Why Succs after Etomidate?

[ck8ws3]

I'm a critical care nurse who's worked in the inpatient setting my entire 10 years of my nursing career. I'm not transitioning to critical care nurse transport and have a few new potential duties, one of which includes supraglottic airways via I-GEL; completely new to me. I've done my research on succs and Etomidate, watched videos, etc. I guess to get right to the point, my question is this:

If you're giving Etomidate, general anesthesia, essentially putting the patient to sleep, why would you need to then follow up with a NBA, I.e. Succs or other? Just to relax the muscles, making it easier for advanced airway placement? I'm so curious to learn more. 

[akulahawkRN, ADN, RN, EMT-P]

You sedate first then use the neuromuscular blockers. It's incredibly frightening to the patient if they're awake and are paralyzed. If you don't sedate them, they'll remember everything you do to them until they're sedated adequately. It's basically a form of torture. 

Also the NMB's are used to completely relax the skeletal muscles which will (usually) greatly facilitate the intubation attempt. Once you paralyze the patient, you also take 100% responsibility for maintaining their airway. Lose that and your patient can suffer severe consequences such as anoxic brain injury or even die.

[Lipoma, BSN, RN]

The airway may also still be reactivate during manipulation (inserting ETT and keeping it there) even after inducing the patient using etomindate or propofol. So NMBAs such as sux and roc further helps to minimize such reaction and minimize bronchospasms. This ensures the patient is able to ventilate and perfuse efficiently. 

Also as the above poster stated, patient safety and comfort is most important. We do not want the patient to be frightened which can cause postop delirium so its best to sedate them first before paralyzing. Imagine trying to breathe spontaneously but that effort was taken away and you're still awake. 

[ck8ws3]

Thank you. The first portion of your comment is what I was trying to get from people. I figured the NBA was to help with ease of placement due to muscle relaxation. I 100% understand the sedate before NBA. I appreciate your input; thank you. 

[Lipoma, BSN, RN]

ck8ws3 said:

Thank you. The first portion of your comment is what I was trying to get from people. I figured the NBA was to help with ease of placement due to muscle relaxation. I 100% understand the sedate before NBA. I appreciate your input; thank you. 

I meant reactive* not reactivate lmao. But no problem! Keep curious as you venture into critical care transport. Good luck.

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi,

As a paramedic who has intubated people who are not paralyzed it can be extremely difficult, because even if the gag reflex is gone, the vocal cords will continue to open and close accordingly, and they will also continue attempting to swallow which moves all the structures you are trying to view.    Obviously, as a medic I am only doing this to save someone's life, so the risks of doing it without paralysis are low vs the risk of not protecting their airway and/or taking over the ventilatory effort. 

If you intubate while the vocal cords and all the other structures are still moving, you risk injuring  their vocal cords (which can cause permanent damage) or any of the other fragile tissue that is in the airway, which can also cause significant bleeding.  There is also a risk that they do in fact still have a gag reflex and you cause them to vomit and aspirate while trying to intubate.  Trust me when I say that it is MUCH easier to intubate someone who has received paralytics than someone who has only received sedation or anesthesia.   Obviously the downside to paralytics is that if you cannot ventilate and cannot intubate, you are now stuck doing a surgical airway on someone who otherwise wouldn't have needed it, but that is a minority of patients, especially with video laryngoscopes and boogies.