Had a pt last night emergently intubated. CRNA asked me to push 4cc Lidocaine...just wondering if you all have heard of that? Why would u need it? Just wondering..sorry if dumb question.
PS it was a reintubation s/p self extubation.... dont know if that makes a difference
Dec 8, '02
Lidocaine, in addition to being an anti-arrhythmic, is a good anesthetic. Given IV, it helps anesthetize the airway, making intubation somewhat more comfortable. Not everyone would do this, but there is an argument that by anesthetizing the airway, the patient more readily accomodates to the tube as the lidocaine wears off.
Dec 8, '02
lidocaine used to be pretty popular as part of the normal induction meds.... and some people are still in the habit of using it, even though there isn't much evidence for its usefulness...
in fact, lidocaine can be pro-arrhythmic in its own right (pretty much every anti-arrhythmic can be pro-arrhythmic) and therefore shouldn't be injected haphazardly...
i would recommend not using it.... why add another "anesthetic" or "laryngospasm-lytic" when you are already pushing other drugs that work just as well with less risks?
my most common use for lidocaine IV is for vein anesthesia: if using propofol/etomidate in a small gauge IV in a distal extremity, i will inject a few ccs into the IV while the arm is tourniqueted and let it sit there for 20-30 seconds before pushing Propofol... never hear a complaint about burning...
Dec 9, '02
Interesting. I assumed it was for comfort but wasnt sure how injecting it intravenously would assist in intubation.
I asked the CRNA why Lido and actually the resident asked as well (which made me feel better for not having used it before), but he didnt answer either of us.
We were trying not to use too many meds prior to the intubation bc the pt's bp was quite low (50/30) and the resident didnt want to start pressors at that time.
Like I said before he also had self extubated early in the day and oh, was a GI Bleed so it definitely was going to be a difficult intubation.
Thanks for the responses.
Dec 9, '02
why was the patients pressure low? was it a real pressure? (proper reading?)....
usually if the pressure is low prior to intubation, i address it after intubation - as intubation is extremely stimulating and will in of itself temporarily lift the pressure...
now that you mention the pressure it makes less sense to use lidocaine.... if this persons pressure is 50/30 then they have self-anesthetized themself and probably don't need lidocaine.
by the way, why would he be a difficult intubation? just curious... self-extubation and a history of GI bleed aren't predictors for difficulty of intubation - unless he was actively upper GI bleeding, in which case that blood pressure better be treated with SOMETHING (blood, etc.)
Dec 9, '02
The pressure was definitely real and was most likely due to his GI bleeding. He put out 2500 mL of frank blood through his NG in two hrs with a hard as a rock gut. He was being intubated for airway protection. He had self extubated himself that AM. He had been intubated and extubated a few times over the past couple of days so there was alot laryngeal edema. We were treating his pressure at that time with PRBC and NS boluses at the time of intubation. He ended up also getting started on Dopa and Levo both maxed out with still pressure of 80. In two hrs I'd given him 6u of PRBC on pressure bags as well as 4u of FFP wide open. He also got 3L of NS boluses. Still crappy pressure even with the Dopa and Levo.
Dec 9, '02
hmmm.... now the story is coming together, and getting interesting.... did the patient get a sengstaken-blakemore tube??? is he on an octreotide drip?
it sounds like he is way behind in fluids.... or he is infarcting heart muscle too on top of it (i am asking this because of his low pressure)? most GI bleeders are coagulopathic to begin with, so the blood that is given will just come out again... i would use FFP as my primary volume replacement and supplement with PRBC... are the platelets OK? assuming he is an average guy (70kg) i would be running my fluids wide open... 3Liters is probably a drop in the bucket (i would have given him 8- to 10 liters right off the bat without blinking)... oh, and has he received any calcium supplementation (that will help his pressure too, especially after all those blood transfusions)
and why does he keep on self-extubating??? he should be knocked out and tied down...
Dec 10, '02
They were getting ready to pass the tube when I left and yes we started an Octreotide gtt right away.
As far as his fluid status, you are right he probably was way behind on fluids....he didnt have a CVP set up or Swan so I can't tell ya for sure. I only had him for a few hrs so I'm just telling you what I gave him.... this was on nights and they were rounding on him as I left so....everything could have changed.
They also thought he had some hepatic enceph.. going on and when he self extubated he was not tied down or knocked out... at the time they had thought his bleed was stabilized..they'd done a scope and angio the day prior and thought everything was stable. I don't know why he wasn't tied down or knocked out then.... he got transfered to us from the neuro icu bc they were getting a neuro trauma and we (ccu) had an open bed although he was on the mricu service.
Anyhow, I found out last night that after over 20 u PRBC, tons of FFP, and platelets...yes they were low as well...... maxing him out on Dopa, Neo, and Levo, running his fluids wide open, the Sengstaken tube, and a scope....he didnt improve at all. He coded a few times and his family ended up deciding to withdraw support.