Ketamine during an emergent intubation - page 2
Hi all, I just want to ask your opinions on the following case that came across our ICU. A 35 year old woman gets admitted to our ICU following emergency C-section due to HELLP syndrome and... Read More
0Jan 3, '12 by BelgianRNQuote from usalsfyreDosage of fentanyl was at around 0,6 µg/kg (50 µg in total) pushed directly following the ketamine. We chose for a low dose approach. We generally use ketamine at 1 mg/kg which is within the dosage range stated on uptodate (0,5 - 2 mg/kg), in hindsight I feel our MD chose a more reserved approach out of fear perhaps for severe hemodynamic compromise and we would have been better pushing 2 mg/kg directly. I find the argument that Ketamine has potential side effects on platelet function something that I will surely bring up when we discuss this situation next time.Couple of thoughts. First, when and how much fent was given? This is as likely your reason for desaturation as the ketamine.Ketamine was an appropriate choice of induction agent in this case as one of the vaunted properties of ketamine is it's ability to sedate while leaving respiratory drive intact. The dose, as has already been noted, was inappropriate. Were you actively ventilating with the BVM or simply allowing the patient to breathe through it? Instead of trying to ventilate a fighting, ****** off patient, try NIPPV, or seal a BVM (better yet a Jackson Rees circuit) with PEEP attached and allow them to breathe through it with the O2 on "sssshhhhh" as an EM doc described to me one day. What you get is better O2 delivery to the distal end of the pulmonary tree without the discomfort and gastric insulation of positive pressure ventilaton. Do this while your preparing the patient for intubation.It sounds like this lady is very lucky she didn't end up dead or with a hole in the trachea. Airway disasters like this have a way of "gut checking" everyone involved to never make the same mistakes again.
We started by pushing Ketamine with Optiflow in place and replacing NRM with the BMV-mask just letting her breath the extra O2. After resps became more shallow we started augmenting her own respiratory efforts by synching active BMV with pt inspirations. We never DCed Optiflow until after ETT was passed. I don't feel the issue is with the BMV that went by the book. I feel our pre-oxygenation was the best we could provide keeping in mind that NIPPV would have likely failed (see below). Preparations for intubation were already done by the time we called the MD that we felt intubation was needed, we learn to be very pro-active as our nurse/patient ratio is 1/4 at night. I just added this information to give a complete image.
Problem was late onset of sedation which would not have been a problem had we used a higher dose of ketamine to induce.
Why would she end up with a hole in her trachea? She was paralysed and we are trained enough not to put the ETT in wrong end first...
I feel the combativeness was due to her hypoxia causing more anxiety followed by even more hyopxia. It was not a result of us forcing resps on her she wasn't ready for.
NIPPV trial was attempted earlier which resulted in severe anxiety and combativeness of the pt. Hence we decided against using it as an aid in pre-oxygenating the pt.
0Jan 3, '12 by usalsfyreQuote from BelgianRNBecause in many parts of the US it's time to start thinking about surgical airway management when things get this bad...Why would she end up with a hole in her trachea?
Sounds like you did the best you could with a bad circumstance. Upfront sedation probably was the failure here.
0Jan 3, '12 by BelgianRNQuote from usalsfyreFirst off I want to say I'm sorry for the "tone of words" in my previous post. Just ended a hectic night shift so I took it the wrong way. In Belgium placement of surgical airways is a rare occurance so I didn't connect the dots right away.Because in many parts of the US it's time to start thinking about surgical airway management when things get this bad...
I agree we managed but barely and sure as *** not elegantly. I'll advocate for a higher paced intubation scenario next time, better to be safe than sorry.
0Jan 3, '12 by Esme12, ASN, BSN, RN Senior Moderatorvery interesting....I would like to see this moved to CRNA and listen in on the debate. It seems to be a grey area these days and I have seen an increase in the use of steroid post intubation in the setting of sepsis. I'd like to hear the CRNAs opinions.
