Sux and hyperK

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bigtuna

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Thought I would post this case from ICU today for discussion.

42 y/o man with chronic cervical quadriplegia originally admitted for worsening sacral decub. Transferred to Icu 3 days ago for respiratory failure due to mucous plugging. Intubated on transfer without difficulty by someone else- got 200mg sux and 20 mg etomidate (he weighs about 100 kg). Had a bronch two days ago and suctioned out. Today cxr clear and looking fine on weaning trial. Extubated this AM and originally did great.

Called to see him urgently about 6 hours post extubation. Sudden desaturation. When I got there sat 60's on Bipap. No breath sounds on right. Awake, pretty SOB.

Got reintubation stuff together. Decided to use sux again since I thought quickest intubation would be best in this scenario. Prop 100mg, Sux 150mg. Easy reintubation. While we were securing ETT developed WCT with Rate 160. Didn't lose pulse. Gave calcium, mg, bicarb -> cardiovert X 1 to NSR and stable since.


I did consider he had some risk factors for hyperK with sux but I guess I was swayed by his tolerance of the prior dose and because he had a chronic cord injury. His serum K 2 hours before this was 3.9


Anyway - seen it happen to others but first time its happened to me after almost 10 yr in the ICU. I guess I am lucky it was not a more refractory hyperK scenario.
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Lol why the **** did you inject sux into this poor man
 
I figured I'd get hammered - kind of posted this to remind others not to be as complacent as I was. Correct on the plugging rather than pneumothorax.
 
I'm idly curious - how old was his spinal injury?

I only ask because I don't believe there is even a single case report for a hyperkalemic arrest with an injury over 10 years old. We discussed this in a thread a while ago but I can't find it now.

I wouldn't use succ 🙂 but thought it was an interesting line of discussion.
 
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Interesting to hear. I probably would not have chosen sux, but your reasoning was pretty logical. He got sux prior and was fine, and his k was 3.9. I guess a good lesson for everyone not to risk it.
 
goddamnit somehow I just read respiratory failure and skipped right over the mucus plugging part.
 
Dchz already mentioned sugammadex. If you have it, paralyze with rocuronium, have the sugammadex vials at bedside just in case. Sounds like the airway was easy in the past and no reason to believe that the airway would be much different this time. We are spoiled with having it easily available, so I have always used high dose roc for all ICU and floor intubations.
 
A couple people above mentioned using rocuronium for RSI if you have suggamadex available.

My question is, who gives a **** if suggamadex is available or not? Prop, 1 mg/kg of rocuronium, tube, propofol gtt. Let him sit there paralyzed on the ventilator until the rocuronium wears off -- it'll help his oxygenation anyway.

And I agree that giving this guy succinylcholine is malpractice. Just because an idiot before you played with fire and succeeded doesn't mean you should.
 
Urzuz said:
A couple people above mentioned using rocuronium for RSI if you have suggamadex available.

My question is, who gives a **** if suggamadex is available or not? Prop, 1 mg/kg of rocuronium, tube, propofol gtt. Let him sit there paralyzed on the ventilator until the rocuronium wears off -- it'll help his oxygenation anyway.

And I agree that giving this guy succinylcholine is malpractice. Just because an idiot before you played with fire and succeeded doesn't mean you should.
Click to expand...

i think they meant if you can't intubate or ventilate the patient at least you can reverse and hope the patient makes it!.
 
anbuitachi said:
i think they meant if you can't intubate or ventilate the patient at least you can reverse and hope the patient makes it!.
Click to expand...

The whole idea of reversing rocuronoum with sugammadex to rescue a difficult airway is bogus. Patient will be apneic from your induction drug. You won' get the patient breathing spontaneously in time to prevent anoxic brain injury
 
He was probably already hyperkalemic from hypercarbia if his sat was in the 60s on bipap. The succinylcholine probably pushed him over the edge.

I almost never use sux for icu intubation because i rarely get a full picture of the patient’s history when i intubate them. If they are a big fat strong looking dude who I know have no history of weakness, then yeah, I’d use sux.
 
eikenhein said:
The whole idea of reversing rocuronoum with sugammadex to rescue a difficult airway is bogus. Patient will be apneic from your induction drug. You won' get the patient breathing spontaneously in time to prevent anoxic brain injury
Click to expand...

