Intubating style - what's yours?

[BLADEMDA]

In many situations you are having to choose between Etomidate and Propofol for your induction agent. In elderly patients for example who need intubation secondary to COPD or Cardiac related conditions the choice between Etomidate and Propofol isn't a good one. Our literature shows even transient hypotension is associated with worse outcome. Etomidate has been linked to worse outcome as well (controversial, debatable). The answer is a low dose combo of Propofol and Ketamine.


Ketofol as a Sole Induction Agent is Associated with Increased Hemodynamic Indices in Low-Risk Patients
Nathan J. Smischney, M.D., Michael L. Beach, M.D.,Ph.D., Thomas M. Dodds, M.D., Matthew D. Koff, M.D., M.S.
Mayo Clinic, Rochester, Minnesota, United States
Background:

Propofol is a non-opioid, non-barbiturate, sedative-hypnotic agent with rapid onset and short duration of action.1 However, there are several undesirable side effects such as cardiovascular and respiratory depression. Ketamine is a phencyclidine derivative commonly classified as a dissociative sedative with fairly rapid onset and short duration of action.2 It causes little or no respiratory and cardiovascular depression. However, ketamine can have some undesirable effects on hemodynamics (opposite of propofol). Effectiveness of the two agents in combination has been recently demonstrated and this new combination could allow a novel induction agent with favorable effects on hemodynamics. This study aimed to ascertain if a combination dose of ketamine and propofol (ketofol) would produce more favorable hemodynamics than the standard induction agent, propofol in healthy patients.

Methods:

In this randomized, double-blinded controlled trial, 85 pts of ASA Class 1-2 scheduled for surgical procedures that involved general anesthesia were assigned to one of two arms, one involving induction with propofol and the other involving induction with ketofol (ketamine/propofol combination). Patients were placed on standard ASA monitors including a BIS monitor and a noninvasive cardiac output monitor (NICOM) prior to induction of general anesthesia.

One minute before induction, baseline hemodynamics were recorded with standard ASA monitors as well as with the NICOM. Providers were given one 20ml syringe and one 10ml syringe for rescue if needed. As part of the induction, fentanyl (1-2mcg/kg) and any relaxant but succinylcholine and pancuronium were given. The 20ml syringe in both groups looked identical, appeared to be propofol but depending on the group they were randomized to, it represented either 2mg/kg of propofol (propofol group) or 0.75mg/kg of ketamine and 1.5mg/kg of propofol (ketofol group). The 10ml rescue syringe, if used, represented 1mg/kg of propofol (propofol group) or 0.25mg/kg of ketamine and 0.5mg/kg of propofol (ketofol group). Hemodynamics were recorded every minute for a total of 30 minutes post-induction. During this time, anesthesia was maintained with any volatile agent excluding nitrous oxide.

Primary analysis evaluated reductions in systolic blood pressure (SBP) of more than 20% from baseline. Secondary analysis evaluated amount of vasoactive agents used between the two groups as well as differences in pain and nausea/vomiting scores. Data was analyzed using an un-paired t-test, chi square or fisher's exact test as appropriate. A p-value of <0.05 was considered significant.

Results:

Comparison of the ketofol and propofol groups demonstrated a significant decrease of more than 20% in SBP from baseline in the propofol group at both 5 minutes (48.8%; 95% confidence interval [CI], 2.07 to 26.15, p=<0.001) and 10 minutes (67.4%; 95% CI, 1.21 to 8.75, p=<0.01). This was also significant for diastolic blood pressure and mean arterial pressure. At 30 minutes, there was no significant difference among the groups (p=0.39).

No significant differences were noted between groups with regard to preoperative vital signs, ASA status, or preoperative home medications. There was a trend towards higher vasoactive agent use in the propofol group as compared to the ketofol group during the 30 minute study period (p-value 0.07). No significant difference in case duration, intraoperative fluid administration, urine output, or estimated blood loss.

Conclusions:

A significant difference in systolic blood pressure, diastolic blood pressure and mean arterial pressure was noted between ketofol and propofol with ketofol demonstrating improved hemodynamics during induction of general anesthesia. Further study is needed to determine if this combination could be of benefit in high risk patients.

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[ihearttriangles]

Just out of curiosity, could any current senior residents or recent graduates give a rough estimate of how many intubations they performed over the course of their residencies?

