RSI Roc before etomidate?

[SpacemanSpifff]

This comment unsurprisingly derailed the multi specialty paralytic use convo into our typical us vs them BS. And this is despite you saying with all due respect 🧐

Yet I’ll repeat it lol. I respect the hell out of EM docs, anyone that thinks you’re not a specialist is an idiot. I wouldn’t want to do your job, and much of that is due to the many ED vs OR differences that have come up in this thread.

With that said I hate this trope where people think all OR intubations are optimized or worked up perfectly, the pt has the ability to be preoxygenated to the full 8min of apneic desat time etc. Or that our head of the bed is free of cables, wires, etc 🙄

The point is it’s lazy and professionally dishonest to attempt to paint our airway experience as optimized chipshots in an optimized location with optimized support. Just like it’s dishonest and posturing to say you guys are just generalists or airway hacks. We each have our weak links, but on average I’d say it’s not true for both sides.

Thank you. Absolutely. The average anesthesia approach to airway and induction is incredibly nuanced, because that is the core of their training. Anyone who disagrees should spend some time over in the anesthesia forum reading some of their educational threads (which are conspicuously lacking in ours) or go to a cardiac OR for a day.

I can feel comfortable managing airways, cardiogenic shock, and hemothoraces, while at the same time understanding there are specialists who, on average, have a broader perspective and deeper knowledge base in these pathologies. Being an EM doc requires that we accept it. There are idiots in every specialty and at times I have counted myself among them. I really don’t understand the need to flex.

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[turkeyjerky]

I’ll give you K+ of 5.9 in an undifferentiated pt not known to have CRF, but otherwise this has been studied, Sux raises serum K+ 0.5 transiently. 4.5–>5 for 5min isn’t killing anybody but the faster tube might be beneficial. But what other contraindications are you talking about?

Like I said before, I'm a simple minded guy and cognitive off-loading makes my life easier. That way I can focus on the important things, like reversing the arch the RT insists on shaping the stylet into, as well as making sure that we have more than one 02 tree in the room.

 

[Apollyon]

I really don’t understand the need to flex.

Step back from medicine, and look at people. We're human. The need to flex is in our psychic milieu.

Now, academic medicine is similar to academics in general, where d-bags are much more free to d-bag, and, so, whether it's being a petty schmuck, or flexing over trivialities or another person's momentary weakness or failure, it goes unaddressed or unpunished, and, in some medical cultures, is even celebrated. The arch difference, though, is that, in medicine, there's a person that could lose a limb or their life, and that's the time to lock it down and get it done. At that point, that's when the pt's anatomy fights back, and that's when, if emotion is injected, it makes everything harder. As a former PhD friend used to say to his PITA colleagues, "Did anyone die? Did anyone lose a leg?" and "There's no such thing as a history emergency".

 

[Dred Pirate]

So like has been mentioned (I didn't read all four pages so apologies if this was beat like a dead horse) - in theory Roc takes longer to take effect than etomidate - so giving it first gives it a chance to kick in at the same time as the sedative. Succs has a faster onset of action - therefore you give it after etomdate (you don't "succ" until you "date"). I have had two of the docs I work with ask for Roc first, but honestly you are talking about a matter of like 5 seconds difference- which I think clinically isn't that important.

I see it in the sort of same manner as why you give D50 before the insulin in hyperkalemia - what happens if you loose IV access between pushes? Now you are screwed (either you have a paralyzed awake pt or a pt with plummeting BG). Rare for it to happen, but it could - and I think it is simpliar to just keep the same process regardless of what paralyticas it would spurise me if a few seconds made a difference clinically

As far as mixing the drugs in one syringe, our paralytics all come in prefilled syringes - so we have no need to mix them. I simply pull up the dose of sedative, and give the prefilled syringe/squirt out extra and had to the RN. It takes me like 2 minutes.

I am surprised some of the doc's here pull up meds - honestly the only drug I have seen a MD actually administer is propofol for sedation or 23.4% saline (our hospital policy). But I guess that is why I have a job.

