opinion on clinical practice

yoga crna · Aug 9, 2004

I have always ventilated before paralysis. There are several reasons that you nicely stated, but the one that I have seen most often, is that for some reason the breathing circuit is not intact, the bag fell off the machine, or the oxygen is not on. Strange things happen to anesthesia equipment, so that extra margin of safety is there. To do otherwise, is simply LAZINESS. MDs can get away with laziness and substandard practice, we can't.

Yoga CRNA

sonessrna · Aug 9, 2004

i have an issue i would like a little feedback on...here's how the discussion went.
me: put pt to sleep, give a few breaths to asses ventilation. (standard induction not rsi)
md: why are you breathing the pt, go ahead and paralyze.
me: i want to see if i can ventilate first, then give the ndmr.(vec in this case)
md: it doesnt matter anyway, you have to get the airway.
me: if i cant ventilate this guy is paralyzed at least an hour.
md: so, you have to get the airway.
me:yeah but if i cant vent. at least he will be in the process of waking up while i try to get the airway, otherwise he wont do any be breathing.
md: how long does propofol last? he's still gonna get braindamage.
me: yeah but he wont be dead.
md: but how long does propofol last, he still wont breathe, he will have brain damage.
me: well it's dose dependant and at least when they put my chart on the wall in the courtroom i can say i was doing my best to vent, wake up the patient and get an airway. the other way pt is dead, i'm dead in court
md: you still have to get the airway
me: i am not paralyzing anyone that i dont know i can ventilate unless i have to. esp with longer acting agents.
so this went on for about 20 minutes, not heated but noone was gonna give any ground.
is there anyone who regularly paralyzes without regard to ventilation with non depolarizers.
or is it more the standard of care to assess ventilation first?
thoughts....comments....
d

Interesting...all the docs I have ever worked with have insisted I have an airway prior to nondepolarizing muscle paralysis. RSI is the only time I have no established that airway. I think you handled that well.

Gotosleepy · Aug 9, 2004

okay.... so now you can't ventilate, patient is desaturating.... are you going to try to intubate? if so, what drugs will you give and why?

gaspassah · Aug 10, 2004

goto,,,i would call for help then...

reposition, oral airway if one was not used.

i would do larygoscopy without paralysis, if i saw the cords i would attempt intubation, if the cords were adducted i would give some succs and intubate.

if i could only see partial cords or the arytnoids i would try a bougee or the bougee you can jet vent through. to place a tube.

if i couldnt see anything i would try a fastrack lma. and attempt ventilation. if successful, let the pt wake up or tube through it if i felt comfortable at that time.

if lma was unsuccessful then combitube attempt.

if neither of these worked then cricothyrotomy or surgical airway should be concidered.

if handy you could try lightwand or fiberoptic. but some choices are not realistic during a crisis. ie setting up the fiberoptic etc.

i just feel as i go throught the diff airway algorythm and the pt is not paralyzed then as time goes on they have a better opportunity to take on spont resp. vs. paralyzed an definetly not going to breathe.

these are the priciples i was taught.

if you have alternatives please share. i am willing to learn. i appreciate your feedback.

d

athomas91 · Aug 11, 2004

i am with you on this one - and, by the way, that was very impressive how you stood your ground.

i likewise have only worked w/ Anesthesiologists who ensure ventilation prior to paralytics.

Gotosleepy · Aug 11, 2004

so if you can ventilate .... does that mean that you can always intubate?

and if you aren't 100% positive that you can intubate, why not do all of your inubations awake?....

food for thought

gaspassah · Aug 12, 2004

i would think the chances of securing an airway are higher in patients that can be ventilated. i could be wrong of course.

no i dont think that just because you can ventilate that guarantees an intubation. but it does almost guarantee that the patient is not going to die because i cant intubate as long as i can ventilate.

and if you aren't 100% positive that you can intubate, why not do all of your inubations awake?....

i think it unwarranted to think that every airway can be intubated. i also think it's unwarrented to treat each one like it can't. to me the key is setting yourself up for success and not failure ( of which your patient may leave in a body bag.)

my point is ventilation GOOD :) . apnea/inability to ventilate BAD :crying2: . therefore before rendering someone absolutely positively apnic see if you can save their life by ventilating them beforehand.

i am beginning to get the inkling you feel every patient should be paralyzed from the get go then go after the airway.

would you mind substantiating your argument with some supporting philosophy? or feel free to disect mine more.

i'm not looking to butt heads, nor am i looking to make this a md vs crna / srna thing either :uhoh3: . but trying to learn more about the philosophy of airway management and providing the most safe and sound practice i can for my patients.

Brenna's Dad · Aug 12, 2004

It amazes me that some think this is even debatable.

So, if I can't ventilate....

I do NOT give a non-depolarizer...

The very reason I do try to ventilate before paralysis is BECAUSE I know that I won't always be able to ventilate.

London88 · Aug 12, 2004

Brenna's Dad,

I was trying to stay out of this discussion because I cannot see how someone would defend giving the paralytic w/out attempting at least one breath. Without attacking Gotosleepy, I do not know that his/her arguments are always objective, and I always detect an element of antagonism even when Gotosleepy knows his/ her argument is not making sense such as the prior discussion on titrating paralytics in a non intubated pt.

Gotosleepy · Aug 12, 2004

nobody can defend giving a paralytic without ventilating... however we do it all the time for RSI.... are all RSI patients easier to intubate? and what do you do for a patient that is MH-susceptible who is going to need RSI??? and is 3 years old and won't cooperate with awake fiberoptic...??

my points in this conversation weren't actually points... just questions to make you think about what you do....

another option to avoiding relaxants is to use high-dose remifentanil!!!

London88 · Aug 12, 2004

Gotosleepy,

I fully undesrstand that for RSI the textbook method is to not give any breaths, but many of the MDAs I have worked with still attempt one breath.The patient who is not paralyzed is going to have a better chance of developing spontaneous respirations than the pt who is paralayzed. Admittedly in both situations the outcome can be ugly. However one can defend to a certain extent in court not being able to ventilate a pt after induction and not giving a paralytic upon failure to be able to ventilate as long as other appropriate interventions were attempted. However if you are not doing a RSI, how can you defend yourself in court when you did not attempt to ventilate and you gave a drug such as norcuron?