Why not RSI on everyone?

[imfrankie]

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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.

No offense to you, but you are a rank greenie, and I assure you I am no dinosaur. However I did my residency before the 80 hour rule (at a top three place) when the dinosaurs were sleeping at home at night and residents had to be independent. (No extra hands sonny. No CRNAs. No attending bailing you out.) Do ten thousand cases all by yourself then you can deride the people who were foundational in this field like Jon Benumof. It's called The ASA Difficult Airway Algorithm. Mind your manners.

 

[imfrankie]

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.

"they generally get the whole syringe of propofol" What??? C'mon, man.

 

[silvester78]

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.

Then your point was of giving muscle relaxant without verifying ventilation. This is totally different and is not RSI.
RSI implies predetermined (http://ceaccp.oxfordjournals.org/content/5/2/45.full), not titrated doses of induction drugs pushed as a bolus, followed imediately by the muscle relaxant (some say that you can give first muscle relaxant i, followed by sleep: "timing principle" http://www.anesthesia-analgesia.org/content/86/5/1137.short).
M & M says in page 288 that RSI is usually associated with hypertension and tachycardia. Probably neither he knows the appropriate dose of induction agent and the patient's catecholamines went up.

 

[nap$ter]

No offense to you, but you are a rank greenie, and I assure you I am no dinosaur. However I did my residency before the 80 hour rule (at a top three place) when the dinosaurs were sleeping at home at night and residents had to be independent. (No extra hands sonny. No CRNAs. No attending bailing you out.) Do ten thousand cases all by yourself then you can deride the people who were foundational in this field like Jon Benumof. It's called The ASA Difficult Airway Algorithm. Mind your manners.

none taken. but - we're not talking about the ASA difficult airway algorithm, and even if we were, "test ventilation" is NOWHERE TO BE FOUND on the algorithm. we are talking about routine cases - taking the time to give a breath after induction before giving the paralytic, which is dogmatic, and has been a waste of your time in all ten thousand of your cases. imperfect practice makes imperfect. it is a misleading bit of information.

i do not need to do ten thousand cases to disagree with your practice, sir. it is not productive to suggest that greenies (and i have around 2500 cases under my slim green belt) need practice for years before forming their own practice habits and contributing to scientific (not anecdotal) discussion in our field.

this has become a rather silly discussion. puff puff give or give puff puff. let's move on.

please see post #44

 

[Bertelman]

"they generally get the whole syringe of propofol" What??? C'mon, man.

C'mon what? What part of my practice are you questioning?

 

[epidural man]

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

Criciod makes your view worse by the way.

Pressure on the Thyroid cartilage can really improve your view.

 

[dhb]

Here's how i see it: if you are test ventilating then you are unsure you will be able to ventilate or intubate (since if you push the relaxant you are confident that is the event you can't ventilate you will be able to intubate).
If you have this uncertainty then you are probably not using the right induction regime and should instead be using a technique that does not abolish spontaneous ventilation: inhalation / awake.

my 2

 

[Idiopathic]

Here's how i see it: if you are test ventilating then you are unsure you will be able to ventilate or intubate (since if you push the relaxant you are confident that is the event you can't ventilate you will be able to intubate).
If you have this uncertainty then you are probably not using the right induction regime and should instead be using a technique that does not abolish spontaneous ventilation: inhalation / awake.

my 2

the key word is confirmation, not test.

 

[proman]

Since working with residents (a lot of CA1s) I've taken to giving the paralytic quickly (BTW the roc is painful). That way I will have optimal intubating conditions by the time it's my turn to take a look or mask. I've also had a patient become un-maskable after paralytic (sux in that case), so masking before means very little.

 

[pgg]

I've also had a patient become un-maskable after paralytic (sux in that case), so masking before means very little.

Anything unusual about that patient?

In the back of my head I'm aware in a theoretical sense that relaxant may abolish my previously established ability to ventilate a patient. Mostly though my impression is that this is a risk for people with abnormal anatomy, eg tumors, congenital anomolies, maybe tracheomalacia, that sort of thing.

I generally don't have that fear in 'normal' patients. So I'm just curious as to whether or not your case was in a patient with some kind of anatomic issue going on.

 

[jetproppilot]

😕

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

Dude it cracks me up how much my writing style irritates you!!