 

[Dred Pirate]

Can... can I have neo sticks?

I really don't understand why these aren't standard in EDs. I worked in one place where they had them, so nice. Just another bizarre example of how dysfunctional most hospitals are. They are plentiful, pre-made and already in the hospital.

The fact that some places still don't stock Rocuronium in the ED is another. Absolutely bizarre. Why do they have vec? There's basically no use for it in our practice.

I am suprised everybody doesn't ahve these? We have pre-made push dose epi and neo sticks - do you carry neo drips? It is often the exact same concentration, just pulled a syringe full out of the pre-made bag and push as needed.

 

[Dantrolene FC]

So like has been mentioned (I didn't read all four pages so apologies if this was beat like a dead horse) - in theory Roc takes longer to take effect than etomidate - so giving it first gives it a chance to kick in at the same time as the sedative. Succs has a faster onset of action - therefore you give it after etomdate (you don't "succ" until you "date"). I have had two of the docs I work with ask for Roc first, but honestly you are talking about a matter of like 5 seconds difference- which I think clinically isn't that important.

I see it in the sort of same manner as why you give D50 before the insulin in hyperkalemia - what happens if you loose IV access between pushes? Now you are screwed (either you have a paralyzed awake pt or a pt with plummeting BG). Rare for it to happen, but it could - and I think it is simpliar to just keep the same process regardless of what paralyticas it would spurise me if a few seconds made a difference clinically

As far as mixing the drugs in one syringe, our paralytics all come in prefilled syringes - so we have no need to mix them. I simply pull up the dose of sedative, and give the prefilled syringe/squirt out extra and had to the RN. It takes me like 2 minutes.

I am surprised some of the doc's here pull up meds - honestly the only drug I have seen a MD actually administer is propofol for sedation or 23.4% saline (our hospital policy). But I guess that is why I have a job

What everyone is talking about is essentially a modified version of the timing technique for an RSI. Give 0.6 mg/kg of rocuronium, wait for the patient to show signs of weakness, then give your sedative. It’s no longer used.

 

[Dantrolene FC]

I am suprised everybody doesn't ahve these? We have pre-made push dose epi and neo sticks - do you carry neo drips? It is often the exact same concentration, just pulled a syringe full out of the pre-made bag and push as needed.

All the phenylephrine infusions I’ve seen are a different concentration than the bolus syringes. I’m sure this various by hospitals.

 

[Dred Pirate]

All the phenylephrine infusions I’ve seen are a different concentration than the bolus syringes. I’m sure this various by hospitals.

I am sure different places have different concentrations - honestly doesn't matter what the concentration is, provided you know what dose you are giving (even though you sort of just titrate it anyway) - that is why we made them the same concentrations - simply to make it easier, then in time of shortages if we can't get the pre-made syringes, we just just use the bag like one poster mentioned.

 

[southerndoc]

What everyone is talking about is essentially a modified version of the timing technique for an RSI. Give 0.6 mg/kg of rocuronium, wait for the patient to show signs of weakness, then give your sedative. It’s no longer used.

No, there is no waiting for signs of weakness. Push the roc, immediately push the etomidate, flush the IV.

 

[Dantrolene FC]

No, there is no waiting for signs of weakness. Push the roc, immediately push the etomidate, flush the IV.

That's why I said it's a modified version fo the timing technique. What I mean is that it is not an absurd concept to give the paralytic prior to the amnestic agent. It's no longer used in anesthesia though due to worries of awareness, which is a bad outcome in an elective case, but it wouldn't be the worst outcome in the ER.

 

[Arch Guillotti]

That's why I said it's a modified version fo the timing technique. What I mean is that it is not an absurd concept to give the paralytic prior to the amnestic agent. It's no longer used in anesthesia though due to worries of awareness, which is a bad outcome in an elective case, but it wouldn't be the worst outcome in the ER.

What isn’t used amymore?

 

[Dantrolene FC]

What isn’t used amymore?

