Why not RSI on everyone?

[epidural man]

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It's like YODA said:

DO or DO NOT

THERE IS NO TRY

!

nice. la la love it.

 

[Mman]

I still don't know the right answer to the ventilate or not question with the succ on every patient. I was taught both by different attendings that trained on different sides of the pond. The right answer depends on who you ask.

If you are worried about potentially not being able to ventilate or intubate the patient, is it better to give yourself the best shot ASAP or is it better to hope that the induction propofol wears off more quickly to allow spontaneously ventilation than the combination of propofol and succinylcholine? I don't know the answer. I've heard fairly convincing arguments both ways.

On the one hand, I'm never sure if being able to ventilate before the succinylcholine hits means I can ventilate after it hits. If that is the case, I'd sure wish I had given it right away so it can wear off faster. I'd also like the longest duration of good intubating conditions so the faster the succinycholine is in, the longer I can attempt intubation until the sat starts dropping. Essentially I'll get more tries at it. If I can't ventilate or intubate, I need to make sure I've got everything up to a cric kit in the room.

On the other hand, the safety margin with the induction is the time from apnea until the return of spontaneous ventilation. If I just give propofol, the time to return to spontaneous ventilation cannot be longer than the combination of the prop + succ. It could potentially be the same amount of time, but in all likelihood it's probably sooner.



But the question is, if you can't ventilate after the propofol, what do you do? If a DL is involved at any point (after trying with oral/nasal airway or LMA), you are better off with the succ already working.


I tend to just push the succ. If I'm that worried about the potential combination of extremely difficult intubation/ventilation I never go down this pathway in the first place. They are either getting an awake FOI or they are still spontaneously breathing from my induction with some combination of sevo/nitrous/ketamine etc. I'm not burning the bridge if I am not reasonably certain we can secure the airway.

 

[Idiopathic]

I still don't know the right answer to the ventilate or not question with the succ on every patient. I was taught both by different attendings that trained on different sides of the pond. The right answer depends on who you ask.

If you are worried about potentially not being able to ventilate or intubate the patient, is it better to give yourself the best shot ASAP or is it better to hope that the induction propofol wears off more quickly to allow spontaneously ventilation than the combination of propofol and succinylcholine? I don't know the answer. I've heard fairly convincing arguments both ways.

On the one hand, I'm never sure if being able to ventilate before the succinylcholine hits means I can ventilate after it hits. If that is the case, I'd sure wish I had given it right away so it can wear off faster. I'd also like the longest duration of good intubating conditions so the faster the succinycholine is in, the longer I can attempt intubation until the sat starts dropping. Essentially I'll get more tries at it. If I can't ventilate or intubate, I need to make sure I've got everything up to a cric kit in the room.

On the other hand, the safety margin with the induction is the time from apnea until the return of spontaneous ventilation. If I just give propofol, the time to return to spontaneous ventilation cannot be longer than the combination of the prop + succ. It could potentially be the same amount of time, but in all likelihood it's probably sooner.



But the question is, if you can't ventilate after the propofol, what do you do? If a DL is involved at any point (after trying with oral/nasal airway or LMA), you are better off with the succ already working.


I tend to just push the succ. If I'm that worried about the potential combination of extremely difficult intubation/ventilation I never go down this pathway in the first place. They are either getting an awake FOI or they are still spontaneously breathing from my induction with some combination of sevo/nitrous/ketamine etc. I'm not burning the bridge if I am not reasonably certain we can secure the airway.

You can always wake the patient up. You should never forget this. As impractical as it sounds (and I truly believe it applies more towards CANNOT intubate, CAN ventilate situations), its still in the algorithm. If you give paralytic and you cannot ventilate, then you are quickly traversing the algorithm, hoping an LMA seats nicely. Otherwise they have a hole in their neck. The healthiest person is not likely to do well with a slug of prop/sux if all of a sudden you cant V/I, and thats what sticks in my mind.