Seriously entertaining. Thanks for the laugh

 

[dhb]

the key word is confirmation, not test.

it still means you are doubting

 

[jetproppilot]

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

Dude,

Attempting intubation is mostly successful. Sometimes not, however, which demands a different course of action.

Succinylcholine when dosed appropriately wears off in a fairly short period. Actually even when dosed inappropriately it wears off relatively quickly, compared to any non depolarizing neuromuscular blocker, which allows the patient to begin breathing again, which makes a fiberoptic intubation easier, which would be a good option if intubation was not successful, or cancel the case and come back another day, or whatever.

If you pound in 50 mg rocuronium, or 20mg cisatracurium, you've essentially removed your safety net if you can't secure a tube....safety net being the patient will start breathing again fairly quickly when using sux....with ROC or cis plan on bagging for a minimum of thirty minutes...maybe a little less with cis since it's such a great, predictable, easily reversed drug....maybe a little more with roc since it can be somewhat unpredictable and hard to reverse sometimes.

I'm struggling with the part of your post that said "hard for me to think of sitting back and waiting for the sux to wear off..hypoxic injury..." or something like that...

No man. If we can't intubate, we're still gonna be masking the patient and if God forbid we can't MASK'EM, well, we've got other options too.

At no point during an unsuccessful intubation do we just quit, stand back and say

"AHhHhHHHh CRAP! I can't intubate this dude! Oh well. I'm gonna go take a whiz...by the time I get back the sux will be worn off."

 

[Idiopathic]

it still means you are doubting

no, you are wrong. having a plan with possible outs for trouble scenarios does not mean that you expect those things to happen. as i tell every patient when discussing catastrophic complications: "things fall from the sky sometimes, we cant predict when they will happen, all we can do is be ready for them"

i happen to believe that if we can easily mask ventilate a patient then i can let the junior resident take 3 looks, try an alternative technique, etc. if its very difficult to mask then im taking the second look, at least until they get further along. that has nothing to do with DOUBT.

 

[Idiopathic]

another thing about sux in the elective, stable operative airway is it limits you to maybe two attempts before you have cords closing and are having to redose it, etc. id much rather give a priming dose of roc when we hit the door, induce, gove some more roc and wait 90 seconds, get some volatile on board, deepen the anesthetic.

again, this is for teaching. my own cases, id probably do exactly what jet does. but if you say that you trained somewhere that nobody mask ventilates, well id just say that doesnt do anyone any good, certainly not the trainees.

 

[proman]

Anything unusual about that patient?

In the back of my head I'm aware in a theoretical sense that relaxant may abolish my previously established ability to ventilate a patient. Mostly though my impression is that this is a risk for people with abnormal anatomy, eg tumors, congenital anomolies, maybe tracheomalacia, that sort of thing.

I generally don't have that fear in 'normal' patients. So I'm just curious as to whether or not your case was in a patient with some kind of anatomic issue going on.

It was a mistake. Call case, neurorads for aneurysm coiling, basement of hospital on a Sunday. I was the CA2, the CA3 did the airway exam brought her down in a hurry and rushed to induce. She had predictors of difficult mask and intubation. No neck, obese, a lot of redundant tissues BMI was big+. She was NPO so no RSI but used sux, lost the ability to ventilate after the sux. Placed LMA, could ventilate. Called for fiberoptic cart (our standard backup method is LMA, FOB/Aintree). While waiting the attending says "since we can ventilate let's try to DL and see". Nothing. Place LMA back in and can't ventilate. Ends up coding from the hypoxia, we get her back when ENT intubated with a Hollinger. Skip the coiling, gets aneurysm clipped next day (neuro exam was fairly intact after the code). Obviously has brain injury after clipping.

2 weeks later is still intubated, the neuro ICU had kept postponing the trach. The nurses turn her to change the bedsheet and extubate her. So now she's an emergency trach in the OR (but was spontaneously ventilating and maintaining). Guess who had the only open room.

We made several decisions that I wouldn't not make again, extremely educational for me.

