Why not RSI on everyone?

[RussianJoo]

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Any contraindications to RSI? besides the contraindications to using Sux. Why not treat everyone like they have a full stomach?

 

[imfrankie]

Any contraindications to RSI? besides the contraindications to using Sux. Why not treat everyone like they have a full stomach?

Outside of RSI, I usually do not push relaxant until I know I can give them a manual breath.

 

[BobBarker]

If you cant give them a manual breath, do you then push succ?

 

[Arch Guillotti]

Outside of RSI, I usually do not push relaxant until I know I can give them a manual breath.

Old habits die hard.

I think this is dogma.

 

[imfrankie]

Old habits die hard.

I think this is dogma.

Do you routinely relax people (outside the RSI world) before you know you can ventilate them? I've known people that do, but not me. (The cardiac guys work the panc in like it's a chaser for the sedative) I like one bag squeeze to feel the "I-can-ventilate" compliance.

Different situation if I know the person has been intubated, or it's a RSI.

 

[Arch Guillotti]

Do you routinely relax people (outside the RSI world) before you know you can ventilate them? I've known people that do, but not me. (The cardiac guys work the panc in like it's a chaser for the sedative) I like one bag squeeze to feel the "I-can-ventilate" compliance.

Different situation if I know the person has been intubated, or it's a RSI.

All the time. Try it and I think you will be surprised and maybe wonder why you have been doing the test ventilation all these years.

 

[imfrankie]

Old habits die hard.

I think this is dogma.

It's old school and strikes me as a good habit. Along with checking you can give positive pressure ventilation, and insuring you've got suction immediately before pushing induction meds (Pay attention residents)

 

[Arch Guillotti]

It's old school and strikes me as a good habit. Along with checking you can give positive pressure ventilation, and insuring you've got suction immediately before pushing induction meds (Pay attention residents)

old school = dogma

😀

 

[imfrankie]

All the time. Try it and I think you will be surprised and maybe wonder why you have been doing the test ventilation all these years.

No disrespect intended, but it's not good mojo in my book. I know why I've been doing the test ventilation all these years--I don't want that one case in a career I wish I had, but didn't.

 

[Bertelman]

(The cardiac guys work the panc in like it's a chaser for the sedative)

Isn't it?

Chasing fentanyl with LR isn't going to get the tube in any faster.

 

[BobBarker]

If you can't ventilate, you put in an oral airway/nasal airway, still cant vent do you try to wake up from fent, versed, prop or push succ and tube 'em?

 

[imfrankie]

Isn't it?

Chasing fentanyl with LR isn't going to get the tube in any faster.

Do you adjust the surgeon's seat in the airplane too?

 

[imfrankie]

If you can't ventilate, you put in an oral airway/nasal airway, still cant vent do you try to wake up from fent, versed, prop or push succ and tube 'em?

Be careful Bob. Be very careful. Don't be lured in to the trap.

 

[Bertelman]

Do you adjust the surgeon's seat in the airplane too?

I'm not really sure I understand where you're going with this.

 

[imfrankie]

I'm not really sure I understand where you're going with this.

Just yanking your chain. My point is, I love getting the tube in quick as anyone.
I don't let it--I try not to let it--predicate my practice, however.

Now as far as the word dogma goes--that connotes mistaken belief in my mind.
So I would say, old school might be a better choice.

Naturally, giving the relaxant will make ventilation easier most all the time. Sure. And you can give the sux a little bit before the pentothal/propofol too because of the onset times and that moves things along.

What about preoxygenating? Is that dogma too?

Don't fall into the bear trap BobBarker.

 

[BobBarker]

As a med student, I did a rotation at UTSW and their "airway guru" was of the belief that their was no pt that couldnt be ventilated if fully relaxed. I don't have enough experience to say one way or the other.

 

[imfrankie]

If you can't ventilate, you put in an oral airway/nasal airway, still cant vent do you try to wake up from fent, versed, prop or push succ and tube 'em?

I pop in an LMA in that rare case. I want to know I can ventilate or intubate. IF instead of an LMA I take a quick look and can see heavenly structures, then paralytic is okay.

Fortunately this is rare. Usually you can give a little breath, or can with some jaw thrust or an axillary device, then move on. If you've preoxygenated generously you've got minutes (but not enough time for an ED90 dose of sux to wear off).

