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

[athomas91]

and since i do love to learn....

what is metalnephrine - can't find it in any books or pubmed....

[mwbeah]

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....(posting from athomas)

Its your job to find those things out (last time I remember....hmmm last night in fact... I didn't magically place the ETT in the patient on the floor. I was paged, I went to the floor, had to make sure the equipment was there, OH and by the way made the nurses give me a history while applying a proper BVM and ventilating), if you are pushing agents with no knowledge......its on you. If you take a second and assess the situation you are only helping the patient, going blindly into a situation is not the right answer.

Metalnephrine is a military analogy for an unresponsive patient getting only a laryngoscope followed by an ETT.

Right now you are practicing on other providers' licenses and you aren't thinking of what you need to think about......... As for expressing your opinions I say go for it, do it professionally, but (as I do) respect the opinions of people who have the experience.

Mike CRNA

[Tenesma]

boy am i glad that we are finally having a clinical discussion

1) I use sux on a regular basis for RSI in the OR setting - especially if I am planning on having them intubated for a while.... but I limit my use of sux to patients who are good candidates.... generally you have a good history and know whether sux is appropriate, and if you don't have a good history (ie: crash c-section or trauma) then sux is worth the risks (as most people who come in as crash c-sections or traumas were ambulating before and don't have much change as far as their acetylcholine receptors go).

2) i DON'T use SUX for codes or for intubations on the floors or in the ICU for the specific reason that usually nobody has a good history of the patient, the patient needs relatively rapid airway control without losing the airway, and you have no idea if the patient has A) pseudocholinesterase deficiency B) been lying around on the floor or ICU for a while and has in the meantime become a set-up for hyperkalemia and hyperkalemic arrest.

Now you could argue this is a blanket statement based on my preferred way of practicing.... but you could also look at the literature which supports NOT using succinylcholine in the above-mentioned settings:

- Eur J Anaesthesiol. 1998 Mar;15(2):240-1 Suxamethonium-induced cardiac arrest and death following 5 days of immobilization

- Anaesth Intensive Care. 1997 Oct;25(5):588-9 Hyperkalaemic cardiac arrest following succinylcholine in a longterm intensive care patient

- BMJ. 1996 Sep 14;313(7058):692 Hyperkalaemic cardiac arrest. Use of suxamethonium should be avoided

- Crit Care. 2001; 5(5): 245-246. Is succinylcholine appropriate or obsolete in the intensive care unit?

- Crit Care Med. 2001 Jun;29(6):1274-6. Succinylcholine-induced hyperkalemia in a patient with mucositis secondary to chemotherapy

- Rev Esp Anestesiol Reanim. 1996 Dec;43(10):349-53 Succinylcholine induces hyperpotassemia in patients in critically ill patients

- Am J Health Syst Pharm. 2003 Apr 1;60(7):694-7. Cardiac arrest from succinylcholine-induced hyperkalemia

- Anesthesiology. 2001 Mar;94(3):523-9 Cardiac arrest after succinylcholine: mortality greater with rhabdomyolysis than receptor upregulation

- Anesthesiology. 2000 Dec;93(6):1539-41 Unexpected hyperkalemia following succinylcholine administration in prolonged immobilized parturients treated with magnesium and ritodrine

- Ned Tijdschr Geneeskd. 1996 Jun 22;140(25):1293-5 Suxamethonium risky in intensive care

- Acad Emerg Med. 2000 Dec;7(12):1362-9. comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients

- Anesth Analg. 2000 Dec;91(6):1552-4, TOC Succinylcholine-induced hyperkalemia and rhabdomyolysis in a patient with necrotizing pancreatitis

- Anesth Analg. 2000 Jul;91(1):237-41 Succinylcholine-induced hyperkalemia in patients with renal failure

- J Clin Anesth. 2000 Feb;12(1):80-2. Cardiac arrest due to succinylcholine-induced hyperkalemia in a patient with wound botulism

- Anaesth Intensive Care. 1999 Dec;27(6):636-8. Suxamethonium and critical illness polyneuropathy (great paper by the way).