Situations where you need to induce/paralyze but are unsure if you can pull off an awake intubation for whatever reason are perfect for etomidate/roc with sugg for backup. Etomidate is absolute trash at causing apnea and suppressing airway reflexes. With a 0.1-0.15mg/kg induction the patient should be spontaneous again in under 5 min.
 
vector2 said:
Situations where you need to induce/paralyze but are unsure if you can pull off an awake intubation for whatever reason are perfect for etomidate/roc with sugg for backup. Etomidate is absolute trash at causing apnea and suppressing airway reflexes. With a 0.1-0.15mg/kg induction the patient should be spontaneous again in under 5 min.
Click to expand...

Under perfect conditions for a healthy patient the 5 minute apneic time might hold true.
 
eikenhein said:
The whole idea of reversing rocuronoum with sugammadex to rescue a difficult airway is bogus. Patient will be apneic from your induction drug. You won' get the patient breathing spontaneously in time to prevent anoxic brain injury
Click to expand...

Sure you will. Although the patient will remain sedated, spontaneous ventilation usually returns within a couple minutes.
 
I'll never understand the succinylcholine for non-elective intubations rationale. If a patient has reached the point of respiratory failure requiring intubation, the odds of them recovering any sort of adequate spontaneous ventilation after your induction is a fallacy. Your hypnotic agent alone is likely throwing them over the edge of whatever respiratory reserve they had, not to mention the added hypercarbia/hypoxia from your failed intubation.

Waking a patient up and letting them recover is a fine exercise in the elective OR case where you encounter a can't intubate/can't ventilate scenario. In patients with decompensated respiratory failure, it's asinine to think that them regaining spontaneous ventilation is going to save your ass if you can't get the tube.

Given that, use the drug that gives you the best shot to get your airway with the least side effects. The answer is RSI dose of rocuronium 10/10 (barring allergy), even in the absence of sugammadex.
 
anbuitachi said:
i think they meant if you can't intubate or ventilate the patient at least you can reverse and hope the patient makes it!.
Click to expand...

bigtuna said:
Intubated on transfer without difficulty by someone else- got 200mg sux and 20 mg etomidate (he weighs about 100 kg).
Click to expand...

Additionally, maybe it's my own hubris, but true can't intubate can't ventilate scenarios are so effing rare, and I would venture to guess that 99% of the time they are predictable (e.g.: a patient with a h/o head+neck cancer, radiation to the neck, and has a BMI of 90), that giving a quadriplegic succinylcholine out of fear of needing to "wake them up" is really, really, really stupid
 
pgg said:
I don't believe there is even a single case report for a hyperkalemic arrest with an injury over 10 years old.
Click to expand...

That’s because no one else was stupid enough to try it.

vector2 said:
The SCI isn't really my biggest concern. It's more the critical illness plus prolonged immobility (sacral decub) that would cause me to avoid sux in this situation.
Click to expand...

Uh dude, the guy has been immobile for 20 years. The fact that he’s now immobile in the unit instead of his living room is irrelevant.
 
If I'm called to airway emergency, I'm much more likely to do awake intubation approach knowing that they are already in or near extremis. That means good topicalization, some judicious versed or fentanyl, then induce after tube is in. I'm not one to put in my cowboy hat and wing a potentially difficult airway

thinkorswim said:
Sure you will. Although the patient will remain sedated, spontaneous ventilation usually returns within a couple minutes.
Click to expand...

I think you are way too hopeful. Way way too hopeful. These are the patients that end up being cric'ed
 
Last edited:
SaltyDog said:
That’s because no one else was stupid enough to try it.



Uh dude, the guy has been immobile for 20 years. The fact that he’s now immobile in the unit instead of his living room is irrelevant.
Click to expand...

Your point is taken and I do think the safe bet is avoiding sch in quads for life, but the fact that he's critically ill isn't irrelevant. Critical illness itself is a risk factor for sch induced hyper K.
 
SaltyDog said:
That’s because no one else was stupid enough to try it.
Click to expand...
I'm sure that's most of it, and the rest is probably publication bias ("hey look I just did something most people think is dumb and look at this bad thing that happened" ), but I do wonder what the real risk is. From the standpoint of morbid curiosity.

Those totally atrophied muscles probably don't have much K to dump even if there are a bunch of extrajunctional receptors on them.
 
bigtuna said:
Thought I would post this case from ICU today for discussion.