Attendings and surgeons will rush you Bob. They got production pressures. You have production pressures too, but you are the airway expert. Be the expert, do the right thing and take care of the patient first.

 

[imfrankie]

As a med student, I did a rotation at UTSW and their "airway guru" was of the belief that their was no pt that couldnt be ventilated if fully relaxed. I don't have enough experience to say one way or the other.

"Belief" is the key word.

Does this guru believe in "can not ventilate, can not intubate?" Let me tell you Bob, there are other gurus who do believe in it. So not only will your patient have a problem, you will have a problem if you ever see one of these gurus in court.

Get the audiodigest by Benumof on The Difficult Airway. He's an old dogma type guru. Hedge your patient's bet. Study both sides of the argument.

 

[nap$ter]

No disrespect intended, but it's not good mojo in my book. I know why I've been doing the test ventilation all these years--I don't want that one case in a career I wish I had, but didn't.

this is falling by the wayside, as dogma should.

test ventilation is a waste of time and potentially harmful.

induction, relaxation, tube.

 

[fakin' the funk]

Any contraindications to RSI? besides the contraindications to using Sux. Why not treat everyone like they have a full stomach?

Some possible, but maybe not good, reasons:
a) the cricoid component can make your view worse
b) giving succ is its own can of worms
c) giving RSI dose of roc is its own can of worms
d) giving succ, then nondepol, is annoying
e) doing RSI is making a commitment that you can ventilate the pt
f) probably don't have a ton of opioid on board to minimize the stimulation

I ask you, RJ: why give paralytic at all?

 

[epidural man]

Old habits die hard.

I think this is dogma.

I think there is recent data to demonstrate this dogma. I wish I had the reference, but essentially, Benumof's teaching of trying to ventilate first is quickly going away.

I still do check by the way because as you say, old habits die hard. Some day I'll have the BALLS to believe the data and do it right and just paralyze the damn patient.

By the way, preoxygenation to 90+ end tidal O2 may be dogma to. I know for sure that extubating on 100% is probably harmful because of the absorption atelectasis that happens. 80% is probably much better.

 

[Bertelman]

Just yanking your chain. My point is, I love getting the tube in quick as anyone.
I don't let it--I try not to let it--predicate my practice, however.

I think you are mistakenly under the impression I am working quicker for the surgeon. That's just wrong.

I do it so I get home faster.

 

[silvester78]

Any contraindications to RSI? besides the contraindications to using Sux. Why not treat everyone like they have a full stomach?

RSI reduces chances to regurgitate and aspirate. beside this it has many problems mainly to cardiovascular stability and apnea toleration.
predetermined, pushed doses (and not titrated) of hypnotics and narcotics can cause great haemodynamic instability. Most times hypotension or insufficient doses cause tachycardia and hypertension during airway manipulation.
Also non ventilation period drops saturation very quickly especially to patients with some respiratory problems.

 

[Planktonmd]

Old habits die hard.

I think this is dogma.

Agree! Strongly!

 

[imfrankie]

Agree! Strongly!

Show me the data, or references, I will be delighted to be disabused by current expert opinion.

 

[imfrankie]

this is falling by the wayside, as dogma should.

test ventilation is a waste of time and potentially harmful.

induction, relaxation, tube.

Show me how it is falling by the wayside please. "Potentially" harmful--what isn't.

 

[RussianJoo]

Some possible, but maybe not good, reasons:
a) the cricoid component can make your view worse
b) giving succ is its own can of worms
c) giving RSI dose of roc is its own can of worms
d) giving succ, then nondepol, is annoying
e) doing RSI is making a commitment that you can ventilate the pt
f) probably don't have a ton of opioid on board to minimize the stimulation

I ask you, RJ: why give paralytic at all?

You don't need to give the paralytic it just makes things easier. I've intubated a few pt's on the floors, the ICU and down in the ER without any paralytics.

I agree with the fact that cricoid can sometimes make your view worse, I've had that a few times.

But checking if you can ventilate the pt after pushing propofol and fentanyl is a waste of time, at least that's what I am being taught by many attendings. Propofol wears off fairly quickly too, I wouldn't want my pt to get paralyzed as the propofol is wearing off.

