sudden bradycardia while attempting intubation in critically ill patient?

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ketap

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hi, just want to ask and to share..

i recently found 2 of my patients (geriatrics) had bradycardia when i was trying to intubate them with lidocaine iv 1mg/kg and also low dose rocuronium (0.6mg/kg)..no amnestic agent as this patients mental status is only 5 and they both had tremendous low blood pressure (hypovolemic shock and DKA,respectively)..
i don't really know why they had such bradycardia event right after i put drugs on them..
i don't believe it was because of rocuronium ( as it has wide therapeutic range)..so i believe if it was not because of this patient itself that was deteriorating..it must be came from lidocaine?..:confused:

what do you think should be the cause?
and how many "bradycardia induced by lidocaine iv (For intubation --1mg/kg)" cases did you find in your whole day as a physician?
please help.., thx u

best regards,Ketap:)
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Hmm...i do believe the VAGUS nerve innervates THE WHOLE hypopharynx and larynx. Occasionally, stimulating it by wedging a metal blade and that giant plastic tube in there, bradycardia can ensue. Although this is true it is not common. If you pull the blade/tube out it should go away IF the problem isnt profound hypoxia (causes tachy until the end when the pt "bradys down") or late hypercarbia. As I re-read your post the CV changes happened BEFORE laryngoscopy....sorry

So...HYPERCARBIA can cause bradycardia. common in pts in resp failure but unlikely if it was hypoxic resp failure. If you were ventillating adequately then this isnt the issue.


Why are you giving lidocaine? Bradycardia is a known side effect in folks with bad cardiac wiring. My money is on this. BTW the dose to "blunt hemodynamic response" to laryngoscopy is 1.5mg/kg and must be given 2-3min before laryngoscopy. I try NOT to blunt laryngoscopy response in most patients crashing from respiratory failure as their BP always hits the crapper once their work of breathing is removed. This isnt true for ICP pts in whom an increase in bloodflow to brain from increased CO is not desirable. Anyways lido is pretty crappy compared to fentanyl for this, so why not give fentanyl? Lido really doesnt have a role in RSI on crashing pt.

The roc dose given here isnt double so its not RSI. Double it in the future.

So, what did you do for it?
 
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You should never intubate the patient without at least low-dose of an induction agent or to the very least some fentanyl. This is torture. Use some push-dose pressors if their BP is really low.
 
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EMIM2011 said:
You should never intubate the patient without at least low-dose of an induction agent or to the very least some fentanyl. This is torture. Use some push-dose pressors if their BP is really low.
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Never? Surely you've done awake intubations using a scope?
 
VentdependenT said:
Thats what the OP did. I wouldnt. Not even to your ferret. If their GCS is that low then I just tube em with brutane, just like in a code.
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That's my impression as well. There are 'safe' ways to induce amnesia even in an unstable patient.

Anyone use atropine just prior to induction in this situation (I'm talking about anticipating the bradycardia thing, no amnesia obviously)? Or do you worry about generating arrhythmias in this population?
 
Stitch said:
That's my impression as well. There are 'safe' ways to induce amnesia even in an unstable patient.

Anyone use atropine just prior to induction in this situation (I'm talking about anticipating the bradycardia thing, no amnesia obviously)? Or do you worry about generating arrhythmias in this population?
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Never.

If gramps is that gorked I go straight for the cold steel. Itll bring his bp up. point is if you paralyse the give something to scramble the marbles. Atropine actually will do this to some degree (scopolomine far superior at this) as it crosses BBB.

Anyways I think lidocaine is not appropriate in this situation.

I would love to have ketamine for induction but its a logistical nightmare at my institution. I will work on it.