42 y/o man with chronic cervical quadriplegia originally admitted for worsening sacral decub. Transferred to Icu 3 days ago for respiratory failure due to mucous plugging. Intubated on transfer without difficulty by someone else- got 200mg sux and 20 mg etomidate (he weighs about 100 kg). Had a bronch two days ago and suctioned out. Today cxr clear and looking fine on weaning trial. Extubated this AM and originally did great.

Called to see him urgently about 6 hours post extubation. Sudden desaturation. When I got there sat 60's on Bipap. No breath sounds on right. Awake, pretty SOB.

Got reintubation stuff together. Decided to use sux again since I thought quickest intubation would be best in this scenario. Prop 100mg, Sux 150mg. Easy reintubation. While we were securing ETT developed WCT with Rate 160. Didn't lose pulse. Gave calcium, mg, bicarb -> cardiovert X 1 to NSR and stable since.


I did consider he had some risk factors for hyperK with sux but I guess I was swayed by his tolerance of the prior dose and because he had a chronic cord injury. His serum K 2 hours before this was 3.9


Anyway - seen it happen to others but first time its happened to me after almost 10 yr in the ICU. I guess I am lucky it was not a more refractory hyperK scenario.
Click to expand...


Is there any evidence that the tachycardia was related to increased K? What was the K after you gave the sux? There are other explanations and causes of sudden tachycardia after intubation not related to K.
 
Ronin786 said:
I'll never understand the succinylcholine for non-elective intubations rationale. If a patient has reached the point of respiratory failure requiring intubation, the odds of them recovering any sort of adequate spontaneous ventilation after your induction is a fallacy. Your hypnotic agent alone is likely throwing them over the edge of whatever respiratory reserve they had, not to mention the added hypercarbia/hypoxia from your failed intubation.

Waking a patient up and letting them recover is a fine exercise in the elective OR case where you encounter a can't intubate/can't ventilate scenario. In patients with decompensated respiratory failure, it's asinine to think that them regaining spontaneous ventilation is going to save your ass if you can't get the tube.

Given that, use the drug that gives you the best shot to get your airway with the least side effects. The answer is RSI dose of rocuronium 10/10 (barring allergy), even in the absence of sugammadex.
Click to expand...

Sux comes on faster, gives excellent intubating conditions, and doesnt require the ICU team to go get sedation ready in a hurry. .. plus whatever can possibly be gained by having that respiratory drive come back if I have trouble, ill take it, though it may not be great.. you can always give the roc after the tub is in if the team wants him paralyzed for whatever reason, but also sux gives the option of putting the person right on PSV or some assisted spontaneous mode..
 
Hoya11 said:
Sux comes on faster, gives excellent intubating conditions, and doesnt require the ICU team to go get sedation ready in a hurry. .. plus whatever can possibly be gained by having that respiratory drive come back if I have trouble, ill take it, though it may not be great.. you can always give the roc after the tub is in if the team wants him paralyzed for whatever reason, but also sux gives the option of putting the person right on PSV or some assisted spontaneous mode..
Click to expand...

Sugammadex for double dose roc makes all those arguments moot
 
If the patient was satting 60’s on BiPap with no BS on the right before an induction dose of propofol and sux, what do you think his respiratory status is going to be if you royally muck around the airway in a can’t intubate scenario and then decide you want to “wake him up?” I don’t understand the rationale for needing something to wear off quickly in this situation. If there’s someone out there who has actually seen a scenario where you had an emergent intubation for respiratory failure go badly and then “woke up” the patient and the patient suddenly was magically no longer in respiratory failure then I would like to hear about it. Maybe I’m thinking about this too simplistically or something.
 
anbuitachi said:
if you get called for an ICU intubation, on a patient whos been in the ICU for over a week. would you pick roc over succ if he's been immobile?
Click to expand...
Depends on the airway and the patient. i may just get the patient "enough asleep" and muscle a DL and time the tube with cord opening or use cisatracurium.
 
Hoya11 said:
Is there any evidence that the tachycardia was related to increased K? What was the K after you gave the sux? There are other explanations and causes of sudden tachycardia after intubation not related to K.
Click to expand...
I questioned it a bit too. I originally though that with prop 100 in a big patient that the patient may have just been "light".
 
eikenhein said:
The whole idea of reversing rocuronoum with sugammadex to rescue a difficult airway is bogus. Patient will be apneic from your induction drug. You won' get the patient breathing spontaneously in time to prevent anoxic brain injury
Click to expand...
Hammer, meet nail. And an RSI dose of succinylcholine will leave them apneic for 10 minutes. In a patient who has no reserve and wasn't pre-oxygenated. It doesn't matter what you do to end their neuromuscular blockade. 10 minutes of apnea due to induction agent or paralytic is bad for neurons if good air isn't going in.

