Intubation - confused about orders

mwlude · Dec 14, 2014

so in this case it might be pertinent to look at your onset times with these medications. The paralytic in question is a non-depolarizing paralytic which typically has a longer onset than say succinylcholine. Its common for docs to request rocuronium to be given BEFORE the sedation package with the idea that by the time it exerts its full clinical effect the etomidate is already in and taking its effect so... no harm no foul, I'm my experience it doesn't make a difference either way, I won't comply typically if we were talking about short acting succinylcholine but for roc I'm usually fine with it. Either way the patient is going to experience pain because remember...etomidate does not provide analgesia...

Don't feel too bad.

Here.I.Stand, BSN, RN · Dec 15, 2014

I see suggestions of being a cutesy nursing and 'suggesting' a dost of etomidate. I cut out the cutesy and simply say, " Let's give a sedative first please and then we will talk our paralytic dosing."

You're right, although when I typed that post (which I tried to edit but then it posted twice...strange) in my head I wasn't thinking cutesy or coy. I was thinking more like a kick under the table and a chance for him to save face. I can see how my wording seemed like I could be dropping a subtle hint, though, and the tone I was thinking in my head doesn't translate to text. If the MD insists on the paralytic first, or if it's an emergent situation then absolutely just cut straight to the "No, I'm giving the sedative first."

OP, your comfort level will get there. Just keep in mind that advocating for your patients will sometimes mean questioning medical orders. Every once in a while, you'll get an order that is simply not appropriate. We're responsible for what we do, although we don't write the orders ourselves.

Sugarcoma, RN · Dec 17, 2014

Roc takes 2 minutes for onset. Etomidate is 50-60 seconds with a duration of 3-5 minutes. I would be more worried about what was ordered for my patient following the intubation ie Fentanyl/Versed combo for comfort after the Etomidate wore off.

Was Roc the only paralytic used? Some docs still use sux and will ask for a small (defasciculating dose that does not paralyze) of rocuronium prior to administration of sux. I have only seen this in ER though.

Do not beat yourself up. Your new to this. You asked your coworkers for help. Sometimes the advice we get from coworkers is not always the best. I would definitely ask your charge what the rationale is for pushing the meds "exactly as the doctor said" just to get her input.

Things happen so fast in the unit there is not always time to look things up. Spend your off time memorizing medications you use frequently. Many nurses make themselves "cheat sheets" with avg. dosages, onset, pharmacology, etc. they keep in their pockets or taped to the back of their badges for reference. It takes awhile between meds, hemodynamics, vents, and conditions to learn ICU. Remember there is nothing wrong with asking the docs why? I spent the first year in the unit saying "I'm new, why are we doing it like this"?

2critical · Dec 17, 2014

That's just the thing... while the ABG was almost normal, the fact that the patient required a non-rebreather mask to maintain the SpO2 of 95% means something is wrong. RR being "normal" is only one part of the puzzle. What was the respiratory effort? Was the patient's tidal volume sufficient? Was this patient tiring out?

Sorry but I have to disagree. The fact that he was on a non-rebreather and not a bipap before intubation shows that he hadn't deteriorated far enough to require one based on 95% sp02 and non acidotic abg results shows that this was non emergent. Paralytic should not have been given first.

Guests · Dec 17, 2014

Our docs always lead with the roc and then follow immediately with the etomidate. I asked about it and was told that the onset of the roc is much slower so the total rsi time is minimized by giving it first.

As the doc put it, "they're still sedated them before we paralyze them."

akulahawkRN, ADN, RN, EMT-P · Dec 17, 2014

Sorry but I have to disagree. The fact that he was on a non-rebreather and not a bipap before intubation shows that he hadn't deteriorated far enough to require one based on 95% sp02 and non acidotic abg results shows that this was non emergent. Paralytic should not have been given first.