BTW, 2 weeks left of residency :)
 
my medicine attending's aren't a fan of this, probably because they have very few airways and are inexperienced with it, but I have started using a lot more prop/sux for all of my tubes (which are all MICU tubes in generally decompensating patients). I used to use a ton of etomidate and I still do quite frequently. But I previously avoided propofol a lot because of hypotension. Then I realized we have ephedrine in our RSI boxes. I have nurse draw up etom/succ, pro/succ, etom/double dose roc on everyone AND 10cc of ephedrine. I tube them and pulse dose 3cc of ephedrine if there pressure drops. then another 3cc if they need it. I have pretty much stopped needing to give anyone a bolus of fluids for post induction hypotension. I think I have done enough tubes that the medicine attending's have just stopped caring that I do it as they can see it works well, though they themselves appear afraid to do it.

Never used lidocaine in an RSI before. Never had brady in an RSI before either
 
Bostonredsox said:
my medicine attending's aren't a fan of this, probably because they have very few airways and are inexperienced with it, but I have started using a lot more prop/sux for all of my tubes (which are all MICU tubes in generally decompensating patients). I used to use a ton of etomidate and I still do quite frequently. But I previously avoided propofol a lot because of hypotension. Then I realized we have ephedrine in our RSI boxes. I have nurse draw up etom/succ, pro/succ, etom/double dose roc on everyone AND 10cc of ephedrine. I tube them and pulse dose 3cc of ephedrine if there pressure drops. then another 3cc if they need it. I have pretty much stopped needing to give anyone a bolus of fluids for post induction hypotension. I think I have done enough tubes that the medicine attending's have just stopped caring that I do it as they can see it works well, though they themselves appear afraid to do it.

Never used lidocaine in an RSI before. Never had brady in an RSI before either
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Do you have phenylephrine in your RSI boxes? If so, try that next time, rather than ephedrine. In truly sick patients, you may not see a great response with ephedrine, or it may take a few extra seconds to see a response. The hypotension from propofol is primarily from vasodilation, which is nicely off-set by the pure alpha effects of phenylephrine, which will also act quickly, even with pts who are catechol-depleted. I generally use prop/sux/phenylephrine in crashing ICU pts, with good effect.
 
VentdependenT said:
Thats what the OP did. I wouldnt. Not even to your ferret. If their GCS is that low then I just tube em with brutane, just like in a code.
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Oh.

I guess I kind of walked in on the middle of the convo.

And I think the brady was because they patients were trying to go to the happy place. Old gorked people trying to die will get bradycardic.

True story.
 
hi,really glad to have some replies from all of you...thank you so much :)

btw,actually i didn't give any induction agent because i've concerned for the hypovolemia and i really have no idea why those patient really need any induction agent as they have quiet low gcs (4-5)...i am just wedging the benefit and risk here..besides that i heard some literature permit us to do that for some certain patients..

btw, i am intending for RSI actually (and not awake intubation), but i am afraid that the hypovolemia will increase the plasma conc.and increase the delivery of the rocuronium to the effect site too much..and besides some believes from my colleagues that rocuronium is going to decrease heart rate ??:confused:.

btw, i didn't use fent as it is kind of hard to have it in my place and it is quiet expensive here..so , i use lidocaine instead..and i believe that the dose is not strict to 1.5 mg/kg but in the range of 1.0-1.5 mg/kg :confused:?

sorry for confusing all of you...:)
regards,ketap
 
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VentdependenT said:
Never.

If gramps is that gorked I go straight for the cold steel. Itll bring his bp up. point is if you paralyse the give something to scramble the marbles. Atropine actually will do this to some degree (scopolomine far superior at this) as it crosses BBB.

Anyways I think lidocaine is not appropriate in this situation.

I would love to have ketamine for induction but its a logistical nightmare at my institution. I will work on it.

BTW, 2 weeks left of residency :)
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I love using ketamine. It's not quite as quick or slick as etomidate, but it's great hemodyamically. I also have no problem with etomidate in most situations or just straight fentanyl. If there's time (i.e. not a RSI) we'll run some dopamine or norepi for 5 minutes or so prior to intubating. If someone is crashing, I'll have 1:100,000 epi available and give a squirt as needed. Probably the same idea as using phenylephrine, but we never use that drug in kids for some reason. Kids tend to have high SVR with a relatively fixed SV, so upping their HR can make a big difference in their CO.
 