 

[imfrankie]

none taken. but - we're not talking about the ASA difficult airway algorithm, and even if we were, "test ventilation" is NOWHERE TO BE FOUND on the algorithm. we are talking about routine cases - taking the time to give a breath after induction before giving the paralytic, which is dogmatic, and has been a waste of your time in all ten thousand of your cases. imperfect practice makes imperfect. it is a misleading bit of information.

i do not need to do ten thousand cases to disagree with your practice, sir. it is not productive to suggest that greenies (and i have around 2500 cases under my slim green belt) need practice for years before forming their own practice habits and contributing to scientific (not anecdotal) discussion in our field.

this has become a rather silly discussion. puff puff give or give puff puff. let's move on.

please see post #44

I believe you were the one offering anecdotes rather than science to support your assertion that the "dogma" no longer had merit. And I certainly don't believe you are in a position to assert what was a waste of my time. How's that for asinine?

 

[imfrankie]

It was a mistake. Call case, neurorads for aneurysm coiling, basement of hospital on a Sunday. I was the CA2, the CA3 did the airway exam brought her down in a hurry and rushed to induce. She had predictors of difficult mask and intubation. No neck, obese, a lot of redundant tissues BMI was big+. She was NPO so no RSI but used sux, lost the ability to ventilate after the sux. Placed LMA, could ventilate. Called for fiberoptic cart (our standard backup method is LMA, FOB/Aintree). While waiting the attending says "since we can ventilate let's try to DL and see". Nothing. Place LMA back in and can't ventilate. Ends up coding from the hypoxia, we get her back when ENT intubated with a Hollinger. Skip the coiling, gets aneurysm clipped next day (neuro exam was fairly intact after the code). Obviously has brain injury after clipping.

2 weeks later is still intubated, the neuro ICU had kept postponing the trach. The nurses turn her to change the bedsheet and extubate her. So now she's an emergency trach in the OR (but was spontaneously ventilating and maintaining). Guess who had the only open room.

We made several decisions that I wouldn't not make again, extremely educational for me.

Educational case for all of us. Thanks for sharing.

 

[imfrankie]

Criciod makes your view worse by the way.

Pressure on the Thyroid cartilage can really improve your view.

'preciate the pedantry, thank you

 

[imfrankie]

none taken. but - we're not talking about the ASA difficult airway algorithm, and even if we were, "test ventilation" is NOWHERE TO BE FOUND on the algorithm. we are talking about routine cases - taking the time to give a breath after induction before giving the paralytic, which is dogmatic, and has been a waste of your time in all ten thousand of your cases. imperfect practice makes imperfect. it is a misleading bit of information.

i do not need to do ten thousand cases to disagree with your practice, sir. it is not productive to suggest that greenies (and i have around 2500 cases under my slim green belt) need practice for years before forming their own practice habits and contributing to scientific (not anecdotal) discussion in our field.

this has become a rather silly discussion. puff puff give or give puff puff. let's move on.

please see post #44

move on? the resident is asking about RSIing everybody. Doesn't seem silly to me.

 

[sevoflurane]

I've always found this topic an interesting one amongst an anesthesia crowd.

Because anesthesia is about.....

being safe....

Paralyzing could get you in trouble (or not... as most of the time it makes ventilation easier)

AND

Not Paralyzing can take longer (perhaps unnecessarily) and may make things slightly more cumbersome when dealing with the difficult vent/intub scenario.

Both sides have their merits. At least I tend to think so as sometimes there may be some truth in dogma (maybe someone has seen something I haven't...yet).

I take it patient by patient. But >98% of the time, I give sux (or roc) and intubate without checking for ventilation. + often you don't have that luxury as the patient may need a definitive AW. I'm def. not checking mask ventilation on the 25 y/o 65 kg. appy (that is just silly).

Certain patient conditions may guide me into checking for mask ventilation. This is a rare event in my daily practice. But I always reserve the option to employ this technique if my spider sense goes off.

The best of both worlds is when you are successful in timing your intubating dose for prop and sux to culminate at the same time (with regards to resumption of spontaneous ventilation).

 

[Arch Guillotti]

I take it patient by patient. But >98% of the time, I give sux (or roc) and intubate without checking for ventilation. + often you don’t have that luxury as the patient may need a definitive AW. On the other hand... I’m not checking mask ventilation of the 25 y/o 65 kg. appy (that is just silly).

Certain patient conditions may guide me into checking for mask ventilation. This is a rare event in my daily practice. But I always reserve the option to employ this technique if my spider sense goes off.

My approach exactly.

I know I have stated that the test ventilation is nonsense, but there is a small subset of patients that i do it on very rarely.

You are a fool if you are test ventilating a healthy skinny person🙂.

 

[imfrankie]

My approach exactly.