Disagree all you want, I'm OK with that. CPAP or Bi-level use is a good bridge and sometimes can prevent or greatly delay an intubation and can/does reduce the amount of time a patient does spend on a vent. We know this. A near normal ABG (which wasn't provided) is part of the puzzle. A "near normal" ABG tells me very little about what's going on and doesn't tell me if this is something that's compensated, partially compensated, or if it's within normal limits and the patient hasn't yet started to decompensate. Unless you can run an ABG basically at the bedside, it's going to be a somewhat lagging indicator of respiratory effectiveness. A patient that needs a non-rebreather to have an SpO2 of 95% isn't actually doing all that well. That means the patient probably has an FiO2 of >90% to maintain that SpO2. If the patient is working to ventilate, that might not yet be reflected in the ABG quite yet. CPAP and Bi-Level depend upon the patient's own drive. If the patient becomes too tired, they're not going to be able to trigger the Bi-Level support all that well. That's why I was asking if the patient was tiring out. Tired patients just don't breathe all that well. When that happens, the patient then needs more emergent airway support with all the risks associated with having to organize and carry out an emergent intubation. I would hope that you wouldn't be calling for intubation based solely on ABG results.

Show me where the ABG was actually shown to be "non-acidotic" and I'll be very glad to say something else. Airway and breathing control is something that it's good to be aggressive about. What we also don't know is what else was going on clinically with the patient. It very well could be that this may have been effectively an elective intubation at that particular time, but on the other hand, it could be that the Doc was anticipating something else coming down the pike and chose to intubate now versus having to do it under more emergent conditions.

I did disagree with pushing the paralytic first. However, I can also see why the paralytic may have been pushed first and then (if done reasonably quickly) the sedative could have been pushed, and that would have been only if the sedative onset would have been faster than the onset of the Roc, thus still sparing the patient the discomfort of paralysis. IMO the sedative should have been given first and then the paralytic. RSI is one of those procedures that should be done deliberately. Very deliberately so that at all times the patient's safety is as assured as possible.

I will certainly disclose that as I was trained as a Paramedic, I do tend to think about being fairly aggressive in terms of airway control and prefer to remain ahead of things whenever possible so that I don't have to deal with crash airway attempts. I also prefer to allow patients to manage their own airway as much as possible.

akulahawkRN, ADN, RN, EMT-P · Dec 17, 2014

Our docs always lead with the roc and then follow immediately with the etomidate. I asked about it and was told that the onset of the roc is much slower so the total rsi time is minimized by giving it first.
As the doc put it, "they're still sedated them before we paralyze them."

Given the onset times of those meds, this makes sense, though I'm sure that your docs are doing this under more of a time crunch than what probably was happening here. Your docs are probably doing RSI under more emergent conditions. While this patient probably needed the tube, it probably didn't have to be done ASAP, given what was presented here so far. If it was an emergent tube, I agree with minimizing the total time to go from NRB to intubated on a vent.

RNexplorer · Dec 17, 2014

Disagree all you want, I'm OK with that. CPAP or Bi-level use is a good bridge and sometimes can prevent or greatly delay an intubation and can/does reduce the amount of time a patient does spend on a vent. We know this. A near normal ABG (which wasn't provided) is part of the puzzle.... What we also don't know is what else was going on clinically with the patient. QUOTE]
The ABG was compensated respiratory ALKALOSIS. He had sleep apnea and CHF... Ejection fraction was not too bad - 45%.... His lungs had a few fine crackles and expiratory wheezes. Another thing I forgot to mention: he was originally on BiPAP, but he had refused this treatment... hence the non-rebreather.
I don't think this was an emergent intubation by any means. I was actually surprised that my patient required the intervention, but as a new nurse I realized there's a lot I still do not know!

Mully · Dec 17, 2014

An important clarification is how quickly after the roc did you give the Etomidate?

As many people have pointed out, the onset of rocuronium is slower than the onset of etomidate, so it makes sense to push the roc first. Because of this, I wouldn't be so forceful/blunt with my response as some of the nurses here have suggested. However, it is ALWAYS okay to question an order if it doesn't seem right or doesn't jive with what you've been taught, and anyone that gives you a hard time for doing that is hindering patient safety.