Hernandez said:
You're using lidocaine in place of fentanyl?
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Yikes. I dont even know where to begin.

The range is actually 1.5-3 for "blunting."

Read up on Roc. It has no effects on CV. Pancuronium does. Who cares if you get prolonged NM blockade in these people. Give full dose...

Its the lido causing brady.

I wouldnt paralyze your gerbile without some form of sedation. If you are so scared about the BP give scopolomine.
 
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ketap said:
btw, i am intending for RSI actually (and not awake intubation), but i am afraid that the hypovolemia will increase the plasma conc.and increase the delivery of the rocuronium to the effect site too much
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For the purposes of RSI, you're either paralyzed or you're not. There's no such thing as "too paralyzed".
 
Had an outside ED (as in WAY outside of town) send a patient to us once who they paralyzed and tubed, but did not sedate because he was being combative . . .
 
Xerxes1729 said:
For the purposes of RSI, you're either paralyzed or you're not. There's no such thing as "too paralyzed".
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agree. and to the OP the reason for the double dose roc is the onset drops to like 60-70 seconds, effectively making it near as fast as sux. It obv lasts longer than sux but if you are prohibited from sux because K is sky high or ICP or something...double dose roc is the way to go. Works every time for me.

to others, I also love ketamine. But as with venty....its like white gold at my shop. can never be found

And I agree on pure alpha agonist being the best for propofol hypotension. But the kits anesthesia designed and control the contents of contain vec/sux/prop/etom/ephedrine. I personally asked them to change the boxes (which are for micu/ed/floor admissions, the majority of which are done by us not anesthesia) to roc/sux/prop/etom/keta. was shot down for essentially no valid reason. I will add ephedrine to neo swap to my demands.
 
Bah, ephedrine is fine dude. You have to dilute neo down and its likely some nurse will push the 1ml vial (like 10mg or some insane number) and kill the pt.
 
I recently had a hypoglycemic diabetic patient with GCS of 5-6 who told me they could remember everything that I said + did to them. He tolerated an oral airway but said he felt it go in. They mentioned specific things I said so I know they weren't making it up or remembering a dream. I agree give your patients some sleepy medicines before tubing them, unless they're dead.
 
hi,thanks for your replies,friends..i really appreciate all of your replies :)..but i am truly confuse because your answers quiet different from what i have learned before..:confused:

You're using lidocaine in place of fentanyl?
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yup... isn't it commonly used as a substitute for fentanyl ?:confused:

If there's time (i.e. not a RSI) we'll run some dopamine or norepi for 5 minutes or so prior to intubating. If someone is crashing, I'll have 1:100,000 epi available and give a squirt as needed.
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i guess i will do that if this patient was a septic patient or a hypotensive normovolemia patient..but i am afraid this patient is not sepsis but hypovolemic shock and i don't think his volume is enough,so i don't want to do give any vasopressor to these patients..

I wouldnt paralyze your gerbile without some form of sedation
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that is what i thought before, but i was blown when i saw some literature (including "miller anesthesia; anesthesia for trauma patient") that in some certain circumstances, they allow us to give only little to none sedation with fast muscle relaxant for RSI..that's how i learned this approach...

thx,
best regards, ketap
 
#1: no. Why are you using lidocaine?

#2: some pressor support to counteract the induction agent/release of respiratory effort induced sympathectomy is fine. I dont stand around and wait until my 2L bolus of crystalloid goes in to intubate someone. Bumps of neo or ephedrine are fine until the drips cone up. Now treat underlying cause.

#3: not even your dung beetle bro. scopolomine at a minimum, unless you are trying to torture someone, like the boston bomber. I would have loved to have been that dudes anesthesiologist. He'd never forget me or his operation. I digress.
 
