The differences in RSI vs Gas

MmacFN · Mar 19, 2006, 08:00 PM

Hye Nitecap

Yes im very excited. Many of the drugs I currently use I learned alot about in an advanced pharmacology class i took a few years ago. I was getting sick of not knowing why it worked.

I really do enjoy learning new stuff. I am so excited to get into school again i cannot even explain it. Once im there its awesome. Ill be glad when the waiting and the decisions are made and i have an acceptance in my hand.

What sortof doses are your using pre intubation of fentanyl. My understanding is it can be up to 50 mcgs per kg. Im sortof limited there as i typically only carry 400 mcg at any given time.

I have also had some hypotension issues with versed but i only ever use it now for continious sedation. Sometimes i go with droperidol 1.25 - 2 and that also does a nice job. Often i slam them with fentanyl since the drug works so well. At times ill use morphine and counter the hypotensive effects with benedryl 12.5 - 25 IV. Turns out the hypotension MS causes is histamine mediated. Other than that i have valiume but i dont find that does a great job. We dont carry ativan currently due to the difficulty in maintaining it prehospital.

My goal with all my intubations is to make sure they dont feel/remember it and stay that way until the wean in the ICU. Ive actually had pts who ive intubated when working flight then in the ICU as they are being weaned. Its sortof unusual.

truthfully, i cant wait to goto those pharm classes. I have recently retaken inorganic chem I & II and really enjoyed them. Also really liked biochem. Now just have to find a school and get in

Originally Posted by Nitecap

Giving the fentanyl before intubation would def. help to blunt the sympathetic response to DL. As the lido does as well. Also if you give a RSI dose of Roc (1.2mg) depending on how long your flight is and how long you need the pt down the Vec may not be necessary though it depends on again how long how need relaxation for. Also as for the versed I guess you are using for centrally mediated relaxation ? as well sedation and anxiolysis if you really need then down long ativan may not be a bad choice since it will last long requiring less freq larger boluses of versed causing more freq changes in hemodynamics. Also propofol is not really know for its muscle relaxant properties.

You seem to have a pretty good head start on your knowledge of some of these drugs. When you enter school and really learn on a molecular, receptor, enzymatic and ion level how these drugs work to cause their effects you will be freaking and amazed. Really if I knew half of what I know now while working in the ICU as a nurse about the drugs that I administered nearly everyday I would have provided way better care for my patients no doubt and been able to make more thought out judegements.

As a nurse you know what. For example you know versed will cause sedation, anxiolysis, amnesia and may decrease my DP, resp drive ect. As a CRNA you understand not only what but how and why. You understand that Versed binds to a benzo site on a GABAa ionotropic receptor causing a conformational change keeping Cl- channels open or opening more ect allowing more Cl- to enter the cell leading to a more negative membrane potential (hyperpolarized)that requires a stronger stimulus to depolarize the neuron to cause its effect.

Sounds like you will do fine though. Good luck and dont loose that desire to learn and succeed.

yoga crna · Mar 19, 2006, 08:22 PM

Don't forget that fentanyl can cause a rigid chest, While it happens infrequently, it can get your attention. It happened last Friday to a patient who I was anesthetizing for a facelift. Oxygen sat dropped quickly, but I was able to ventilate her after the muscle relaxant started to work.

Mike,
You are asking good questions. Try to spend some time in the operating room with a good CRNA. It will be invaluable for you and get a good perspective of the level of knowledge need to be a CRNA. Also, pick up a basic anesthesia text on Amazon and read, read, read.

Yoga

MmacFN · Mar 19, 2006, 08:30 PM

Hey Yoga

Funny you should mention that, i did buy 3 books from amazon recently!

I spent about 2 weeks shadowing various CRNAs (since you all do a different job really). I thought it was awesome. I didnt, however, like the surgi center stuff Boring. The rest was awesome.

Yes i have come accross chest rigidy once and quickly reversed it with narcan. I had a BREATHING patient who had a pelic and femur fx. Bar none, the best drug for break through pain is fent., i have him 150 and in about one minute he was complaining of D/B SOB. since it occured with the fent i gave him narcan and fixed it. Sadly, he was still in alot of pain so i eneded up dosing him with etomidate and droperidol. That, at least, kept him from screaming as loud.

here is part of a study i had read a few years ago

Low-dose fentanyl, 2.2 to 6.5 micrograms per kilogram body weight, induced chest wall rigidity in 8 of 89 (9%) term or preterm neonates, who received a total of 204 doses (incidence, 4%). Doses were administered as a slow intravenous bolus over 2 to 3 minutes. One infant developed chest wall rigidity 9 hours after the infusion had been discontinued. Laryngospasm occurred in 2 of the infants. Naloxone immediately reversed rigidity in all cases (Fahnenstich et al, 2000).