I know I have stated that the test ventilation is nonsense, but there is a small subset of patients that i do it on very rarely.

You are a fool if you are test ventilating a healthy skinny person🙂.

One of the most difficult intubations I ever had was a healthy skinny little nun.
Never forget it.

I don't know, it just doesn't seem any time spent for me. I do my own cases and push drug with a mask on my patient. They go apneic I give a breath, next syringe.

 

[imfrankie]

My approach exactly.

I know I have stated that the test ventilation is nonsense, but there is a small subset of patients that i do it on very rarely.

You are a fool if you are test ventilating a healthy skinny person🙂.

So I'm a fool. Pull your pants up.

 

[jetproppilot]

I've always found this topic an interesting one amongst an anesthesia crowd.

Because anesthesia is about.....

being safe....

Paralyzing could get you in trouble (or not... as most of the time it makes ventilation easier)

AND

Not Paralyzing can take longer (perhaps unnecessarily) and may make things slightly more cumbersome when dealing with the difficult vent/intub scenario.

Both sides have their merits. At least I tend to think so as sometimes there may be some truth in dogma (maybe someone has seen something I haven't...yet).

I take it patient by patient. But >98% of the time, I give sux (or roc) and intubate without checking for ventilation. + often you don't have that luxury as the patient may need a definitive AW. I'm def. not checking mask ventilation on the 25 y/o 65 kg. appy (that is just silly).

Certain patient conditions may guide me into checking for mask ventilation. This is a rare event in my daily practice. But I always reserve the option to employ this technique if my spider sense goes off.

The best of both worlds is when you are successful in timing your intubating dose for prop and sux to culminate at the same time (with regards to resumption of spontaneous ventilation).

So let's say your spider sense goes off, you pre oxygenate,nice & careful, obese maybe so a little reverse t-berg, you're worried about whatever..

you give your induction dose of propofol.

You have difficulty mask ventilating.

Whatcha gonna do?

I know what the books say to do.

I wanna know what you would do.

Assume this scenario does not involve the aside corollary below.

(aside: there does exist a cuppla scenarios where I would not immediately relax the pt. They are very specific scenarios. We all know what said specific scenarios are.)

 

[Idiopathic]

My approach exactly.

I know I have stated that the test ventilation is nonsense, but there is a small subset of patients that i do it on very rarely.

You are a fool if you are test ventilating a healthy skinny person🙂.

fool: def A person who acts unwisely or imprudently; a silly person: "what a fool I was to do this".

so does that describe more the person who takes ten seconds to confirm mask ventilation or the person who doesnt?

 

[ssmallz]

Pushing relaxant allows you to get to intubating conditions quicker preserving the precious oxygen in your FRC. If you fumble around and waste time by pushing prop, trying to vent, failing to vent, then futzing around w/an OA you might burning up precious time. We all know that relaxants make ventilation easier. I don't care if I can't intubate a pt after they are paralyzed, I care about ventilating them. If you don't think you will be able to mask ventilate a pt, you probably shouldn't be giving them a slug of induction agent and trying to ventilate w/out muscle relaxant. These types of pts that deserve a mask induction w/SV or an awake technique of some sort. Gotta agree w/Jet on this one, it's all about the FRC and being able to establish ventilation ASAP.

 

[dhb]

If you don't think you will be able to mask ventilate a pt, you probably shouldn't be giving them a slug of induction agent and trying to ventilate w/out muscle relaxant. These types of pts that deserve a mask induction w/SV or an awake technique of some sort.

What i said...

 

[Idiopathic]

What i said...

dude, seriously, we arent talking about the anticipated difficult patient, that one is a no brainer. im talking about EVERYONE WHO DOESNT HAVE A REASON TO BE AN RSI. i.e. trauma, full stomach, pregnant, achalasia, bad hiatal hernia, and most super fatties (i.e. lap bands). all other patients get confirmation of mask ventilation because its a teaching exercise - almost all get 2 minutes of bagging and volatile anesthetic along the way. in no way am i a dinosaur.

you cant really argue that your way is better, all you can say is that it might be as good, but id wager that over a career, you are more likely to get in trouble pushing everything at once rather than the way i do it

 

[Arcan57]

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

Think more about the patients you are intubating for airway protection (usually TBI patients). Most of the patients scheduled for surgery are going to have at least decent pulmonary function/airway prior to induction, so waiting for the sux to wear off is a valid strategy. Also, from an EM perspective, the few airways I've seen go completely south have universally ignored optimizied bag-valve mask ventilation as a temporizing measure. Delaying a needed cric is all sorts of bad, but jumping to a cric solely because you can't get the patient intubated is also wrong.

