i have an issue i would like a little feedback on...here's how the discussion went.
me: put pt to sleep, give a few breaths to asses ventilation. (standard induction not rsi)
md: why are you breathing the pt, go ahead and paralyze.
me: i want to see if i can ventilate first, then give the ndmr.(vec in this case)
md: it doesnt matter anyway, you have to get the airway.
me: if i cant ventilate this guy is paralyzed at least an hour.
md: so, you have to get the airway.
me:yeah but if i cant vent. at least he will be in the process of waking up while i try to get the airway, otherwise he wont do any be breathing.
md: how long does propofol last? he's still gonna get braindamage.
me: yeah but he wont be dead.
md: but how long does propofol last, he still wont breathe, he will have brain damage.
me: well it's dose dependant and at least when they put my chart on the wall in the courtroom i can say i was doing my best to vent, wake up the patient and get an airway. the other way pt is dead, i'm dead in court
md: you still have to get the airway
me: i am not paralyzing anyone that i dont know i can ventilate unless i have to. esp with longer acting agents.
so this went on for about 20 minutes, not heated but noone was gonna give any ground.
is there anyone who regularly paralyzes without regard to ventilation with non depolarizers.
or is it more the standard of care to assess ventilation first?
As we all know, fairly frequently you may be able to intubate without any paralytics at all.
The RSI arena is an entirely different ball-of-wax since you are trying to prevent aspiration in the susceptible patient. In this situation, you are making a judgement call that the risk if aspiration is higher than the risk of cannot-ventilate-cannot intubate. If you are really worried, an awake fiberoptic should be done.
In the situation you suggested Gotosleey, (ie. 3 year-old RSI susceptible to MH), your options (as you know) are high dose Rocuronium which burns you spontaneous ventilation bridge or to use nothing at all except your Propofol, which you'll be using for maintanence anyway.
Glad to know BTW, that Gotosleepy isn't defending not ventilating before paralytics, however, in gasspassah's narrative, that's exactly what the other individual was doing.
i don't think giving NDMB prior to establishing an airway is very smart at all... However, I frequently give NDMB prior to establishing an airway if I know that the patient has a recent history of intubations and was easy mask/easy intubation, or in a trauma situation where I know I need to secure the airway one way or another (tube or trach).... primarily to speed things along. Would that be defensible in court? i don't know.
but i think this board should focus more on these interesting clinical discussions, because they provide a lot of food for thought and provide for interesting contributions from different clinical view points
but i think this board should focus more on these interesting clinical discussions, because they provide a lot of food for thought and provide for interesting contributions from different clinical view points
Agree!! Some nights I wonder why I even check the forum anymore. This is the first subject where I have actually learned something in quite sometime. Thank you for posting your story. Tia Sophia
I had a case which pertains to this topic yesterday. One-and-a-half year-old born with VATERS syndome. No cardiac abnormalities. Transesophargeal fistula repair during first few days of life, multiple esophageal dilations and a Nissen since that time. Scheduled for PE tubes. No resent colds. J-tube, G-tube. Mother says he aspirates when he lies down and is also scheduled for a re-do Nissen.
Obviously a RSI is in order. What we did... Versed syrup... followed by 70% NItrous in the OR suite to start the line while he sat on my lap. Made it a bit difficult since he was a moving target. After the line was started, we immediately laid him on the table. Applied Cricoid pressure and did a RSI with Propofol and Succinylcholine.
Any comments... Would anyone have done this without the Succ and just straight propofol? Would anyone have used IM ketamine?
These are my kind of cases. I love peds. I like the way you had him in your lap. Nice touch. I may have placed the Sevo at 8 (yes, 8) placed in on the bed until the circuit an bag were full, then placed it on his face. If old enough get him to "sing" into the "microphone" or if he wants to cry, great, more inhaled. I never use nitrous. I prefer 100% O2 and gas. Never know when a kid will desaturate and I may need all the O2 possible. Good job. Love those cases!!!
Brenna's dad, did you use nitrous instead of agent because of aspiration factor after he would fall to sleep?
succs to me is kinda scary in kids that have genetic or metabolic disorders, i would be more likely to use succs on a kid with an appendix, etc.
also was this his first surgery, you said g and j tubes, could these be suctioned before you started to decrease asp risk.
i probably would have gone with roc with a priming dose. just to avoid the succs
also for me, i know it's tough on the kid but right now i feel better putting the child on the table and fighting than worrying something may go wrong and the kids in my lap, then got to put them on the bed position etc. for me it's about eliminating a step if a crisis were to occur.
Exactly gasspassah, we didn't want to use any agent because of the aspiration risk. When he was squirming, I thought pretty seriously about turning on a little agent, but never did. I also sat him in my lap speccifically becasue of the aspiration risk, although I like to induce all my kids under three or so in my lap.
Regarding the J-tube and G-tube, we did indeed suction the G-tube and then left it open to air while we intubated.
Does anyone think we could have just used straight Propofol.
Brenna's Dad
394 Posts
As we all know, fairly frequently you may be able to intubate without any paralytics at all.
The RSI arena is an entirely different ball-of-wax since you are trying to prevent aspiration in the susceptible patient. In this situation, you are making a judgement call that the risk if aspiration is higher than the risk of cannot-ventilate-cannot intubate. If you are really worried, an awake fiberoptic should be done.
In the situation you suggested Gotosleey, (ie. 3 year-old RSI susceptible to MH), your options (as you know) are high dose Rocuronium which burns you spontaneous ventilation bridge or to use nothing at all except your Propofol, which you'll be using for maintanence anyway.
Glad to know BTW, that Gotosleepy isn't defending not ventilating before paralytics, however, in gasspassah's narrative, that's exactly what the other individual was doing.