The timing technique in the OR for RSI. In this technique, you give 0.6 mg/kg of rocuronium, wait until clinical signs of weakness, then give propofol (or other induction med). The standard technique is either induction agent followed by succinylcholine or 1.2 mg/kg of rocuronium.

 

[coffeebythelake]

For those who use roc and etomidate for RSI, we’re you taught to push roc before etomidate, to help reduce apneic oxygenation time? This is opposed to sux, where you push etomidate first then sux.

Nah

 

[nimbus]

All the phenylephrine infusions I’ve seen are a different concentration than the bolus syringes. I’m sure this various by hospitals.

Drips are usually 200mcg/ml. Syringes are usually 100mcg/ml. 100mcg and 200mcg are both reasonable IV push doses.

 

[Robotic Wis-Hipple]

I’ve seen 80 and 100mcg pre made Neo sticks. And I’ve seen 80 and 160mcg/mL drip bags. I’ve never actually seen a 200mcg/mL drip bag.

 

[GassYous]

I’ve seen 80 and 100mcg pre made Neo sticks. And I’ve seen 80 and 160mcg/mL drip bags. I’ve never actually seen a 200mcg/mL drip bag.

We had one with 250 and I got chewed out by the attending as I refilled my neo syringe from the bag as we were transporting a postop cardiac patient to the icu

 

[Groove]

Late to the discussion, not sure how I missed this one. I always given sedation prior to paralytics. Always. It's not only how I was trained but as someone else said, the last thing I want is for someone to remember being paralyzed. Hell, I don't want them remember anything. I think all this paralytics before sedation is crazy talk. As much as I love Weingart, sometimes I feel like he is obsessed with practicing outside the envelope and cobbling together data to support some new, often weird, approach to medical management. The whole delayed sequence intubation thing just makes my eyes roll independently. I could never get over how that single study took the EM world by storm and I heard everybody talking about it simply because Weingart had come up with it. It was lectured at all the conferences. They didn't even need to see any validation studies, I mean...it's WEINGART! All those fighting, altered respiratory failure pt's where Weingart would be pushing ketamine for DSI, are the exact very few exception cases where I'd probably just be slamming them with paralytics first followed by sedation or both at the same time and just tubing them. Maybe the guy is a genius and I'm just stubborn and resistant. Who knows.

I used to use Sux a lot more than I do these days. I find myself using Roc more and more because nursing is absolutely terrible at sedation parameters and inevitably my pt's wake up on the CT table and start grabbing for all the tubes and lines. At least with Roc they've got 45 mins or so to get the sedation right.

Anybody else seeing a lot of ICU docs giving 50mg Roc boluses with sedation? I've seen 2 diff intensivists lately give really low paralytic doses prior to intubation and I can't figure out why. Is it because they are trying to optimize the airway but are afraid of complete paralysis? I have no clue but I'm seeing it more and more at a couple of hospitals where I work.

I used to do more "take a look" airway views after sedation but got burned in residency doing this during my ICU rotations (intensivists didn't like paralytics in the first place) and had some bad cases where the pt would vomit and end up with a rip roaring aspiration pneumonia and delay their ICU stay by 2 weeks. I only do it these days for the really hairy airway cases where I'm legitimately afraid to paralyze them without taking a quick peek first. I seem to get less emesis with ketafol or propofol alone vs strictly ketamine which I seem to remember fits the pharmacokinetic profile.

Man, I really miss Neo. I've never had ready access to it outside residency. Every time I ask a nurse or pharmacist for a stick of Neo, they look at me with wide eyes like I just spoke a foreign language.

I'll have to remember the mixing sedation meds with paralytics in the same syringe. I never thought of that. I'll have to see if nursing will be copasetic or if they will demand a 10 min educational discussion for "group learning" along with a "phone a friend" call to the pharmacy to make sure there's no drug/drug interaction prior to making an informed decision whether to refuse a physician order under the auspices of "endangerment to my nursing license".

