Awake intubation question

[Toby's mum]

CRNAs & SRNAs:

I recently witnessed an awake intubation on an elderly female patient. The patient's dx was CHF and possible aspiration/pulmonary edema. After suffering from increasing respiratory distress while on the telemetry floor, she was transferred to the ICU. I had the opportunity to follow her progress. Within 30 minutes of entering the ICU, she underwent an awake intubation. Although she received approx 8 mg Versed and 2 mg morphine (I think?), there was no succinylcholine on the ICU floor, which is what the CRNA requested. Since the patient was rapidly desating and going into bradycardia, the CRNA made a decision to do an awake intubation. The patient was not paralyzed at this point. After intubation, the respiratory therapist assisted with respiration. Shortly after this time, the patient's belly significantly expanded outward and, while being suctioned, significant amounts of a pink, frothy substance was expressed. It even looked like there may have been tissue mixed in. The patient then coded twice.

My questions related to this experience are as follows:

1) is it typical to keep succ on the ICU floor for emergency intubation or do you use something else--perhaps Nimbex (sp?)

2) What is the significance of the belly expanding shortly after intubation and manual bagging? The CRNA was pretty confident that the tube was placed correctly since he didn't hear any gurgling in the LUQ.

3) How can you tell the difference between aspiration (that may have severely damaged the lungs) and pulmonary edema that was suctioned out in a profuse amount.

I really appreciate your analysis of this situation and look forward to learning from your comments. Thanks in advance, Stephanie

[Tenesma]

sux... is a bad drug... in an unstable patient why would you want to use a drug that will rob them of their spontaneous ventilation??? ideally you would want to intubate everybody while they are still breathing... and if they aren't breathing spontaneously, then why do you need sux... it is a bad, bad drug...

[mwbeah]

If you are fearful of it, your intubation skills, and your airway algorithm, then I guess it is a "bad bad drug". If you remember to preoxygenate appropriately, then the patient will have at least 2-3 minutes (4 vital capacity breaths with FiO2 of 1.0 with the average patient) without desaturation and if you use a lower dose (remember we use 3x the ED95 during intubation so if you use 1x the ED95 or 0.3 mg/kg then it will be gone within that timeframe). Your induction agent will last longer (making the pt apneic that is). I won't dictate your practice, and its OK to disagree but I use what I am comfortable with, and I stated it is a case by case basis that requires evaluation and thought. Your training probably dictates much of your practice, I know for a fact that most MDAs and CRNAs that are military trained use this agent for most emergent intubations, especially if the pt's tone is inhibiting the view. Low dose sux will provide just enough (ultra short acting) relaxation to decrease muscular tone and increase your grade view (ie the pt isn't fighting against you).

For intubations that need spontaneous ventilation, I am not cavalier I understand your point but my point is that your blanket statement that sux is a terrible drug just does not hold water especially when you walk into a bad scene and hear "the vec is in" and the patient is blue and the BVM is ineffective and the pt's airway has been bloodied to a pulp (if sux was that terrible of a drug, it would have been removed long ago but it had been used for eons). If low dose sux would have been used then the patient would have been able to resume breathing on their own, and then an awake intubation (FOB, blind nasal, awake light wand) could have been performed.

Posting a blanket statement to an informed audience is going to create friction.

Mike CRNA

[Pete495]

I didn't mean anything bad toward the anes. providers. I am at the beginning of crna school myself, and have a high respect for anesthesia providers. I have worked with some good ones. I just pointed it out because it is something I commonly see. I wish I could hang neo or something a lot of times in many of these patients, but typically when I have to have someone intubated, it is on an off shift, thus no doc around to give me orders for neo or whatever, and when I call, I get the routine it will come back up after the patient has stabled out after the intubation. In my experience, the patient does better when my anes. provider brings something with them however. I'm tired of following these docs orders, and doing nothing sometimes, thus my entrance into crna school.

I was surprised you are able to bill for bronchs. I think it should be done more after intubations actually for stable patients, cuz pulmonary edema is half the battle in resp. distress.

Thanks for your input. David

[deepz]

....MOST DEFINITELY NEVER USE SUX!!!!!!

..... I have NEVER EVER needed to use SUX.........

'Never' is a long, long time.

.

[gaspassah]

". If you remember to preoxygenate appropriately, then the patient will have at least 2-3 minutes (4 vital capacity breaths with FiO2 of 1.0 with the average patient) without desaturation

i realize we have gotten into the general discussion of sux, but remember in this particular case the pt was in pul edema, and already desaturating with bvm. you may not get an adequate preoxygenation in all pts.

d

[jwk]

sux... is a bad drug... in an unstable patient why would you want to use a drug that will rob them of their spontaneous ventilation??? ideally you would want to intubate everybody while they are still breathing... and if they aren't breathing spontaneously, then why do you need sux... it is a bad, bad drug...

I'm curious if you ever use sux. I work with a couple of docs who don't like it on ANY patient for ANY reason, in the OR, ICU or wherever. After 25 years, I still think overall it's one of the wonder-drugs for anesthesia. If someone came up with a ultra-short-acting non-depolarizing agent that matched the great qualities that sux has (rapid onset, rapid offset, CHEAP), then I think everyone would use it. Until such a drug appears in our formulary, sux will be a mainstay in most practices.

Anyway - why would an urgent intubation in the ICU be any different than an RSI on a very sick patient in the OR? It's essentially the same thing, except no surgical procedure follows the intubation.

