refreshingred said:
My attending told me that after inducing I should give my sux or nimbex or whatever immediately, just like in RSI, AND not bag to see if I can ventilate. He stated that I should give the paralytic right after the induction agent for all patients. He said that it is NOT neccessary to bag the pt to see 'if i can ventilate before giving the paralytic.' His reasoning was that if i am that worried about NOT being able to bag a patient then my plan should have been awake fiber optic from the beggining. He said that the whole idea of FIRST seeing if one can bag a patient before you 'burn you bridges' with a paralytic is old fashioned and not based on the most current data. He underscored his point by asking: "If a patient isn't bagable after giving the induction agent what would any anesthesiologist do? They would intubate. Which is of course what you would do ANYWAY after giving the paralytic, so the bagging b4 paralyzing is superfluous.
Hope that makes sense. So, what is the current thinking on this? I can't seem to find much info on the net or in my textbooks that addresses this particular area.
Great post....I agree with your attending more than I disagree with him.
When I see one of our students giving propofol, ventilating, then giving the succinylcholine, it goes like this:
Jet "Why did you wait to give the sux?"
SRNA "To make sure I can ventilate before I paralyze."
"Thats the right answer for your boards and your hard-ass, rigid instructors. Good job. But let me ask you a question...whens the last time you gave propofol/or whatever, had a hard time ventilating, and subsequently woke the patient up?"
"Uhhh...I don't think I've ever done that."
Exactly. My opinion is, at least for sux (which I like because when used properly it works well, works quickly so youre not wasting time waiting for the non-depolarizer to kick in, costs pennies), your parylitic given IMMEDIATELY after the patient looses lash reflex will give you optimum intubating conditions in 45 seconds. I dont think theres any harm in ventilating during this time and additionally, but for ASA 1 and 2 patients you dont really have to ventilate. On the other hand, if someone has low FRC for whatever reason or if the intubation takes a little longer than anticipated, if you've ventilated for that 45 seconds, you've bought yourself more time before desaturation occurs.
Bottom line is if you cant ventilate after the propofol, youre gonna give the relaxant anyway. and 99.99999% of the time you can ventilate well after the relaxant. On that rare occasion you cannot, the sux will wear off quickly, usually quickly enough that aggressive mask airway management will get you through. And if not, well, you STILL have options. I've had to put ONE 14" angio in the cricothyroid membrane and jet-ventilate in NINE YEARS of practice. No need to modify procedures for something that happens so rarely as long as you can handle it when it does happen.
My take, in conclusion, is to give the sux, usually no need to ventilate before you give it, but theres no harm in ventilating while youre waiting to intubate.
When using a nondepolarizer to intubate, if you have problems ventilating after giving the induction agent, you can switch to sux. Or, as your skill progresses, you'll probably just start giving it after loss of lid reflex. Problem is, if you run into the very-occasional difficult intubation (and many times this rare patient looks pre-op like you can intubate them), youve made it harder on yourself to fiberoptic cuz its easier when the cords are moving, or you have to bag for a while, or you have to resort to an LMA (which may not be appropriate for some cases).
The difficult intubation scenerio in private practice is more a pain in the ass than an emergency because if you have to do a surprise fiberoptic its gonna add 15 minutes or more...and in this scenerio its good to be in a MD-CRNA group because 2 clinicians are better than one.
If you are an MD doing your own cases, there may or may not be another doc available. And in this scenerio its a very lonely feeling.
In conclusion, I agree with your attending in the vast majority of cases.
This was the opinion of my Chairman at Tulane, Alan Grogono, and I've practiced how he preached. Incidentally he was a British dude who I never saw miss an intubation. Not once.