It sucks to bag a patient for 20-30 minutes waiting for anesthesia or ENT to get to the ED, but it sucks even more to have the patient wind up with severe anoxic brain injury in the ICU because the crich went badly.

 

[dhb]

all other patients get confirmation of mask ventilation because its a teaching exercise
in no way am i a dinosaur.

Well you're the only one talking about a teaching exercise
I didn't call you a dinosaur

you cant really argue that your way is better, all you can say is that it might be as good

that's what i'm saying

 

[rsgillmd]

One of the most difficult intubations I ever had was a healthy skinny little nun.
Never forget it.

I don't know, it just doesn't seem any time spent for me. I do my own cases and push drug with a mask on my patient. They go apneic I give a breath, next syringe.

imfrankie voiced my thoughts -- if you decide to ventilate before pushing a non-depolarizing muscle relaxant, you really aren't wasting a lot of time. Lets say you have a bunch of bread and butter cases and a fast surgeon with fast turnover, and get 12 cases done in a day. What do you lose, 2 minutes? Big deal.

If a patient is a difficult mask ventilation before relaxant, in my book that is one good reason to consider not doing a deep extubation.

Forgetting about "test ventilation" and and getting back to what I think Russianjoo's original question was, I would argue not giving Sux to everyone who doesn't need it (as part of RSI) allows you to avoid sux induced myalgias (very rare in my experience), avoids wasting a drug of which there is a relative shortage right now, allows you to stay comfortable with your own mask ventilation skills, allows for teaching of residents/medical students about mask ventilation and intubation without having to worry about redosing sux (very very minor issue even with sux for non-RSI), and allows you to avoid prolonged ventilation in those rare people with abnormal/low pseudocholinesterase.

Giving titrated doses of induction agent allows you to minimize both hypotension and hypertension, as well as tachycardia as compared to dosing based on educated guesses. We usually do fine when making judgment calls in RSI, but if there is no need to rush, why do it.

Applying cricoid pressure for RSI can hinder your view, but this is a minor point because it barely takes a second to release it.

In the uncooperative/poorly cooperative patients who don't need RSI, you will probably get better denitrogenation with mask ventilation than with asking them to take an arbitrary number of breaths or watching for an arbitrary value of etO2 on the monitor (if you have that option).

Is that enough reasons not to do RSI on everyone?

 

[epidural man]

Great discussion..

By the way, this months issue of Anesthesiology has an article on video assited intubations, and then a bunch of reply's to the editor on that topic and this topic of checking ventilation, etc.

Timely really.

 

[epidural man]

Here are some really great reads on the subject in the literature. I suggest the ASA news letter, page 11. Good discussion on why you shouldn't check ventilation.

In that publication, Pennant and Joshi have noted that “the more logical and safer approach in all patients would be to administer neuromuscular blockers at the earliest opportunity without having to demonstrate face mask ventilation beforehand.”

In another publication, Salem and Ovassapian (Yes, that’s Andranik Ovassapian, the father of fiberoptic intubation and the foremost expert in the US on the difficult airway!) emphasized the same point, noting this
particular dogma is not supported by available clinical evidence.

And how about this recent publication? Found the same thing - that mask ventilation is much more succesful with NMB on board.

Finally, another editorial on the subject with good points that we should not be checking ventilation.

 

[RussianJoo]

imfrankie voiced my thoughts -- if you decide to ventilate before pushing a non-depolarizing muscle relaxant, you really aren't wasting a lot of time. Lets say you have a bunch of bread and butter cases and a fast surgeon with fast turnover, and get 12 cases done in a day. What do you lose, 2 minutes? Big deal.

If a patient is a difficult mask ventilation before relaxant, in my book that is one good reason to consider not doing a deep extubation.

Forgetting about "test ventilation" and and getting back to what I think Russianjoo's original question was, I would argue not giving Sux to everyone who doesn't need it (as part of RSI) allows you to avoid sux induced myalgias (very rare in my experience), avoids wasting a drug of which there is a relative shortage right now, allows you to stay comfortable with your own mask ventilation skills, allows for teaching of residents/medical students about mask ventilation and intubation without having to worry about redosing sux (very very minor issue even with sux for non-RSI), and allows you to avoid prolonged ventilation in those rare people with abnormal/low pseudocholinesterase.