 

[RussianJoo]

RSI reduces chances to regurgitate and aspirate. beside this it has many problems mainly to cardiovascular stability and apnea toleration.
predetermined, pushed doses (and not titrated) of hypnotics and narcotics can cause great haemodynamic instability. Most times hypotension or insufficient doses cause tachycardia and hypertension during airway manipulation.
Also non ventilation period drops saturation very quickly especially to patients with some respiratory problems.

Huh?? I don't mean to be rude but are you even in med school? If you give appropriate doses of meds you can easily intubate without getting hypotension or tachycardia, I've done it. And you totally missed the point of my original question.

 

[dbiddy808]

I never ventilate before intubating and I don't use cricoid.

 

[RussianJoo]

I pop in an LMA in that rare case. I want to know I can ventilate or intubate. IF instead of an LMA I take a quick look and can see heavenly structures, then paralytic is okay.

Fortunately this is rare. Usually you can give a little breath, or can with some jaw thrust or an axillary device, then move on. If you've preoxygenated generously you've got minutes (but not enough time for an ED90 dose of sux to wear off).

Attendings and surgeons will rush you Bob. They got production pressures. You have production pressures too, but you are the airway expert. Be the expert, do the right thing and take care of the patient first.

So if you can't ventilate a patient you push more propofol and stick in an LMA? do you have an open lubed up LMA for every case you start? Paralytics make ventilation easier, many people who can't ventilate just push succ and then ventilate. So why waste the time and just push it all at once.


One attending at my hospital uses propofol sparingly but pushes 250mcgs of fentanyl and washes it all down with succ, and then take a look.

 

[RussianJoo]

So it seems like RSI or at least pushing induction drugs in rapid sequence is what most people do around here.

 

[doctadre]

I pop in an LMA in that rare case. I want to know I can ventilate or intubate. IF instead of an LMA I take a quick look and can see heavenly structures, then paralytic is okay.

what if you can't pop the LMA in? and when you take a quick look, you can't see cords? then what do you do?

i think the whole issue of "test ventilation" comes down this rare but serious situation. the one where you have an unrelaxed patient who you can't ventilate/intubate/LMA. in this situation, do you sit back passively and pray that the induction doses of versed/fentanyl/propofol etc wear off and that the patient is able to wake up spontaneously? or do you take action and give relaxant which improves your chances of ventilating/intubating/LMA?

personally, i push the relaxant.

 

[vector2]

what if you can't pop the LMA in? and when you take a quick look, you can't see cords? then what do you do?

glidescope 'em?

 

[jetproppilot]

No disrespect intended, but it's not good mojo in my book. I know why I've been doing the test ventilation all these years--I don't want that one case in a career I wish I had, but didn't.

Arch is right. You are practicing

Anesthesia

DOGMA.


Concerning succinylcholine utilization, there is no need to make sure you can ventilate after induction agent hits.

Quite honestly you are

WASTING TIME

if you hesitate pushing the sux

as soon as you realize the patient is asleep.

I've posted about this philosophy many times.

In contrast to the perpetuated anesthesia dogma concerning this subject,

"OMG!

(MAJOR ANXIETY)

Ya gotta be able to see at least ONE breath before you paralyze, RIGHT?"

Uhhhhhhhhhhhhhhhhh....

No.

I WAS TAUGHT DIFFERENT AS A RESIDENT:

Push the sux as soon as the pt is asleep.

NO NEED TO "CHECK VENTILATION.".😱

Yep.

Turns out

MY CHAIRMAN WHO TAUGHT THIS PHILOSOPHY

WAS RIGHT.

You guys have

FALLEN ONCE AGAIN INTO A FAIRY TALE

If it wasn't

SHARK WEEK

I'd proliferate.

Love watching Great Whites so

buh bye. We'll talk about this later.

 

[Arch Guillotti]

As a med student, I did a rotation at UTSW and their "airway guru" was of the belief that their was no pt that couldnt be ventilated if fully relaxed. I don't have enough experience to say one way or the other.

I think that guy is a fool.

Anyone who has been in a true "can't intubate, can't ventilate" scenario will corroborate this.