- J Clin Neurophysiol. 1999 Jan;16(1):46-50 Succinylcholine induced hyperkalemia and cardiac arrest death related to an EEG study

- Acta Anaesthesiol Sin. 1998 Sep;36(3):165-8 Succinylcholine-induced cardiac arrest in unsuspected becker muscular dystrophy

so here is the evidence in the literature (most of which is very current). Now I can understand that some people need the crutch of a muscle relaxant in order to intubate somebody (this is a little tongue-in-cheek response for the person who suggested I am insecure in my intubation skills :) ), but I would suggest that if you talk to the patient, and provide them with some minimal sedation, it is actually quite do-able! Now for those who still think sux is a god-send, then i think this is the opportunity to show me the LITERATUREE that sux is better for airway management on the floors or in the ICU (i am excluding the ER, because in the combative trauma patient, sux is the appropriate drug - even though the Emergency Medicine literature is starting to sway more towards roc).

and if I were ever to enter a room, and they are bag-masking a purple patient, despite the patient having received "VEC" then sux would not really come to mind, as it appears obvious that this patient is 1) non-combative 2) ready to be intubated 3) already is paralyzed.

[mwbeah]

Tenesma,

I have been following your post here and at the student doc forum and the "intubation skill" comment was only meant to create thought since most of the posters here seem to be students and may not be thinking about airway algorithms when they are in the moment (you know as well as I that being calm and collected comes with experience).

I respect the way you practice and I stated that sux has its place (by the way, obviously, when the vec was in I didn't need anymore paralysis:) ). I guess my comments that every situation is unique and requires thought keeps getting forgotten. Of course there are the usual suspects for the contraindication of sux (and we should all (for the posters) know the physiology behind why), I never said that there weren't.

Also, as you well know, there is literature on both sides of the argument (I will post the references after I pull them out of my pdf files if you wish). My point is this, as long as people are thinking about what they do and the pros/cons of what they are doing then they are actively thinking and adjusting fire accordingly.

I may have been aggressive in my comments and I apologize for them.

Thanks for the references, I always read (at the least the abstracts) them. In fact here is a review you might be interested in:

Summary of a Cochrane Review (The Cochrane Library, published by Wiley & Sons, Chicester. Issue 1 of 2004)

Title Rocuronium versus succinylcholine for rapid sequence induction intubation

Author Perry J, Lee J, Wells G

Mike CRNA

[gaspassah]

Right now you are practicing on other providers' licenses and you aren't thinking of what you need to think about.........

crna or not this is really not appropriate in a discussion among professionals. yes i am a professional, i dont have the licensure yet but my years of experience as a rn make me one. my status as student does not make me less of one.

to suggest that students haphazadly run hilly nilly filling ppl full of paralytic is not fair. part of the learning process is and should be discussions from preceptors explaining why certain drugs are given. also from a student standpoint learning about the drugs we give, why we give them, and under what circumstances to give them are what we do.

do i think about what is going to happen every time i push a med...especially a paralytic, you bet your a$$ i do. am i contemplating the alternative of airway control if i cant intubate? you bet, if youre not, you need to get out of the OR. just because i am not "technically" liable for my actions during clinical does not mean i dont treat my actions as though i am.

if you look at my first post in this thread i stated that each case is individual (paraphrased). you have to look at each situation and determine the appropriate action for that situation.

as a student i feel it is necessary to stand up for us as a whole, are there some students who do what they are told without thinking? probably but not all of us. on the day i graduate, that does not make me all the sudden omnipotent and all knowing about anesthesia. i have seen crna's and mda's with years of experience that scare me. licensure does not make you flawless.

as a student we look to people with experience for guidance, that is what we are here for, but also we must learn to think and act as though OUR license is on the line.

these are but my humble opinions. i have no malice in this discussion.

d

[athomas91]

i will say amen, amen and amen again.....

mike - i truly am continually in learning mode... and i agree with sux when indicated - and this isn't always "my decision" because you are right - i am practicing under other licenses and i am very careful when doing that - out of respect for them. i guess my overall point was...that as a student...in the icu/floor setting - from the limited amount i have seen - i have found that keeping them breathing and intubating has been successful..

and thanks for the definition!

Andrea

[qanik]

"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........."

Well I guess this is not the place to make a comment and try to learn or question something. I will take my humble thousand or so intubations over the past 19 years and keep opinions to myself untill I finish school and reach such "big dog" crna status

Humble student

[mwbeah]

Don't be so defensive, if you take the time and peruse the threads that have been posted, you will get my drift. Some of the postings seem to be somewhat embellished (some of them are real questionable).

