Intubation - confused about orders

[RNexplorer]

I have a question about the intubation I saw today...

Is it normal for neuromuscular blockers to be ordered before the sedative....??? I had drawn up etomidate and rocuronium... And I kept thinking to myself, he's probably going to ask for the etomidate first.... I have always heard that the patient should be sedated first because the feeling of becoming paralyzed is NOT NICE!!

I was really surprised when the doc asked for rocuronium first. I repeated everything back to the MD to make sure I heard everything correctly...

The patient did not look peaceful during this intubation!

[OBigdog26, MSN, RN, NP]

Usually sedate than paralyze. These meds are given one after the other in quick succession. So, practically I see no issue. However, if his spo2 is 95% on NRB nppv should have been implemented rather than intubation.

Again, I don't know all the facts and medical issues going on with this pt. So, just my 2 cents

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[Mully]

95% On how many L of 02? It was never specified. 10-15L is a huge window to be maintaining 95% sp02. The patient could have been on 10L for all we know. Exhaustion plays a large role, but use of a BIPAP prior to intubation is crucial to any intubation protocol. VAP and trauma from intubation should be avoided if an easier intervention can be utilized. Every ICU nurse knows this and most docs will order a BIPAP before moving to intubation, unless emergent. I agree, seeing the ABGs would help.

Regardless of the flowrate, the patient will get the same Fi02 with a non-rebreather. The flowrate just works to provide the 02 to the bag which the patient then breathes from. Non-rebreather valves open during exhalation, and 02 from the bag supplies 02 during inhalation. 10-15L is just what it takes to maintain the bag's 02 volume.

The patient was getting >80% Fi02 if the mask was applied correctly.