Hyperkalemic arrests are rarely reversible.

 

[pgg]

Really???
I love it when people project their personal comprehension of an issue and make it sound like a fact!

Oh FFS

Even a fourth grader who'd just had his very first class assignment on "fact or opinion?" would be able to easily tell that what I wrote was an opinion. I gave my reasons for having that opinion. You don't have to agree with it.

I've experienced the myalgias from succ personally. It was far worse than the surgical pain associated with an ORIF of comminuted fractures of my radius and ulna. It was miserable. I thought maybe I'd had CPR during the case. Every bit of me hurt to move. The myalgias are a known side effect of the drug. All the things that can be done to minimize or mitigate them (NSAIDs, defasciculating dose of a nondepolarizer, etc) are unreliable.

There is just no reason to use succ for most cases. Succinylcholine has its place - namely laryngospasm, RSIs, or other cases where you have a compelling need to get the best intubating conditions as quickly as possible.

If you're routinely using a drug with a painful side effect, when a suitable alternative exists, you're unkind.

That's an opinion too, in case you're still confused.

 

[Planktonmd]

Oh FFS

Even a fourth grader who'd just had his very first class assignment on "fact or opinion?" would be able to easily tell that what I wrote was an opinion. I gave my reasons for having that opinion. You don't have to agree with it.

I've experienced the myalgias from succ personally. It was far worse than the surgical pain associated with an ORIF of comminuted fractures of my radius and ulna. It was miserable. I thought maybe I'd had CPR during the case. Every bit of me hurt to move. The myalgias are a known side effect of the drug. All the things that can be done to minimize or mitigate them (NSAIDs, defasciculating dose of a nondepolarizer, etc) are unreliable.

There is just no reason to use succ for most cases. Succinylcholine has its place - namely laryngospasm, RSIs, or other cases where you have a compelling need to get the best intubating conditions as quickly as possible.

If you're routinely using a drug with a painful side effect, when a suitable alternative exists, you're unkind.

That's an opinion too, in case you're still confused.

I think you need to calm down and forget that you are a moderator by SDN criteria!

 

[Noyac]

Oh FFS

Even a fourth grader who'd just had his very first class assignment on "fact or opinion?" would be able to easily tell that what I wrote was an opinion. I gave my reasons for having that opinion. You don't have to agree with it.

I've experienced the myalgias from succ personally. It was far worse than the surgical pain associated with an ORIF of comminuted fractures of my radius and ulna. It was miserable. I thought maybe I'd had CPR during the case. Every bit of me hurt to move. The myalgias are a known side effect of the drug. All the things that can be done to minimize or mitigate them (NSAIDs, defasciculating dose of a nondepolarizer, etc) are unreliable.

There is just no reason to use succ for most cases. Succinylcholine has its place - namely laryngospasm, RSIs, or other cases where you have a compelling need to get the best intubating conditions as quickly as possible.

If you're routinely using a drug with a painful side effect, when a suitable alternative exists, you're unkind.

That's an opinion too, in case you're still confused.

Are you a rather muscular person?

 

[Planktonmd]

Are you a rather muscular person?

He is muscular in his own perception!

 

[Arch Guillotti]

I think you need to calm down and forget that you are a moderator by SDN criteria!

 

[pgg]

Are you a rather muscular person?

No.

This is an interesting question - some of the literature suggest a lot of muscle mass is a risk factor for the myalgias, and some suggest that deconditioning is. I am/was neither. To me this underscores how unpredictable the effect is.

And another reason not to use the drug, unless you really need it.

 

[Mman]

Myalgias from succinylcholine are truly terrible for patients. The usual description is the patient feeling like they got ran over by a bus and every part of them hurts for a day or two. Thankfully, however, they are very rare.

 

[Planktonmd]

Myalgias from succinylcholine are truly terrible for patients. The usual description is the patient feeling like they got ran over by a bus and every part of them hurts for a day or two. Thankfully, however, they are very rare.

True, the myalgias are very rare as are other sux side effects, which is why Succinylcholine is still a good option when you want to achieve ideal intubating conditions quickly.

 

[Southpaw]

True, the myalgias are very rare as are other sux side effects, which is why Succinylcholine is still a good option when you want to achieve ideal intubating conditions quickly.

I’ve spoken to enough patients who describe what I believe are succ myalgias that I’ve historically avoided it unless truly indicated. With suggamadex the indications are fewer and farther between. It also isn’t often stored properly, and therefore often doesn’t work as it should in the rare instances that I use it. In my opinion, it’s a drug that’s used far, far more often than really necessary.

 

[Noyac]

I’ve spoken to enough patients who describe what I believe are succ myalgias that I’ve historically avoided it unless truly indicated. With suggamadex the indications are fewer and farther between. It also isn’t often stored properly, and therefore often doesn’t work as it should in the rare instances that I use it. In my opinion, it’s a drug that’s used far, far more often than really necessary.

I think everyone is practicing this way, use it when needed. Nobody should be using it routinely. But myalgia is not a reason to avoid it entirely IMO. All of our drugs have side effects. We just weigh the risks and benefits and move on. Sugamadex has side effect too.

Dogmatic comments tend to get terse responses here. But we all look like a bunch of snobs when we argue back and forth about common sense ****, myself included.

 

[Hork Bajir]

4mcg or more is fine in an ASA1 patient and gives you good intubating conditions in less than 60sec with minor hypotension if you don't crank the sevo up right after intubation.
The same dose or even half will result in profound hypotension and probably arrest in a ASA 3 or 4 patient.

I have done remi RSIs in sick patients many times, without killing any of them. Just have to pre-treat with enough glyco/ephedrine (or epi if really worried), and go light on the propofol. 4mcg/kg gives acceptable intubating conditions, but agree with others that it's not as good as sux or roc. 8mcg/kg is better in terms of intubating conditions, but would think twice about doing this in a true sicko (at least not without some epi running prophylactically). For average ASA 3/4s though, remi RSI is definitely not a no-go; just think about what you're doing and precede cautiously, as i'm sure you would do regardless of which agent you choose

 

[pgg]

True, the myalgias are very rare

I'm not convinced they're all that rare. As a group we anesthesiologists aren't that diligent about asking patients how they feel 24h out. I suspect they're undermeasured in the same way PDPHs probably are.

Succinylcholine is still a good option when you want to achieve ideal intubating conditions quickly.

Agreed. 😉