[athomas91]

For intubations that need spontaneous ventilation, I am not cavalier I understand your point but my point is that your blanket statement that sux is a terrible drug just does not hold water especially when you walk into a bad scene and hear "the vec is in" and the patient is blue and the BVM is ineffective and the pt's airway has been bloodied to a pulp (if sux was that terrible of a drug, it would have been removed long ago but it had been used for eons). If low dose sux would have been used then the patient would have been able to resume breathing on their own, and then an awake intubation (FOB, blind nasal, awake light wand) could have been performed.

i, likewise, am still a student - but in response.....

when responding to the floor...

when isn't the patient critically ill, coding, or unable to adequately preO2?

when doesn't the patient have heart dz, hx of stroke, or an altered K+ ?

when do you have adequate help to apply sellick maneuver?

when are you given an accurate hx by the care provider - most can't even tell you a hx much less allergies or NPO status...

i like sux - don't get me wrong - but there are better meds to use on the floor in these situations especially the situation mentioned at the beginning of this discussion.

when you aren't privy to much information in an emergent situation - sux isn't the drug to use. Tenesma is absolutely right - these people are worn down enough that a small dose of etomidate (i have used as little as 6 mg) is enough to do an awake intubation without seeing sympathetic reaction yet they are still breathing on their own. why take an airway when you don't have to or until you absolutely have to?

just my 2 cents.

and... i dont' know why anyone would every give vec on the floor... again - hx of the patient is important there...and is that long of a paralysis neccesary?

[jwk]

i, likewise, am still a student - but in response.....

when responding to the floor...

when isn't the patient critically ill, coding, or unable to adequately preO2?

when doesn't the patient have heart dz, hx of stroke, or an altered K+ ?

when do you have adequate help to apply sellick maneuver?

when are you given an accurate hx by the care provider - most can't even tell you a hx much less allergies or NPO status...

i like sux - don't get me wrong - but there are better meds to use on the floor in these situations especially the situation mentioned at the beginning of this discussion.

when you aren't privy to much information in an emergent situation - sux isn't the drug to use. Tenesma is absolutely right - these people are worn down enough that a small dose of etomidate (i have used as little as 6 mg) is enough to do an awake intubation without seeing sympathetic reaction yet they are still breathing on their own. why take an airway when you don't have to or until you absolutely have to?

just my 2 cents.

and... i dont' know why anyone would every give vec on the floor... again - hx of the patient is important there...and is that long of a paralysis neccesary?

I think "on the floor", we wouldn't be giving sux. It's not on our code carts, and we wouldn't be carrying it with us. If we respond to a code or similar emegent situation on a nursing floor, we're not going to be giving anything at all, sux included.

I think in the ICU, it's a little different, because it's usually a more controlled situation. At least in our institution, two of us usually go to the ICU or ER for intubations, so we almost always have a second set of skilled hands. We really do treat it like an RSI - pre-O2, sellick, etc. This might not always be possible in some hospitalls, but we have a large staff, and there's almost always a second anesthesia provider involved in these situations.

[qanik]

I have been following the post for the past few days. I found it interesting the anti sux comments. I will admit I am only an SRNA so the anesthesia side of things is new to me. On the other hand I have been a paramedic for 17 years and a flight nurse for the last eight. I have flown with many different programs and nearly every intubation (96% last year) is done as RSI with sux. We respond to all the inhouse codes and airway emergencies and again we use sux (Obviously not the codes). Now I have done my fair share of awake intubations as a medic when we didn't carry paralytics. What I found back then is the same I find watching the ED docs do an awake intubation- to little sedation and five people holding the patient while they get manhandled. The flip side is as mentioned the patient and the BP are in the crapper from over sedation and then we deal with getting screamed at beacause we have to start something for the BP. It is great to see other points of view. It is really amazing to see how different things are done (good and bad) in the different areas.

Qanik

[mwbeah]

Again I am not cavalier in using sux and if a patient is crumping on the floor---- "METALPHRINE---ETT" and I wouldn't use sux (I think I have stated MANY times that each case is individual).

The situation that was describe in the original post sounded like a cluster from the start.

But to say you never use something..............

Additionally, this forum has some great information and some questionable.....it seems that most posters still aren't CRNAs and are offering "their experiences". I would be a wee bit more humble.........

"Just my 2 Cents"

Mike

[mwbeah]

when responding to the floor...

when isn't the patient critically ill, coding, or unable to adequately preO2?

when doesn't the patient have heart dz, hx of stroke, or an altered K+ ?

when do you have adequate help to apply sellick maneuver?

when are you given an accurate hx by the care provider - most can't even tell you a hx much less allergies or NPO status...(From athomas posting)

You obviously didn't thoroughly read my post, I think I said that cases were individual and require active thinking, in less than 30 seconds you can have a quick assessment and decide if sux is appropriate or not. Critical analysis is part of the job.

Mike CRNA

[athomas91]

You obviously didn't thoroughly read my post, I think I said that cases were individual and require active thinking, in less than 30 seconds you can have a quick assessment and decide if sux is appropriate or not. Critical analysis is part of the job.

granted you did say that AFTER you basically stated that Tenesma was a dumba$$ for stating he never used sux...and if in less than 30 seconds you can find allergies on a patient from nurses who are overworked with too many patients and not enough time than more power to you. The last time I was in ICU to intubate the nurse didn't even know the patient's name.

and...what i find very funny is that students are now not permitted to share their experiences or have opinions?!?!? well - i suppose i am not your typical student. but that is beside the point...i have worked with MDA's from Columbia, Mass General and multiple other well known leaders in anesthesia as well as CRNA's with 25+ years of experience....and guess who I learned those things from?!?!? but i guess noone knows as much as those who are unaccepting of others thoughts and practices...more than one way to skin a cat my friend.....