Confidence in a provider is a huge asset, arrogance in a provider puts a patient at risk. When your the only one around and are expected to be the expert, I hope that your training serves you well (I really do). :)

If you are getting this upset over the forums then you will get agitated over clinical scenarios and possibly not think straight. Intubation is a task that with practice anyone can learn, managing a patient requires a cool head. (you should know that by now). Knowing what you do and why you do it is what you are learning (and will continue to learn throughout). Hey I know I am not always right, I know what I know and I know what I don't know (which is what collaboration is all about).

Again, don't be so defensive. You will find that questioning EVERYTHING with tact and poise will be one of your best assets. You have got to be able to get your point across and stand your ground while not stepping on toes(remember all of the CRNAs were on the floor and have years of experience also). Hey, I respect someone with a firm stance, shucks (if you can't already tell) I have my own. The way you explain yourself, your opinions, your language will set a tone in the minds of all CRNAs, RNs, MDAs, PAs, etc that you work with (your reputation basically will be founded on how you carry yourself).

All CRNAs have been in the shoes of SRNAs (don't forget that), you may not believe me but everyone "disappears" after graduation and you are all of a sudden omnipotent. Judgments will be yours and yours alone, you will be expected to handle certain things on your own and also be expected to collaborate with your senior clinicians and MDAs when appropriate.

My point is that this discussion was a perfect example of how people do things differently and thats OK as long as you have an evidence based reason for why you did it and can defend it at M&M if something goes wrong. I am sure you have attended those and can see what kind of shark frenzy can arise if the clinician cannot defend their actions.

Mike CRNA

[athomas91]

If you are getting this upset over the forums then you will get agitated over clinical scenarios and possibly not think straight. Intubation is a task that with practice anyone can learn, managing a patient requires a cool head. (you should know that by now). Knowing what you do and why you do it is what you are learning (and will continue to learn throughout). Hey I know I am not always right, I know what I know and I know what I don't know (which is what collaboration is all about).

now see....it is things like this that get tired cranky unpaid students riled up... it is complete BS to think that speaking our mind on an internet forum and letting you know about it means that we become agitated in clinical scenarios and "possibly" not think straight...that is kind of a broad generalization, don't you think? clinical setting is completely different from the comfort of my own home...here we are not on our toes and we are not demanding 100% of ourselves... I would have to say, the majority of us wouldn't be in school if we didn't demonstrate complete professionalism and grace under fire...or we would shortly be dismissed. Speaking from years as an ER and Trauma nurse...many of us thrive under pressure...so...be careful of the generalizations.

have a good holiday!

[mwbeah]

now see....it is things like this that get tired cranky unpaid students riled up... it is complete BS to think that speaking our mind on an internet forum and letting you know about it means that we become agitated in clinical scenarios and "possibly" not think straight...that is kind of a broad generalization, don't you think? clinical setting is completely different from the comfort of my own home...here we are not on our toes and we are not demanding 100% of ourselves... I would have to say, the majority of us wouldn't be in school if we didn't demonstrate complete professionalism and grace under fire...or we would shortly be dismissed. Speaking from years as an ER and Trauma nurse...many of us thrive under pressure...so...be careful of the generalizations.

have a good holiday!

This is what I am talking about, let me see, you were born in 75, that means that you are what 28 (December you turn 29)? So you at the earliest graduated at 22-23? OK three to four years nursing experience........get my point. If you read the postings from you and your colleagues it appears that you are padding your stories to potential candidates. Just be who you are, not more, not less. There is no point in intimidating potential candidates (unless that person feels some gratification at that type of thing which would be very unprofessional).

I guess it bothers me when people embellish because its an integrity issue, if people are not forthright about their background or "pad" their resume......are they honest to their staff about what they have given a patient? Are they forthright when they answer their instructors..."have you checked {so and so}....." If you are offended by what I have said I am sorry but it is said the "if the glove fits........."

So when you say "speaking your mind (as a student)", are you really speaking the truth? (Hey, whomever wants to know my background, I am an open book and with provide it upon request. I am very upfront about what I am and what I am not.) To me, integrity is part of professionalism.

Everyone wants to throw in their "ER" or "trauma" experience. Have you ever seen a 21 year old soldier with both of his legs traumatically amputated by an RPG? Or a 22 year old marine with no face? How about a 27 years old marine with the back of his skull gone? I can send you pictures of battlefield trauma and anesthesia if you wish. There are only a few of us that have and we are a small community of CRNAs (Army, Navy, Air Force).