Giving titrated doses of induction agent allows you to minimize both hypotension and hypertension, as well as tachycardia as compared to dosing based on educated guesses. We usually do fine when making judgment calls in RSI, but if there is no need to rush, why do it.

Applying cricoid pressure for RSI can hinder your view, but this is a minor point because it barely takes a second to release it.

In the uncooperative/poorly cooperative patients who don't need RSI, you will probably get better denitrogenation with mask ventilation than with asking them to take an arbitrary number of breaths or watching for an arbitrary value of etO2 on the monitor (if you have that option).

Is that enough reasons not to do RSI on everyone?

thanks, this is exactly what i was asking for.

 

[Planktonmd]

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

There is no data and you can either take what I said or not.
I am saying attempting to ventilate people before muscle relaxation is useless and many people who can't be ventialted before muscle relaxation are usually ventilatable after.
If you disagree then I have zero interest in convincing you!

 

[Hamhock]

Think more about the patients you are intubating for airway protection (usually TBI patients). Most of the patients scheduled for surgery are going to have at least decent pulmonary function/airway prior to induction, so waiting for the sux to wear off is a valid strategy. Also, from an EM perspective, the few airways I've seen go completely south have universally ignored optimizied bag-valve mask ventilation as a temporizing measure. Delaying a needed cric is all sorts of bad, but jumping to a cric solely because you can't get the patient intubated is also wrong.

It sucks to bag a patient for 20-30 minutes waiting for anesthesia or ENT to get to the ED, but it sucks even more to have the patient wind up with severe anoxic brain injury in the ICU because the crich went badly.

I think you misread my post. I would of course never cut a patient if I can bag. By definition, a patient I can bag does not meet can't intubate/can't ventilate.

HH

 

[epidural man]

There is no data and you can either take what I said or not.
I am saying attempting to ventilate people before muscle relaxation is useless and many people who can't be ventialted before muscle relaxation are usually ventilatable after.
If you disagree then I have zero interest in convincing you!

Yeah there is.

See post #84

 

[Idiopathic]

Here are some really great reads on the subject in the literature. I suggest the ASA news letter, page 11. Good discussion on why you shouldn't check ventilation.

In that publication, Pennant and Joshi have noted that “the more logical and safer approach in all patients would be to administer neuromuscular blockers at the earliest opportunity without having to demonstrate face mask ventilation beforehand.”

In another publication, Salem and Ovassapian (Yes, that’s Andranik Ovassapian, the father of fiberoptic intubation and the foremost expert in the US on the difficult airway!) emphasized the same point, noting this
particular dogma is not supported by available clinical evidence.

And how about this recent publication? Found the same thing - that mask ventilation is much more succesful with NMB on board.

Finally, another editorial on the subject with good points that we should not be checking ventilation.

Thanks for this, im going to spend some time with these tomorrow.

 

[Arch Guillotti]

One of the most difficult intubations I ever had was a healthy skinny little nun.
Never forget it.

Fair enough, everyone has one of these at some point.

What did you do?

 

[Arch Guillotti]

fool: def A person who acts unwisely or imprudently; a silly person: "what a fool I was to do this".

so does that describe more the person who takes ten seconds to confirm mask ventilation or the person who doesnt?

Did you not see the little smiley icon at the end of the post??????🙂

I meant this in jest, although I do disagree with your approach.

 

[Arch Guillotti]

imfrankie voiced my thoughts -- if you decide to ventilate before pushing a non-depolarizing muscle relaxant, you really aren't wasting a lot of time. Lets say you have a bunch of bread and butter cases and a fast surgeon with fast turnover, and get 12 cases done in a day. What do you lose, 2 minutes? Big deal.

If a patient is a difficult mask ventilation before relaxant, in my book that is one good reason to consider not doing a deep extubation.

My reason for pushing the relaxant early is not to speed things up or decrease case times.

I supervise and it really isn't worth the hassle to try and do deep extubations with the nurses so this isn't an issue. Too much hassle.

 

[Arch Guillotti]

Finally, at least something other than anecdote!

Nice job digging those up although the last link came up dead.

I have seen a couple of the references before and they make sense to me.