The best nursing order refusal I got one time was "Inhumane patient treatment" when I told them to roll this 500 lb guy up like a burrito so he would fit in the CT scanner because I was sure he had an SBO. Charge nurse refused saying it was unethical treatment and inhumane. Guy gets admitted. Hospitalist decides the burrito plan was actually not half bad and talks his floor nurses into some Chipotle maneuvering to get this guy in the scanner. Sure enough...SBO.

 

[WilcoWorld]

As much as I love Weingart, sometimes I feel like he is obsessed with practicing outside the envelope and cobbling together data to support some new, often weird, approach to medical management.

 

[PTPoeny]

It is so interesting how different areas of the same hospital are stocked with different emergency meds. In the ICU I work in we have push dose dilute epi readily available but no levo. I was surprised to find out the anesthesia department here has both and the ED has neither...

 

[GassYous]

It is so interesting how different areas of the same hospital are stocked with different emergency meds. In the ICU I work in we have push dose dilute epi readily available but no levo. I was surprised to find out the anesthesia department here has both and the ED has neither...

If anyone needs push dose epi it is the ed
You don't really need push dose levo when you have neo and ephedrine

 

[Robotic Wis-Hipple]

I used to use Sux a lot more than I do these days. I find myself using Roc more and more because nursing is absolutely terrible at sedation parameters and inevitably my pt's wake up on the CT table and start grabbing for all the tubes and lines. At least with Roc they've got 45 mins or so to get the sedation right.

Anybody else seeing a lot of ICU docs giving 50mg Roc boluses with sedation? I've seen 2 diff intensivists lately give really low paralytic doses prior to intubation and I can't figure out why. Is it because they are trying to optimize the airway but are afraid of complete paralysis? I have no clue but I'm seeing it more and more at a couple of hospitals where I work.

I used to do more "take a look" airway views after sedation but got burned in residency doing this during my ICU rotations (intensivists didn't like paralytics in the first place) and had some bad cases where the pt would vomit and end up with a rip roaring aspiration pneumonia and delay their ICU stay by 2 weeks. I only do it these days for the really hairy airway cases where I'm legitimately afraid to paralyze them without taking a quick peek first. I seem to get less emesis with ketafol or propofol alone vs strictly ketamine which I seem to remember fits the pharmacokinetic profile.

Man, I really miss Neo. I've never had ready access to it outside residency. Every time I ask a nurse or pharmacist for a stick of Neo, they look at me with wide eyes like I just spoke a foreign language.

I'll have to remember the mixing sedation meds with paralytics in the same syringe. I never thought of that. I'll have to see if nursing will be copasetic or if they will demand a 10 min educational discussion for "group learning" along with a "phone a friend" call to the pharmacy to make sure there's no drug/drug interaction prior to making an informed decision whether to refuse a physician order under the auspices of "endangerment to my nursing license".

The best nursing order refusal I got one time was "Inhumane patient treatment" when I told them to roll this 500 lb guy up like a burrito so he would fit in the CT scanner because I was sure he had an SBO. Charge nurse refused saying it was unethical treatment and inhumane. Guy gets admitted. Hospitalist decides the burrito plan was actually not half bad and talks his floor nurses into some Chipotle maneuvering to get this guy in the scanner. Sure enough...SBO.

A lot to unpack here but a few thoughts and anecdotes that you all can take or leave.

As most have said, the idea for paralytics before sedative hypnotic is literally just trying to align the onset time. With that said, I typically don’t do this because it’s just as easy to swing the other way (as you’ve alluded) and provide weakness/air hunger/terror to your pt prior to anesthesia. Now in a true life/death scenario I guess the risk/reward is still in favor of saving them at the expense of a few seconds of discomfort. But I typically just use propofol flushed with sux. In controlled inductions when I have either precurarized or given a defasciculation dose it’s not entirely rare for you to see patients eyes go wide or them to note a noticeable weakness/onset of difficulty breathing. And that’s with 5 or 10mg of Roc literally seconds before induction dose of sedative. In elective or semi elective inductions I think it’s cruel. For this reason I just use Roc for my elective or controlled non-emergent inductions (which is in large part because sugammadex is so available to me these days). In your typically crashing life saving scenario? I’d use sux if no contraindications as it’s just faster, though 1.2mg/kg of Roc isn’t all that much slower.

