Clinical - Induction Sequence and Ventilation

DreamMatrix · Oct 3, 2005

I always ventilate my patient prior to pushing muscle relaxants, unless I'm doing a rapid sequence induction. If I can't ventilate despite my most ardent attempts (I would suspect some pathology if that happened, since the major reason you can't ventilate is obstruction), I would allow my patient to wake up. You should always pre-oxygenate/denitrogenate your patient for an adequate amount of time to fill the FRC with oxygen and prevent desaturation.

athomas91 · Oct 3, 2005

charles-thor-

i likewise (if not RSI or contraindicated) attempt ventilation prior to paralyzation - i don't think that i have nearly enough experience to risk it - :)

rn29306 · Oct 4, 2005

Ventilate before norcuron always, unless my anesthesiologist goes down the line pushing all syringes at once. You know how it is, some prefer to push their own drugs and you just have to let them be the BIG man. Others prefer to let us learn and push our own drugs. I guess they have confidence in a senior, then also themselves if I don't get it (very rare, but does happen).

Debatable with sux.

gaspassah · Oct 4, 2005

ventilate

rsi no ventilate.

although i had a mda question why i ventilate prior to muscle relaxant, his argument is that the sleep agent keeps then apnic long enough for brain damage :eek: . my argument was that if it goes to court, at least i was trying to let the patient wake up since i couldnt vent./intubate.

NCgirl · Oct 4, 2005

ventilate
rsi no ventilate.
although i had a mda question why i ventilate prior to muscle relaxant, his argument is that the sleep agent keeps then apnic long enough for brain damage . my argument was that if it goes to court, at least i was trying to let the patient wake up since i couldnt vent./intubate.

Same here, ventilate unless RSI. If I tube on Sux, a couple of breaths then go. If tubing on Roc, I turn on some sevo and ventilate until I feel the bag change compliance. If I'm not ventilating, I first reposition my hand and then mask. If that doesn't work, then I use an oral airway. I've been lucky, that's always worked for me. I've been told that in order to say a pt is "unable to ventilate", you must have an oral a/w in, as well as a trumpet in each nare. That would be my next step.

mwbeah · Oct 4, 2005

On induction, I ventilate (unless RSI) but I rarely use nondepolarizing muscle relaxants. I give roughly .6 mg/kg of sux as my intubating dose (2x ED95). I have to have a reason not to use sux (of course we all know the usual suspects with reference to using sux).

My take on it is this, 2x ED 95 gives roughly 3 minutes of paralysis (as compare to 5-8 with 1 mg/kg or more). If I were to run into a problem I know that they will return to SV quickly.

(also, with experience you will find that you don't need nearly as much propofol, pent, etc to induce your patient).

Just my take,

Mike

mwbeah · Oct 4, 2005

On induction, I ventilate (unless RSI) but I rarely use nondepolarizing muscle relaxants. I give roughly .6 mg/kg of sux as my intubating dose (2x ED95). I have to have a reason not to use sux (of course we all know the usual suspects with reference to using sux).
My take on it is this, 2x ED 95 gives roughly 3 minutes of paralysis (as compare to 5-8 with 1 mg/kg or more). If I were to run into a problem I know that they will return to SV quickly.
(also, with experience you will find that you don't need nearly as much propofol, pent, etc to induce your patient).
Just my take,
Mike

Just wanted to add that situations will stress you from time to time and you will find yourself without backup (some if not most of you all):

"Don't panic, just handle it".

Offtopic: (below, this topic reminds me of a "dance")

I have seen a few SRNAs do this "pinball dance" when things don't go exactly as planned (you know move to the machine to the cart to the OR table to the machine to the cart to the OR table......... in fact I am sure I did it as a student :lol2: )

charles-thor · Oct 5, 2005

I posted this question due to the wide discrepancy in practice I've observed as a student, however I didn't expect to get pretty much the same answer from everyone.

I've heard that lots of practitioners would push the sux if unable to ventilate, as this loosens up the airway and will, in fact, make ventilation, LMA insertion if can't ventilate, ect easier 99.99999% of the time. They go on further to say that it therefore makes more sense to push everything at once.

Thanks for the replies.

versatile_kat · Oct 5, 2005

Same here, ventilate unless RSI. If I tube on Sux, a couple of breaths then go. If tubing on Roc, I turn on some sevo and ventilate until I feel the bag change compliance. If I'm not ventilating, I first reposition my hand and then mask. If that doesn't work, then I use an oral airway. I've been lucky, that's always worked for me. I've been told that in order to say a pt is "unable to ventilate", you must have an oral a/w in, as well as a trumpet in each nare. That would be my next step.

I think I was with the same CRNA that told you about the 2 nasal trumpets and oral airway, tonight! He makes a good point ...

yoga crna · Oct 12, 2005

I like to ventilate first for another reason. It gives you and the patient a chance to correct any problems that may happen at the last minute. Did the bag mysteriously fall off the machine, was the circuit not properly checked after the soda lime was changed and other strange things that can and do happen in an OR. I would rather correct these things prior to paralyzing a patient.

The other big reason, is knowing I can ventilate prior to paralysis.

Safety is always the most important thing we do.

Yoga

TraumaNurse · Oct 12, 2005

NCgirl and Versatile_Kat,

That is too funny. When I was training to be a flight nurse, the Ologist I was working with said the exact same thing...."you can't say 'unable to ventilate' until you have an oral and two nasal airways". I guess he had a point. I am glad I have never had to go that far.