Here in some parts of the US the are quicker to difficult airway protocols and surgical airway intervention earlier. I don't think you sounded "snarky"...just puzzled, I knew then for sure you weren't in the US.
2Jan 3, '12 by GilaRRTThis is an anamolus issue. Ketamine generally has a rapid onset of action. One thing to seriously consider is the fact that the medication was not given properly or for some reason did not make it into the patient. A similar situation occurred with a flight crew in my area of the woods. Etomidate was given without any effect. A second dose was given without significant effect. Someone apparently had the idea to start another IV and another dose was administered with desired effect. The crew swore the IV was good, but were open to suggestions. This scenario was actually turned into a new hire test to look at critical thinking. A bad lot may be another consideration.
2Jan 3, '12 by RedCellCuppla thoughts:
1) If anesthesia reported the patient was a difficult intubation it would have been optimal for anesthesia to have been there to reintubate the patient. Preggos are already documented as being a potential airway disaster and in this patient's case, it was made known by anesthesia during the c-section.
2) Micro aspiration is not usually caught with a bronch. Doesn't mean the patient did not aspirate, it just means that it was not observed initially by the dude doing the scoping. The chest film proves this point.
3) Preoxygenating this patient is not going to buy much time. FRC is crap already in this population and she has ARDS. Still should make an attempt though while getting toys and drugs ready. She needs PPV and PEEP to fix her.
4) Being that she recently delivered she remains at high risk for aspiration and I would have treated her as such. RSI with cricoid pressure until ETCO2 verified sort of thing.
5) Pick any induction drug you want. If dosed properly they all give you the same desired response. With a HR in the 130's and elevated BP, ketamine would not have been my first choice. Not giving any midaz with that dose is odd. Dissociative anesthesia without benzos is wrong (unless you are Jerry Garcia). The Wolf is right, etomidate is a nasty drug. Propofol 2mg/kg would get the job done nicely. Quick onset with fewer side effects. Arguing that propofol decreases oxygen supply to tissues is weak in my opinion. It lowers CRMO2 so that is good enough for me.
6) Rocuronium is nice too, but it is a long acting paralytic that takes a while to give you desirable relaxation for intubation. Also, if you cannot place your tube correctly, you have potentially hosed the patient. You guys do have sugammadex over in Europe so at least you have an out if intubation cannot be accomplished. In the United States that drug was burned down in phase III trials and is unavailable. I like succinycholine for these scenarios. Quick onset and unless you have a pseudocholinesterase deficiency, it is gone quickly.
7) I think my 5 year old could still beat me on the Xbox with 50mcgs of fentanyl in her.
8) I don't think things were too bad yet. Take a look at the ASA difficult airway algorithm ASA Difficult Airway Algorithm - Ether - Resources for Anesthesia Research and Education - Stanford University School of Medicine There are many pathways to take before slashing the neck. Video assisted laryngoscopy is not listed in the algorithm yet, but should certainly be considered an option with this patient probably before direct laryngoscopy since anesthesia has already declared this patient difficult to intubate.
Like Wolfman says, it is easy to Monday morning quarterback a case. Don't mean to sound harsh, just wanted to post a few thoughts that crossed my mind upon reading this.
1Jan 4, '12 by BelgianRNWell I don't mind quarterbacking as long as it says polite and constructive. It's how we learn and how we improve. It's just hard at times because every institution has its way and materials available, so sometimes you just don't have what you want/need.
@ GilaRRT: all meds were pushed over a CVC distal lumen with proper CVP-curve before and after pushing meds. So 99.9% certain it ended up intravascular.
@ Redcell: Good thoughts. Dunno about the intensivists and training intensivists over there but here in Belgium they all have a base specialty first either internal medicine, pediatrics or anesthesia or subspecialties. All our surgical patients are cared for by an anesthesist doing ICU specialisation or an anesthesist in the final years of training so they are generally very skilled at getting the ETT in even with difficult airways. And to put this diplomatically the true extent of the difficult airway remained a mystery. What we knew then and heard later did not really add up had we know the true story we would have been twice as prepared. If you want the undiplomatic version feel free to PM. Generally (as is apparent from this case) they struggle with selection of drugs in the ICU and tend to worry a lot about pushing too much medication. I think we were caught with our pants down because we tried to be very careful.