Considering ED drug and nursing logistics I understand your guys issues. But I’ve seen many many pts brought in by EMS or post intubation in the trauma bay hypertensive/tearing etc because they got 10-20mg of etomidate with 50-100mg of Roc 30 minutes ago. I don’t know how to fix that aside from a decent slug of versed or system based reform to protocolize benzo or your amnestic/sedative of choice to show up with your RSI kits. You could also have Neo added to the same protocol. Yes, this is a naive anesthesiologist thinking I could change ED culture or entrenched rules but I will tell you, no group of anesthesiologists would let that fly if the hospital or pharmacy tried to enact restrictions like that on us. In particular I think no push dose pressor readily available at inductions is a non starter.

Regarding weak paralytic dosing? This makes zero sense to me. If the airway is scary the decision isn’t light relaxant it’s sleep or no sleep. If you give enough sedative to get to intubation you’ve already walked out onto the bridge of apnea or at least suboptimal ventilation, giving a partial dose of paralytic probably extends your time to secured airway due to suboptimal views. Then you hit a point where you either give more paralytic to improve your look but then hypnotic is wearing off. I just see that as a wandering cluster of suboptimized conditions.

Last anecdote I’ll mention is regarding ketamine. I think, at least in my hands, in adults, it’s a garbage induction agent. I completely understand the idea and why you guys like it, it maintains spontaneous ventilation (usually) and it likely provides much longer effective sedation and pain control for your patients you have to scan or line up etc post secured airway and paralysis. I get it and I’m not trying to convince any of you to change your practice. What I will say, is it isn’t always the perfect respiratory drive preserving drug without hemodynamic compromise. In patients that are tapped out and living on their sympathetics, you will see significant hemodynamic collapse. When I was fresh out of training I used to try to do tamponade inductions by the book; maintain negative pressure ventilation, maintain sympathetic outflow, avoid hemodynamically depressant drugs etc. So, urgent/emergent pericardial windows I’d try to induce with Ketamine, DL/ETT, light PPV to see ventilatory impact on pulse pressure etc. You know what? Ketamine or maybe just an un-relaxed/non-paralyzed DL sucks. It just does. You then give more Ketamine. Then they don’t have the SNS molecules to throw at you and they tank anyways. So now, I’m a wiser less concerned with what the book may say type guy and the question still boils down to sleep or not to sleep. If they’re that sick, they can’t lie back, can’t speak in full sentences, they look terrified, etc? Sorry, you get an awake local anesthetic assisted percutaneous drain. Then we go to sleep. If you look stable-ish or I think I can secure the airway without an impending crash? Prop/sux or roc/push dose pressor, tube.

You guys have a hard job, you guys need to fight the pharmacy and clipboard warriors and get the tools you need. Not having push dose meds or sedatives readily available would drive me nuts.

 

[Groove]

A lot to unpack here but a few thoughts and anecdotes that you all can take or leave.

As most have said, the idea for paralytics before sedative hypnotic is literally just trying to align the onset time. With that said, I typically don’t do this because it’s just as easy to swing the other way (as you’ve alluded) and provide weakness/air hunger/terror to your pt prior to anesthesia. Now in a true life/death scenario I guess the risk/reward is still in favor of saving them at the expense of a few seconds of discomfort. But I typically just use propofol flushed with sux. In controlled inductions when I have either precurarized or given a defasciculation dose it’s not entirely rare for you to see patients eyes go wide or them to note a noticeable weakness/onset of difficulty breathing. And that’s with 5 or 10mg of Roc literally seconds before induction dose of sedative. In elective or semi elective inductions I think it’s cruel. For this reason I just use Roc for my elective or controlled non-emergent inductions (which is in large part because sugammadex is so available to me these days). In your typically crashing life saving scenario? I’d use sux if no contraindications as it’s just faster, though 1.2mg/kg of Roc isn’t all that much slower.