 

[imfrankie]

what if you can't pop the LMA in? and when you take a quick look, you can't see cords? then what do you do?

i think the whole issue of "test ventilation" comes down this rare but serious situation. the one where you have an unrelaxed patient who you can't ventilate/intubate/LMA. in this situation, do you sit back passively and pray that the induction doses of versed/fentanyl/propofol etc wear off and that the patient is able to wake up spontaneously? or do you take action and give relaxant which improves your chances of ventilating/intubating/LMA?

personally, i push the relaxant.

The patient doesn't need to wake up, they need to start breathing.

 

[Idiopathic]

ill humbly disagree, for this reason. mask ventilation can save someones life, its a skill that should be practiced as often as possible, in the controlled setting of the operating room, because you may be called upon to use it in the bowels of the hospital, the parking garage, the helipad, the roadside...

if you work with trainees, then you mask ventilate. pure and simple.

i also think there is value in knowing the patient was an easy/difficult mask when you plan to extubate deep, or you are concerned about laryngospasm, etc. (after ENT surgery).

saving 30 seconds by not checking mask-ability is not 30 seconds you will be proud to have saved at the end of the day, so do yourselves a favor, go through the motions, check the mask, and then do whatever you want.

 

[Idiopathic]

The patient doesn't need to wake up, they need to start breathing.

there are ways to induce a patient where they keep breathing. 100mg of propofol wont make everyone apneic, but its enough to be able to mask.

 

[imfrankie]

So if you can't ventilate a patient you push more propofol and stick in an LMA? do you have an open lubed up LMA for every case you start? Paralytics make ventilation easier, many people who can't ventilate just push succ and then ventilate. So why waste the time and just push it all at once.


One attending at my hospital uses propofol sparingly but pushes 250mcgs of fentanyl and washes it all down with succ, and then take a look.

That's nice. How special to be aware loaded up on sux.

No I don't have a lubed up LMA ready. But I know where an LMA is.

Finally, this doesn't really apply in the sux case, because I rarely use sux except for rapid sequence and in that event don't check a breath as I explained. Mostly this is prior to pushing the vec/roc/panc.

 

[imfrankie]

I never ventilate before intubating and I don't use cricoid.

Only time I cricoid is to adjust my view in DL.

 

[imfrankie]

You don't need to give the paralytic it just makes things easier. I've intubated a few pt's on the floors, the ICU and down in the ER without any paralytics.

I agree with the fact that cricoid can sometimes make your view worse, I've had that a few times.

But checking if you can ventilate the pt after pushing propofol and fentanyl is a waste of time, at least that's what I am being taught by many attendings. Propofol wears off fairly quickly too, I wouldn't want my pt to get paralyzed as the propofol is wearing off.

It takes virtually no time. I'm not talking about sitting and waiting after the propofol goes in, I'm talking about as I'm working it in and when the patient becomes apneic I check to make sure I can assist a breath then paralyze. It takes no time.

 

[imfrankie]

there are ways to induce a patient where they keep breathing. 100mg of propofol wont make everyone apneic, but its enough to be able to mask.

Exactly

 

[lord_jeebus]

So it seems like RSI or at least pushing induction drugs in rapid sequence is what most people do around here.

Regardless of the significance of the test breath, I think that if a RSI is not indicated, it makes sense to confirm that your patient is unresponsive before paralyzing them.

 

[jetproppilot]

ill humbly disagree, for this reason. mask ventilation can save someones life, its a skill that should be practiced as often as possible, in the controlled setting of the operating room, because you may be called upon to use it in the bowels of the hospital, the parking garage, the helipad, the roadside...

if you work with trainees, then you mask ventilate. pure and simple.

i also think there is value in knowing the patient was an easy/difficult mask when you plan to extubate deep, or you are concerned about laryngospasm, etc. (after ENT surgery).

saving 30 seconds by not checking mask-ability is not 30 seconds you will be proud to have saved at the end of the day, so do yourselves a favor, go through the motions, check the mask, and then do whatever you want.

Big assumption man.

Mask Ventilation.

You are assuming

If I can mask 'em now,

I CAN MASK'EM LATER.

And , Uhhhhhhhhhhhhhhhhh, when I say

Later,

I'm referring to like

THIRTY SECONDS LATER.

There's no guarantees in this business man.

THINGS CHANGE SECOND TO SECOND.

Assuring ventilation on induction after administration of induction agent but before administration of a paralyzing agent is preached to our residents as some kind of

HOLY GRAIL TO AVOIDING TRAGEDY

when in fact, concerning succinylcholine administration,

The complete opposite is true.