Our reasoning was BP/HR are elevated (both rose in the last few hours leading up to intubation) due to stressfactors. So better to use ketamine to not stress out her hemodynamics once she was sedated.
So wouldn't you be worried about BP/HR crashing down once the stress factors get sedated away and propofol also influencing the hemodynamics negatively on top of that?
My only experience with propofol during emergent airways is limited to usage in severely hypertensive patients (BPsyst > 160 - 180 mmHg) or ill-used for patients with HD-compromise with a low BP that only hope and endogenous epi kept up (needless to say all of those ended up in a code). We tend to stay away from it when BP is only moderately elevated. So perhaps I'm negatively biassed when it comes to propofol as a drug as we tend to see the worst of it.
Next time I'm working I'm checking the OR/ED to see if they have succinylcholine. But in the ICU it's not available we either have rocuronium or cisatracurium and in the OR i've seen them use atracurium and rocuronium. So it could even be we don't have it in the hospital or perhaps it is standing somewhere in a layer of dust together with the good old THAM and the overpriced Novo7 ^^Last edit by BelgianRN on Jan 4, '12
1Jan 4, '12 by PetERNurseKetamine causes increased HR and myocardial oxygen demand, while decreasing ventricular filling time. Don't fall into the trap of thinking it doesn't "stress out hemodynamics".
Given that the patient needed RSI, a little transient hypotension was the least of your worries. I don't think propofol at the dose described above (2 mg/kg) would have the crashing down effect you describe when administered correctly, though each patient responds differently.
Again, I stick with drugs that have the "best" side effect profile (fentanyl, midazolam, sux), and limit the use/dose of drugs with "worse" side effect profiles (propofol, ketamine, etomidate). It's all relative though.
1Jan 4, '12 by WolfpackRedjust a caution with succinylcholine - specifically in this pt scenario (I am assuming that the pt was primarily bed bound/rest p delivery, extubation and in the 48hr between reintubation) that there could be a risk for upregulated extrajunctional neuromuscular receptors. the use of sux in RSI could lead to higher than expected release of intracellular potassium potentially leading to cardiac irritability and really bad hemodynamics.
I think the use of roc in this case was appropriate and if given in high doses (1.2mg/kg) can have an onset time similar to sux. as someone said previously, the only downside to the use of roc is that you cannot have a "can't intubate/can't ventilate" scenario.
1Jan 4, '12 by wtbcrna, MSN, DNP, CRNA GuideJust a couple of thoughts:
1. Versed isn't necessary when giving Ketamine as an induction for long term intubations/overnight intubations in the ICU. The patient is going to be intubated and sedated long enough for the ketamine to have worn off. Versed would give some synergistic reactions with the other meds and could have helped the overall situation though.
2. Succinylcholine in this patient situation shouldn't matter. The patient is unlikely to have enough muscle wasting in this matter of time to really matter.
3. The dose for fentanyly should have been 1-2mcg/kg at least otherwise you might as well just be squirting the fentanyl in the trash for all the reaction you are probably going to get from it.
4. Etomidate as a single dose is unlikely to cause significant problems, but if the patient has to be reintubated what induction drug is most likely to get pulled the second time around. Subsequent doses of etomidate can be dangerous, and the initial adrenal suppression from etomidate can last up to 72hrs.
5. As someone already mentioned there is no right or wrong drug to use in these kind of situations, but how you use/dose the drugs. One of my favorite techniques to use in unstable patients is to use etomidate with a small dose of propofol as the induction agent(s). You get much smoother induction conditions IMO than just using etomidate alone. The same thing will work with ketamine inductions by just adding a small dose of propofol the induction will be much smoother.