If anything to be cautious in this scenario, I'd just make sure I had an appropriately sized LMA available and neuromuscularly block with rocuronium.
 
Not that it makes a whole lot of difference - but both 200 and 150mg of sux for a 100kg pt are kinda whopping doses.
 
Thanks for all the comments. I wasnt worried about a cant intubate scenario in someone that was a routine intubation several days before. I did think there was a chance that mask ventilation would be ineffective because of the plugging. This sort of guy could desaturate and even brady/code very quickly after induction and thats where i thought sux might have an advantage.

The tachycardia was definitely VT. The acidosis definitely exacerbated things. K was 5.2 after about 10 min on vent. ph was 7.22 so definitely lower before.

This has definitely changed my view. I was aware there was a risk of hyperk but just didnt think it was that high. Here is a study where a significant number of sci pts got sux.
I’m not suggesting i will do this again.


Altered cardiovascular responses to tracheal intubation in patients with complete spinal cord injury: relation to time course and affected level. - PubMed - NCBI
 
Psai said:
Sugammadex for double dose roc makes all those arguments moot
Click to expand...

But why put yourself in the situation where you are relying on suggamadex? The clinical significance of you elevating the K by using sux is minimal.. and sugga may take a while to get it (not sure its in the icu/er) ... obviously in a quad or someone with a stronger contraindication to sux its a different story
 
bigtuna said:
Thanks for all the comments. I wasnt worried about a cant intubate scenario in someone that was a routine intubation several days before. I did think there was a chance that mask ventilation would be ineffective because of the plugging. This sort of guy could desaturate and even brady/code very quickly after induction and thats where i thought sux might have an advantage.

The tachycardia was definitely VT. The acidosis definitely exacerbated things. K was 5.2 after about 10 min on vent. ph was 7.22 so definitely lower before.

This has definitely changed my view. I was aware there was a risk of hyperk but just didnt think it was that high. Here is a study where a significant number of sci pts got sux.
I’m not suggesting i will do this again.


Altered cardiovascular responses to tracheal intubation in patients with complete spinal cord injury: relation to time course and affected level. - PubMed - NCBI
Click to expand...

I would not expect a K of 5.2 to cause problems..
 
Hoya11 said:
I would not expect a K of 5.2 to cause problems..
Click to expand...

He said that was after 10 minutes on the vent correcting the hypercarbia/acidemia. Was probably 6ish around the time of intubation.
 
I didn’t use Sch (or any paralytic) but a handful of times during floor intubations in residency. I think it’s over used.
 
Hoya11 said:
Sux comes on faster, gives excellent intubating conditions, and doesnt require the ICU team to go get sedation ready in a hurry. .. plus whatever can possibly be gained by having that respiratory drive come back if I have trouble, ill take it, though it may not be great.. you can always give the roc after the tub is in if the team wants him paralyzed for whatever reason, but also sux gives the option of putting the person right on PSV or some assisted spontaneous mode..
Click to expand...
Why would you intubate somebody for respiratory failure and then put them on an assisted mode? Sux in respiratory failure, IMO, is a relic of olden anesthesia and has no real role in this age. Especially when you think of how serious the harm you can cause with it is.
 
Dr.whom said:
I almost never use sux for icu intubation because i rarely get a full picture of the patient’s history when i intubate them. If they are a big fat strong looking dude who I know have no history of weakness, then yeah, I’d use sux.
Click to expand...

Yes. This. It's a dirty and dangerous drug. Most ICU patients have a contraindication, and usually the short duration and profound relaxation arent desirable or necessary.
 
WholeLottaGame7 said:
He said that was after 10 minutes on the vent correcting the hypercarbia/acidemia. Was probably 6ish around the time of intubation.
Click to expand...

So you have a K of >6. Which according to the logic here is caused by Sch. Then you put a patient on a vent for 10 minutes and correct his Co2 (which was not the primiary cause of hyperkalemia) . You think that K is now 5? With no other correction? No. Something else probably caused the tachycardia.
 
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