Considering ED drug and nursing logistics I understand your guys issues. But I’ve seen many many pts brought in by EMS or post intubation in the trauma bay hypertensive/tearing etc because they got 10-20mg of etomidate with 50-100mg of Roc 30 minutes ago. I don’t know how to fix that aside from a decent slug of versed or system based reform to protocolize benzo or your amnestic/sedative of choice to show up with your RSI kits. You could also have Neo added to the same protocol. Yes, this is a naive anesthesiologist thinking I could change ED culture or entrenched rules but I will tell you, no group of anesthesiologists would let that fly if the hospital or pharmacy tried to enact restrictions like that on us. In particular I think no push dose pressor readily available at inductions is a non starter.

Regarding weak paralytic dosing? This makes zero sense to me. If the airway is scary the decision isn’t light relaxant it’s sleep or no sleep. If you give enough sedative to get to intubation you’ve already walked out onto the bridge of apnea or at least suboptimal ventilation, giving a partial dose of paralytic probably extends your time to secured airway due to suboptimal views. Then you hit a point where you either give more paralytic to improve your look but then hypnotic is wearing off. I just see that as a wandering cluster of suboptimized conditions.

Last anecdote I’ll mention is regarding ketamine. I think, at least in my hands, in adults, it’s a garbage induction agent. I completely understand the idea and why you guys like it, it maintains spontaneous ventilation (usually) and it likely provides much longer effective sedation and pain control for your patients you have to scan or line up etc post secured airway and paralysis. I get it and I’m not trying to convince any of you to change your practice. What I will say, is it isn’t always the perfect respiratory drive preserving drug without hemodynamic compromise. In patients that are tapped out and living on their sympathetics, you will see significant hemodynamic collapse. When I was fresh out of training I used to try to do tamponade inductions by the book; maintain negative pressure ventilation, maintain sympathetic outflow, avoid hemodynamically depressant drugs etc. So, urgent/emergent pericardial windows I’d try to induce with Ketamine, DL/ETT, light PPV to see ventilatory impact on pulse pressure etc. You know what? Ketamine or maybe just an un-relaxed/non-paralyzed DL sucks. It just does. You then give more Ketamine. Then they don’t have the SNS molecules to throw at you and they tank anyways. So now, I’m a wiser less concerned with what the book may say type guy and the question still boils down to sleep or not to sleep. If they’re that sick, they can’t lie back, can’t speak in full sentences, they look terrified, etc? Sorry, you get an awake local anesthetic assisted percutaneous drain. Then we go to sleep. If you look stable-ish or I think I can secure the airway without an impending crash? Prop/sux or roc/push dose pressor, tube.

You guys have a hard job, you guys need to fight the pharmacy and clipboard warriors and get the tools you need. Not having push dose meds or sedatives readily available would drive me nuts.

Really appreciate the post. Love the insight and knowledge you guys have to share in here that is very relevant to our day to day challenges. It's also a fresh perspective that some of us lack having been conditioned for so long in broken ED systems where we often forget how things function in other parts of the hospital and SHOULD function for us in the ED.

 

[Dred Pirate]

I used to use Sux a lot more than I do these days. I find myself using Roc more and more because nursing is absolutely terrible at sedation parameters and inevitably my pt's wake up on the CT table and start grabbing for all the tubes and lines. At least with Roc they've got 45 mins or so to get the sedation right.




Man, I really miss Neo. I've never had ready access to it outside residency. Every time I ask a nurse or pharmacist for a stick of Neo, they look at me with wide eyes like I just spoke a foreign language.

I agree with just about everything you say, my only issues is the bolded part - if this is the case - they are awake, but paralyzed (assuming intact neurologically)- when our docs first starting using Roc - I was definitely the sedation nazi to avoid this. Now when I prep the RSI meds I go ahead and ask what does the doc want post-sedation - We usually do a propofol drip, so I go ahead and pull and prime line, set up pump, etc so the RN simply has to push the start button and we can avoid issues.