In anesthesia, we give rocuronium after the sedative, but we bag them with anesthetic gases in the meantime while we wait for the roc to kick in. Since on the floor that is not an option, I understand the order of drugs pushed.

A few clarifications: Technically what your docs did is a standard induction, not a rapid sequence induction (RSI). A rapid sequence means you used succs and you didn't ventilate the pt at all (likely due to aspiration risk/Mendelson's syndrome).

Etomidate/Propofol/Ketamine's onset is one arm-to-brain circulation time. Basically, as fast as that drug can get to the brain, it starts working. I'd be comfortable giving roc and waiting a good minute before giving my sedative due to this. The first thing you're likely to see when giving a conscious patient a NMB is they'll complain that it's getting harder to breath. This would be your signal that the NMB is taking effect and they really need to be sedated. However, this may not be an option in someone who is already struggling to breath or isn't conscious to begin with.

It's hard to navigate the waters as a new grad. Don't be too hard on yourself. However, in the future, if something doesn't feel right, it should be verbalized. It is wise to get into the habit of asking the questions that are burning inside of you. It will likely save you and/or your patient some day.

akulahawkRN, ADN, RN, EMT-P · Dec 17, 2014

Disagree all you want, I'm OK with that. CPAP or Bi-level use is a good bridge and sometimes can prevent or greatly delay an intubation and can/does reduce the amount of time a patient does spend on a vent. We know this. A near normal ABG (which wasn't provided) is part of the puzzle.... What we also don't know is what else was going on clinically with the patient.
The ABG was compensated respiratory ALKALOSIS. He had sleep apnea and CHF... Ejection fraction was not too bad - 45%.... His lungs had a few fine crackles and expiratory wheezes. Another thing I forgot to mention: he was originally on BiPAP, but he had refused this treatment... hence the non-rebreather.
I don't think this was an emergent intubation by any means. I was actually surprised that my patient required the intervention, but as a new nurse I realized there's a lot I still do not know!

Then this further makes me wonder... because why would the patient be in compensated respiratory alkalosis and refusing a BiPAP mask? I would normally expect that someone in alkalosis could be managed by medication that decreases a person's respiratory drive and eventually cause an increase in retained CO2, thereby increasing the body's pH a little bit. I would expect that a BiPAP would/could make this worse because of the increased ventilation that it can provide, so do you have any idea what was causing the patient such strong stimulus to breathe fast enough to go into compensated respiratory alkalosis?

If you remember/have the ABG results, that would probably help make things more clear.

Guests · Dec 17, 2014

It is wise to get into the habit of asking the questions that are burning inside of you. It will likely save you and/or your patient some day.

It will also save you from looking foolish.

When I realized that my docs were leading with the roc, I was well aware of the standard sedative-before-paralytic paradigm but if I had responded the way that some have suggested in this thread, I'd have looked foolish and lost some credibility with the docs. Instead, I presumed that they must have had their reasons, which they did, and which they were happy to share when asked.

There's no disagreement that the patient should ideally be sedated prior to being paralyzed but the drugs don't necessarily need to be given in that order.

RNexplorer · Dec 17, 2014

Then this further makes me wonder... because why would the patient be in compensated respiratory alkalosis and refusing a BiPAP mask? I would normally expect that someone in alkalosis could be managed by medication that decreases a person's respiratory drive and eventually cause an increase in retained CO2, thereby increasing the body's pH a little bit. I would expect that a BiPAP would/could make this worse because of the increased ventilation that it can provide, so do you have any idea what was causing the patient such strong stimulus to breathe fast enough to go into compensated respiratory alkalosis?
If you remember/have the ABG results, that would probably help make things more clear.

That's a good point and made me wonder at the time... It all seemed so weird to me. Sorry, I can't remember the exact numbers. However, I do recall a normal pH, on the upper end of normal (7.41 to 7.45; therefore FULLY compensated). pCO2 was on the low end, but again I can't recall the value. Bicarb was on the low end (indicating compensation)...

I found his ABG strange because I would have expected respiratory acidosis with the diagnosis... I agree that it's impossible to analyze now without all the data.