Induce the patient.

Give an appropriate amount of sux

as soon as possible.

Doing this will give you the conditions you need for successful intubation AS SOON AS POSSIBLE.

The patient's

FRC

is your friend...problem is you don't know how long your friendship will last...

Giving sux early allows you the

BEST SHOT with the

MOST TIME.

Dosed appropriately it'll wear off in time for you to save you and your patient, if the situation comes to that.

 

[Consigliere]

Big assumption man.

You are assuming

If I can mask 'em now,

I CAN MASK'EM LATER.

And , Uhhhhhhhhhhhhhhhhh, when I say

Later,

I'm referring to like

THIRTY SECONDS LATER.

There's no guarantees in this business man.

THINGS CHANGE SECOND TO SECOND.

Assuring ventilation on induction after administration of induction agent but before administration of a paralyzing agent is preached to our residents as some kind of

HOLY GRAIL TO AVOIDING TRAGEDY

when in fact, concerning succinylcholine administration,

The complete opposite is true.

Induce the patient.

Give an appropriate amount of sux

as soon as possible.

Doing this will give you the conditions you need for successful intubation AS SOON AS POSSIBLE.

The patient's

FRC

is your friend...trouble is you don't know how long your friendship will last...

Giving sux early allows you the

BEST SHOT with the

MOST TIME.

Dosed appropriately it'll wear off in time for you to save you and your patient, if the situation comes to that.

Could someone please print this out, laminate it and distribute it to every residency program in the USA and make the residents wear it like their name badge? Thanks in advance.

 

[Idiopathic]

you have become a caricature of yourself. congratulations.

 

[Hamhock]

Dosed appropriately it'll wear off in time for you to save you and your patient, if the situation comes to that.

I have never understood this thinking.

This is often a big argument in the world of EM; and I am firmly on the side of not waiting for sux to "wear off" when I can't intubate and can't ventilate.

Perhaps this is because >75% of the people I intubate need and airway (not elective)...so, if they need an airway before RSI, they will only need an airway all the more after RSI/sux wears off.

Maybe I am dosing too much sux...but I can't imagine waiting for it to "wear off" with hypoxic injury pending...if all options have failed (very rare) and it really is a case of can't ventilate/can't intubate, I say it's time to stop playing games and start cutting.

...but I work in a different atmosphere...

HH

 

[nap$ter]

Show me how it is falling by the wayside please. "Potentially" harmful--what isn't.

i just graduated from a large residency program - no one there "test ventilates" - except for a handful of dinosaurs. during my residency i rotated at a large private hospital - no one there "test ventilates" - they have no academic dinosaurs. at my current job no one, and i mean no one, "test ventilates". look around you, man, you are in the minority for a reason. this is how it has fallen by the wayside. ask around, show yourself.

no offense, but your second bit of wisdom is asinine.

i am having my hair rubbed by a nurse in the pacu as i type this - it feels very nice, in an awkward sort of way.

please see post #44.

 

[fakin' the funk]

Propofol wears off fairly quickly too, I wouldn't want my pt to get paralyzed as the propofol is wearing off.

😕

Define "fairly quickly"

Even if your patient has magically redistributed and metabolized all the propofol in their body in <5 minutes, I'm willing to bet you're gonna hit 'em with a dose of volatile anesthetic approaching 1 MAC immediately thereafter and ensure profound amnesia.

And just for kicks,
HERE IS SOME RANDOM LARGE FONT FOR NO REASON

 

[Bertelman]

Huh?? I don't mean to be rude but are you even in med school? If you give appropriate doses of meds you can easily intubate without getting hypotension or tachycardia, I've done it. And you totally missed the point of my original question.

So, what is the "appropriate dose" of propofol? Do you know the magic dose for all patients? Just enough to get them off to sleep, but not to much hypotension?

His point was accurate- in an RSI, you push drugs too quickly to titrate. They (generally) get the whole syringe of propofol, followed quickly by the sux. If you're thumbing in the propofol to monitor effect, then it's not really an RSI. Get a few more true RSIs under your belt- you know, the 85 y/o SBO that's been vomiting for a couple days, not the 17 y/o acute appy. You'll see some very real hypotension with induction, unless you pretreat.