I do agree RN's are horrible at sedation parameters. If I had a dollar every time a RN would say, "they are waking up, can we give them some vecuronium?" As a side note I did a study over the past two years only about 50% of pt's who received a paralytic received a sedative within 15 minutes regardless of whether they got roc or succ - so I guess since there really wasn't a difference, our chances of awareness was low. Now we didn't dig deeper yet to see if this was an ordering issue or a administration issue (RN has orders but didn't give).

And I have to ask what rph doesn't know what a neo stick is? If they are working in the ED/ICU and they don't know that, that makes my head hurt for my profession,

in regards to concentration - our neo sticks are 80 per ml - which is the same as our standard drips (we do have concentrated drips for those that are fluid overloaded

 

[Arch Guillotti]

The timing technique in the OR for RSI. In this technique, you give 0.6 mg/kg of rocuronium, wait until clinical signs of weakness, then give propofol (or other induction med).

I have never heard anyone remotely mention this technique. It isn't an RSI if you are giving .6 mg/kg of roc. Period.

 

[bravotwozero]

The best nursing order refusal I got one time was "Inhumane patient treatment" when I told them to roll this 500 lb guy up like a burrito so he would fit in the CT scanner because I was sure he had an SBO. Charge nurse refused saying it was unethical treatment and inhumane. Guy gets admitted. Hospitalist decides the burrito plan was actually not half bad and talks his floor nurses into some Chipotle maneuvering to get this guy in the scanner. Sure enough...SBO.

I burst out laughing.

You just made my otherwise crappy day (new thread on it), thanks for that.

 

[Dantrolene FC]

I have never heard anyone remotely mention this technique. It isn't an RSI if you are giving .6 mg/kg of roc. Period.

It’s described in Miller under the RSI section of the neuromuscular blockers chapter.

 

[GassYous]

I have never heard anyone remotely mention this technique. It isn't an RSI if you are giving .6 mg/kg of roc. Period.

RSI is just pushing meds quickly and tubing asap

 

[coffeebythelake]

RSI is just pushing meds quickly and tubing asap

Yes I suppose if you get jnto the exact meaning of the words.. Rapid Sequence Induction. But wouldn't you want ideal intubating conditions without all the gagging and coughing and potentially vomiting in a full stomach patient because the roc hasn't kicked in yet? If your intent with Rapid Sequence Induction is to follow through with Rapid Intubation then you ain't going to do it well with a small dose of rocuronium. In my book, 0.6 mg/kg is synonymous with routine induction and 1.2 mg/kg of rocuronium or suxx is congruent with an RSI.

 

[coffeebythelake]

It’s described in Miller under the RSI section of the neuromuscular blockers chapter.

Need to look into this...

 

[GassYous]

Yes I suppose if you get jnto the exact meaning of the words.. Rapid Sequence Induction. But wouldn't you want ideal intubating conditions without all the gagging and coughing and potentially vomiting in a full stomach patient because the roc hasn't kicked in yet? If your intent with Rapid Sequence Induction is to follow through with Rapid Intubation then you ain't going to do it well with a small dose of rocuronium. In my book, 0.6 mg/kg is synonymous with routine induction and 1.2 mg/kg of rocuronium or suxx is congruent with an RSI.

Does what you describe happen?

 

[coffeebythelake]

Does what you describe happen?

haven't you ever got impatient with routine induction and didn't wait long enough, and had the patient gag or buck during intubatjon? For a fasted patient no big deal, maybe slightly less ideal intubating conditions and maybe slightly worse CL view. But now imagine if they weren't fasted. They could have a mouth full from vomit, not passive regurgitation. Would also consider that not infrequently RSI are done in patients who are physiologically unstable and you are using lower than typical induction doses of your sedative hypnotic.

 

[Arch Guillotti]

Does what you describe happen?

yep

 

[GassYous]

Actually I thought about it and usually it doesn't happen but it definitely does you guys are right