Originally Posted by yoga crna

Don't forget that fentanyl can cause a rigid chest, While it happens infrequently, it can get your attention. It happened last Friday to a patient who I was anesthetizing for a facelift. Oxygen sat dropped quickly, but I was able to ventilate her after the muscle relaxant started to work.

Mike,
You are asking good questions. Try to spend some time in the operating room with a good CRNA. It will be invaluable for you and get a good perspective of the level of knowledge need to be a CRNA. Also, pick up a basic anesthesia text on Amazon and read, read, read.

Yoga

yoga crna · Mar 20, 2006, 07:45 AM

Mike,
The fentanyl issue is one of the big differences in what you do and what I do as a CRNA. I honestly can not tell you the last time I reversed a narcotic (maybe 20 years ago). When you are giving fentanyl as part of the induction, intubation regimen for general anesthesia, it is best to proceed with the general and not reverse.

Sorry that outpatient surgery was so boring. I practice all alone in a plastic surgery office and have had most of the exciting moments in my career in that setting. I just try to keep those moments as few as possible.

Yoga

MmacFN · Mar 20, 2006, 08:33 AM

Ok so then the question is this:

Will an non-depolatizing (like roc) or depolarizing (like succs) paralytic reverse this chest rigidity and is it simply beause of the paralytic effect? If thats the case then it sortof seems irrelevant when performing RSI, dont you think?

Im thinking this way: 60 seconds before intubation fent, 50 seconds before intibation etomidate, 10 seconds before intubation succs, wait for paralysis bag until ready intubate.

Its so fast for me that by the time chest rigidy set in, they'd be paralyzed!

Nitecap · Mar 20, 2006, 05:36 PM

Originally Posted by MmacFN

Ok so then the question is this:

Will an non-depolatizing (like roc) or depolarizing (like succs) paralytic reverse this chest rigidity and is it simply beause of the paralytic effect? If thats the case then it sortof seems irrelevant when performing RSI, dont you think?

Im thinking this way: 60 seconds before intubation fent, 50 seconds before intibation etomidate, 10 seconds before intubation succs, wait for paralysis bag until ready intubate.

Its so fast for me that by the time chest rigidy set in, they'd be paralyzed!

Not mush exp with chest ridgity here but in most anesthesia texts say that a relaxant can help this. However though man times in anesthesia you may start the titrate the fentanyl early. Like earlier than the minute or so you stated b/f giving the relaxant. Your titrating a bit in and preoxygenating the pt while you and others are positioning and what not. It is here that the chest ridgitiy cause larger issues. Miller says a small defisiculating dose of nondepolarizer can help prevent but not all the time. They think this is a centrally mediate issue so you can give relaxant, which doesnt cross the BBB and it have no effect in the CNS.

rn29306 · Mar 20, 2006, 06:14 PM

Originally Posted by MmacFN

Hey Yoga

Funny you should mention that, i did buy 3 books from amazon recently!

So give it up, what 3 books were they?

MmacFN · Mar 20, 2006, 06:19 PM

hehe

Here is what i bought:
Nursing Anesthesia Secrets
Handbook of Anesthesiology, 2004-2005 Edition
Watchful Care: A History of Americas Nurse Anesthetists

I already own millers and Rosens EM along with Hursts The Heart. I teach most of that stuff weekly.

What do you think of the other three?

rn29306 · Mar 20, 2006, 06:39 PM

Originally Posted by MmacFN

hehe

Here is what i bought:
Nursing Anesthesia Secrets
Handbook of Anesthesiology, 2004-2005 Edition
Watchful Care: A History of Americas Nurse Anesthetists

I already own millers and Rosens EM along with Hursts The Heart. I teach most of that stuff weekly.

What do you think of the other three?

Very good choices might I add, esp since the Handbook was my idea...
Anesthesia Secrets is an excellent book. Good start.

In my previous EMS gig there was a flight medic and flight RN hubby/wife team that came to Atlanta after working flight in AZ. I'll ask them what company they used to fly for and get back to ya.

Pete495 · Mar 20, 2006, 06:40 PM

Good Books. I haven't read Watchful Care, but always wanted to. Don't have time for it right now. too many other required readings. physio is kicking my ass, but I'm getting through. Anesthesia school is hard, and will probably be the hardest thing you do. I'm only 3 months into it, and I'm spent.

Another one useful for clinical besides anesthesia secrets is secrets of anesthesia. I know, sounds the same, but it's a different book. also if you have a pda, get The Manual of Anesthesia, and soto's drug book. I have a pda, but don't use it much at this point. Actually, I think the thing is a piece of garbage, but they made us buy it.

Keep coming back and posting. we need more topics on this site.