Here are some really great reads on the subject in the literature. I suggest the ASA news letter, page 11. Good discussion on why you shouldn't check ventilation.

In that publication, Pennant and Joshi have noted that “the more logical and safer approach in all patients would be to administer neuromuscular blockers at the earliest opportunity without having to demonstrate face mask ventilation beforehand.”

In another publication, Salem and Ovassapian (Yes, that’s Andranik Ovassapian, the father of fiberoptic intubation and the foremost expert in the US on the difficult airway!) emphasized the same point, noting this
particular dogma is not supported by available clinical evidence.

And how about this recent publication? Found the same thing - that mask ventilation is much more succesful with NMB on board.

Finally, another editorial on the subject with good points that we should not be checking ventilation.

 

[Arch Guillotti]

Thanks for this, im going to spend some time with these tomorrow.

Let us know what you think. Nobody should base their practice on a few articles but I think that some very good points are made.

 

[dhb]

Slightly off topic but i nice article i stumbled upon measuring gastric volume and pH 2h post coffee or orange juice:
http://www.ncbi.nlm.nih.gov/pubmed/3349549

 

[epidural man]

Finally, at least something other than anecdote!

Nice job digging those up although the last link came up dead.

Sorry 'bout that. Attached to this post is the editorial. I love the title.
Could 'Safe Practice' be comprimising safe practice?

That title sums up nicely a lot of the comments on this thread.

 

[sevoflurane]

Just want to send a shout out to Imfrankie for sticking to his guns and posting his thoughts on this topic. Great thread.

🙂

👍

 

[sevoflurane]

So let's say your spider sense goes off, you pre oxygenate,nice & careful, obese maybe so a little reverse t-berg, you're worried about whatever..

you give your induction dose of propofol.

You have difficulty mask ventilating.

Whatcha gonna do?

I know what the books say to do.

I wanna know what you would do.

Assume this scenario does not involve the aside corollary below.

(aside: there does exist a cuppla scenarios where I would not immediately relax the pt. They are very specific scenarios. We all know what said specific scenarios are.)

Haha... you trying to get me caught up in a catch 22? C'mmon dawg.

Sneaky JET..... youza ninja.... and trix are for rabbits...!

Ahh... but I have spider sense....😀

Hard to answer your question over the internet without seeing the patient, doing a history/physical assessment (AW, neck girth, abdominal girth, hypoxia at rest. etc.)

What would I MOST LIKELY DO is a better question.

Prolly relax them, from the Get Go.... without testing for mask ventilation...

It's like YODA said:

DO or DO NOT

THERE IS NO TRY

BUT....

There are certain patients I would test for mask ventilation. If it's easy (or somewhat difficult) then I relax. IF IT IS NOT:

Then I ALWAYS reserve the right to WAKE THEM UP!

This means:

Do an AFOI

or

CALL FOR HELP

How often has this happened during my time in PP?

Not a single time.

Doesn't mean that I'm gonna relax every patient I can't ventilate (which is different than difficult ventilating).

If my spider sense is going off and saying...

"I might not be able to ventilate after I push the sux"

Then I'm not tempting fate.

I'm staying safe.

Like idio stated... 100mg of propofol is a good test amount. Rendering someone apneic for 10 seconds isn't gonna kill them or you!

DOGMA???? Prolly

But I'm not 100%...

Being able to wake up a patient is a safety valve I refuse to throw out the door....

Even though I haven't had to use it.

When you play on my team... I like to have all tools available to me.

😀

And as a final word:

I RARELY TEST FOR VENTILATION. NEARLY ALWAYS CHASE THE PROP WITH THE PARALYTIC!

 

[sevoflurane]

It's like YODA said:

DO or DO NOT

THERE IS NO TRY

There are times that 40mg (2cc's of sux) just ain't gonna do it.

Often times you want "best intubating conditions". And this may mean more than 40mg in the biggens. This then needs to be weighed against apnea.

This biz of anesthesia has some serious decisions we make on the fly.... but they aren't ones to be ignored.

 

[sevoflurane]

HOW MANY TIMES HAVE YOU GUYS BEEN IN A SCENARIO WHERE YOU CAN'T VENTILATE AFTER PUSHING RELAXANT?

I'VE BEEN THERE.

DIDN'T LIKE IT. 🙁

[YOUTUBE]http://www.youtube.com/watch?v=R6Mj1Us13Yk[/YOUTUBE]