WIth my N of 2000 or so, Ive yet to see a patient that I could ventilate before paralytic that I couldnt ventilate after paralytic.

Also, this discussion is completely separate from the anticipated difficult mask/intubation. This is just routine run of the mill patients with no obvious risk factors.

 

[Mman]

You can always wake the patient up. You should never forget this. As impractical as it sounds (and I truly believe it applies more towards CANNOT intubate, CAN ventilate situations), its still in the algorithm. If you give paralytic and you cannot ventilate, then you are quickly traversing the algorithm, hoping an LMA seats nicely. Otherwise they have a hole in their neck. The healthiest person is not likely to do well with a slug of prop/sux if all of a sudden you cant V/I, and thats what sticks in my mind.

WIth my N of 2000 or so, Ive yet to see a patient that I could ventilate before paralytic that I couldnt ventilate after paralytic.

Also, this discussion is completely separate from the anticipated difficult mask/intubation. This is just routine run of the mill patients with no obvious risk factors.

Agree. But if I give a slug of propofol and immediately push the succ, I can still wake the patient up. Time to significant desat on a young healthy adult with perfect preoxygenation is over 10 minutes. The succ is long gone by then.

That's my point. The time to meaningful spontaneous ventilation after induction dose of propofol is not that different than after a dose of propofol immediately followed by succinylcholine. In some patients at some doses, the time is identical (in other words, the rate limiting step is the propofol).

In my N of 10,000 in busy private practice I (big knock on wood) still haven't had the cannot intubate/cannot ventilate. I've had patients that we couldn't do one or the other on, but not both. Frequently in morbidly obese patients with good mouth opening I know it will be very difficult to ventilate but that intubation should be very easy (or at least easy with glidescope).

The algorthim that sort of gets used is: Prop+succ
Attempt ventilation while waiting for succ to kick in.
If can't ventilate, place oral and or nasal airway and attempt ventilation.
If can't ventilate, have 2nd person help try to ventilate.
If can't ventilate, succ probably working and try to intubate.
If can't intubate, try LMA or better attempt at intubation (perhaps glidescope).

Then you get into other folks helping you, other intubation or ventilation aides, repositioning, etc.

But from the moment you induced, the are already starting to wake up. It's just a question of you being able to either get the tube in or ventilate them adequately until they are spontaneously breathing.

There are really only 2 differences between giving the succinylcholine immediately or trying to ventilate first.

1) Giving the succinylcholine first gives you a much better shot at getting the tube in if that is part of your algorthim if you can't ventilate.
2) Not giving the succinylcholine first potentially allows spontaneous ventilation sooner (key word potentially).

 

[Idiopathic]

Agree. But if I give a slug of propofol and immediately push the succ, I can still wake the patient up. Time to significant desat on a young healthy adult with perfect preoxygenation is over 10 minutes. The succ is long gone by then.

That's my point. The time to meaningful spontaneous ventilation after induction dose of propofol is not that different than after a dose of propofol immediately followed by succinylcholine. In some patients at some doses, the time is identical (in other words, the rate limiting step is the propofol)..

really...is this true? i dont do many young healthy people and i see significant desat in <3 minutes in most every patient i take care of. you could still make the argument that confirming ventilation is wasting time, and im not sure that my way is right, but i like knowing before a CA1/junior SRNA puts a blade in the mouth and I have to wait 30 seconds before i hear "okay i see epiglottis...lifting up...i think those are arytenoids...can i have a bougie?"

 

[Arch Guillotti]

Agree. But if I give a slug of propofol and immediately push the succ, I can still wake the patient up. Time to significant desat on a young healthy adult with perfect preoxygenation is over 10 minutes. The succ is long gone by then.

2 big assumptions/conditions in my book.

I am somewhat guilty of pushing induction drugs without doing a prolonged preoxygenation although if I am really concerned about the airway I will insist on 4-5 minutes of solid preoxygenation.