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hi,VentdependenT..thx for your reply.:)
actually we often use lidocaine because it is still quiet expensive in my place..and i am ok with it because some text show us that lidocaine is an alternative for fentanyl..
i am very sorry ,but i still don't really understand why does this patient still need a sedatives hypnotics? why don't we avoid or just give a titrated small dose of hypnotic sedative so this patients don't need any of those additional drug (ephedrin,etc.)?

i am sorry for being so disturbing..but i really don't get it..
thx u so much for the attention..:)

best regards,Ketap:)
 
ketap said:
hi,VentdependenT..thx for your reply.:)
actually we often use lidocaine because it is still quiet expensive in my place..and i am ok with it because some text show us that lidocaine is an alternative for fentanyl..
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I've never seen lidocaine used as an alternative to fentanyl, nor have I seen any text say that.

I have seen lidocaine as an pre-RSI treatment to either 1) decrease "fentanyl cough" or 2) decrease ICP or 3) relieve bronchospasm
 
Hernandez said:
I've never seen lidocaine used as an alternative to fentanyl, nor have I seen any text say that.

I have seen lidocaine as an pre-RSI treatment to either 1) decrease "fentanyl cough" or 2) decrease ICP or 3) relieve bronchospasm
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I may be mistaken but I believe he is referring to blunting sympathetic response with lidocaine. Was common practice as I understand but has been debunked.


Sent from my iPhone using Tapatalk
 
Dwindlin: yes,that is exactly what i mean:) using lido instead of fentanyl to blunt sympathetic system..sorry if i have confused you all :(
but i don't really understand..what is the other function of fentanyl (when u intubate) besides blunting sympathetic system that all of you have thought before? thx u

regards,Ketap
 
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ketap said:
Dwindlin: yes,that is exactly what i mean:) using lido instead of fentanyl to blunt sympathetic system..sorry if i have confused you all :(
but i don't really understand..what is the other function of fentanyl (when u intubate) besides blunting sympathetic system that all of you have thought before? thx u

regards,Ketap
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Bro, best of luck out there. Remember, not even your chinchillas pubic lice.
 
Interesting discussion.
I don't get pushing epi or neo boluses to treat peri intubation hypotension. That's what gas guys do in the OR. Not real intensivists (apologies to my anesthesiologist brothers and sisters). Lot of these patients don't have central access initially. Why not anticipate hypotension and start the fluid bolus BEFORE pushing the drugs. Also don't tell the nurse to bolus. She ll just hang the bag with the pump at 999. Hang to gravity and squeeze with your own hands.
As far as using NM blockers without sedation is concerned, I agree one should err towards giving sedation. Unless its a code situation ofcourse. Then just go for it. Under most circumstances fentanyl alone can be used and in small doses causes little hemodynamics effect.
Just my 2 cents.
 
Mrishi said:
Interesting discussion.
I don't get pushing epi or neo boluses to treat peri intubation hypotension. That's what gas guys do in the OR. Not real intensivists (apologies to my anesthesiologist brothers and sisters). Lot of these patients don't have central access initially. Why not anticipate hypotension and start the fluid bolus BEFORE pushing the drugs. Also don't tell the nurse to bolus. She ll just hang the bag with the pump at 999. Hang to gravity and squeeze with your own hands.
As far as using NM blockers without sedation is concerned, I agree one should err towards giving sedation. Unless its a code situation ofcourse. Then just go for it. Under most circumstances fentanyl alone can be used and in small doses causes little hemodynamics effect.
Just my 2 cents.
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I disagree with the above. The reason anesthesiologists may do this in the OR is to treat the actual problem with the correct solution. Is the BP drop after propofol bolus caused by hypovolemia (best corrected with fluids) or transient decrease in peripheral vascular resistance (best treated with pure alpha agonists such as phenylephrine)? Dumping a bunch of fluids into a crumping patient MAY mitigate peri-intubation hypotension (though probably not real well) at the expense of having a potentially fluid overloaded patient in 5 minutes when the propofol's hemodynamic effects are gone. Giving 100-200 mcg phenylephrine supports the SVR (the real problem) for about the same amount of time as the effective duration of propfol. I prefer to treat the actual problem with a mechanistically appropriate pharmaceutical. But, to each his own I guess.
 
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