Don't get peeved when someone with more experience in your specialty makes "general" statements (we make them because we have seen it happen). I know I certainly listen to my senior (experience wise) colleagues and try to learn from their experience.

And in my opinion, you should always demand 100% of yourself no matter where you are at......

Have a nice holiday,

Mike CRNA

[athomas91]

This is what I am talking about, let me see, you were born in 75, that means that you are what 28 (December you turn 29)? So you at the earliest graduated at 22-23? OK three to four years nursing experience........get my point. If you read the postings from you and your colleagues it appears that you are padding your stories to potential candidates. Just be who you are, not more, not less. There is no point in intimidating potential candidates (unless that person feels some gratification at that type of thing which would be very unprofessional).

I guess it bothers me when people embellish because its an integrity issue, if people are not forthright about their background or "pad" their resume......are they honest to their staff about what they have given a patient? Are they forthright when they answer their instructors..."have you checked {so and so}....." If you are offended by what I have said I am sorry but it is said the "if the glove fits........."

So when you say "speaking your mind (as a student)", are you really speaking the truth? (Hey, whomever wants to know my background, I am an open book and with provide it upon request. I am very upfront about what I am and what I am not.) To me, integrity is part of professionalism.

Everyone wants to throw in their "ER" or "trauma" experience. Have you ever seen a 21 year old soldier with both of his legs traumatically amputated by an RPG? Or a 22 year old marine with no face? How about a 27 years old marine with the back of his skull gone? I can send you pictures of battlefield trauma and anesthesia if you wish. There are only a few of us that have and we are a small community of CRNAs (Army, Navy, Air Force).

Don't get peeved when someone with more experience in your specialty makes "general" statements (we make them because we have seen it happen). I know I certainly listen to my senior (experience wise) colleagues and try to learn from their experience.

And in my opinion, you should always demand 100% of yourself no matter where you are at......

Have a nice holiday,

Mike CRNA

ok..first of all I graduated with my BSN in 1998 - so this spring i will have been a nurse for 7 years...and i am only in my first year (soon to be second) - secondly because you do not personally know me i will not hold your assumptions against you but chalk them up to ignorance. I have no need to pad stories - like just about every SRNA and CRNA out there I have strived for perfection and success my entire life. I have worked in between 10-15 ER/Trauma Centers - many of them at once... and scholastically I am privaledged to have amazing sites that provide me with a ton of experience with very little "problems" as many of my classmates have encountered at other facilities. You are correct - I haven't seen soldiers with injuries you mentioned - but i have cared for 12 y/o with their brains hanging out, infants who have been so critically injured by their own parents they have died, car accident victims with so many injuries it is a wonder they lived... so I have seen horror as well -yet it doesn't make me an expert - nor does it make you.

I thoroughly enjoy learning from my instructors when they are willing teachers rather than ... well rather than the type of CRNA you have come off as in your posts. I am sure you are an excellent provider - but you speak of me (directly) and other students (indirectly) as if you have any idea of how we practice or what we know or how we value learning. I demand 125% of myself at all times and my clinical staff as well as my didactical staff HAVE put that in writing. I have no need to embellish - and anyone who actually knows me would tell you that without blinking.... it is really sad that you function in such a negative fashion..

i will no longer respond - because this forum is for learning and not ignorant idle spats. good luck to you -

[Pete495]

Mike, I understand your point that students should submit to learning, but one could interpret your comments meaning teachers can't learn anything from their students. I don't understand why you think people are padding their resumes, stories, and such. maybe some do, but the majority come to this board because it is useful no matter what their background. To say otherwise is a lot of assumption, and hithers to minimize the effect of this board. Yeah, maybe I'm "just a student," but as a leader in other situations, I have the respect of my followers, as well as my leaders, and if I become a CRNA, I intend to be humble to my subordinates as well as those above me. On the same end, one needs to earn the respect of those below and above. Looking back at the posts, it appears athomas was only discussing his own experiences and knowledge, which is what the board is for. Nobody's pretending to know more. there just trying to learn as much as they can.

The bottom line is it's a discussion between professionals of different backgrounds and personalities. So what happen to the discussion on sux and intubating anyway?