 

[Hamhock]

What I'm posting here is that perhaps the BEST agent(s) for an emergency induction is
a combo of Propofol and Ketamine. The next time you need to do an intubation give it a try: 1 mg/kg of propofol IV followed Immediately by 1 mg/kg IV of ketamine then the muscle relaxant (Sux).

Blade -- with all due respect to your experience and knowledge:

(1) Why propofol BEFORE the ketamine? I am aware of onset times for both, but I am most interested in HD stability over "smooth".

(2) Why sux? This is "emergency induction" (as you have been quoted). In other words, the tube needs to get in one way or the other. How is roc -- especially without a medical history -- not the superior drug?

(I often find my RSI/induction practice more similar to that of anesthesiologists than my EM friends-in-training, except for how much anesthesiologists (1) love early and high-dose propofol and (2) how much anesthesiologists love sux in trauma)

HH

 

[Bostonredsox]

Just out of curiosity, could any current senior residents or recent graduates give a rough estimate of how many intubations they performed over the course of their residencies?

I am 2/3+ through IM and I have about 95. Have an anesthesia month at the end and 2 CCM months left so hoping to be around 150.

 

[dotcb]

Unfortunately our neurosurgeons will throw a tizzy if we use any ketamine for any patients with possible head injury.

It's a pity, as the literature suggests this belief is false, and none of our ED staff agree with them.

l.

2. Propofol- 10 mg/ml. One of the best all around sedative drugs ever invented.

3. I use Ketamine on a regular basis in the operating room as an adjunct for my anesthetic. For short procedures in the ER it would be nice of you to limit the dosage of ketamine to 0.5 mg/kg. This should all but eliminate unwanted side-effects. Ketamine should be given after the propofol or mixed with the propofol but not before the propofol.

By administering low dose ketamine to the patient in the ER you will be providing analgesia and reducing the amount of propofol needed for the procedure. This reduction in propofol will diminish the chance of apnea or respiratory depression (which is usually just airway obstruction 99% of the time).

 

[Bostonredsox]

Blade -- with all due respect to your experience and knowledge:

(1) Why propofol BEFORE the ketamine? I am aware of onset times for both, but I am most interested in HD stability over "smooth".

(2) Why sux? This is "emergency induction" (as you have been quoted). In other words, the tube needs to get in one way or the other. How is roc -- especially without a medical history -- not the superior drug?

(I often find my RSI/induction practice more similar to that of anesthesiologists than my EM friends-in-training, except for how much anesthesiologists (1) love early and high-dose propofol and (2) how much anesthesiologists love sux in trauma)

HH

I don't have much experience with "keto-fol" but I here great things about it. Ketamine is almost non existent here so I am prop/sux...etom/sux...versed/sux

As for the why sux....the onset is the fastest. The clearance is the fastest. In HD pts with Ks >6 I use double dose roc (1.2mg/kg) but from my experience that is still a good 80 seconds or so till onset. Sux is like 45.

But if you have no medical history and thus no idea about the K....in a hypotensive pt...I usually go versed/DD Roc.

Also...trauma pts often have rhabdo and thus are prone for high K+, wouldn't roc be preferred in them unless you know the K is ok?

I was not a fan of large dose propofol for induction until I realized our RSI kits have ephedrine vials in them. Now If I choose to use it, I always have a syringe of ephed drawn up to pulse dose In case I get the vasodilatory hypotension post induction.

 

[Hamhock]

I use double dose roc (1.2mg/kg)

Although I'll admit, I am most interested in Blade's opinion, I will respond to your post quickly:

Consider "DD roc" to be 1.5-2 mg/kg and not 1.2 mg/kg and then let me know how you feel about the onset of roc vs. sux.

HH

 

[Bostonredsox]

Although I'll admit, I am most interested in Blade's opinion, I will respond to your post quickly:

Consider "DD roc" to be 1.5-2 mg/kg and not 1.2 mg/kg and then let me know how you feel about the onset of roc vs. sux.

HH

Hmmm. I have never seen this dose of roc given before. Is there any Literature on it or just trial/error over a career and user preference? (not that that doesn't mean its a great option)

 

[Hamhock]

Hmmm. I have never seen this dose of roc given before. Is there any Literature on it or just trial/error over a career and user preference? (not that that doesn't mean its a great option)

Both (although I don't think I want to call it a career, yet)

HH

 

[BLADEMDA]

Although I'll admit, I am most interested in Blade's opinion, I will respond to your post quickly:

Consider "DD roc" to be 1.5-2 mg/kg and not 1.2 mg/kg and then let me know how you feel about the onset of roc vs. sux.

HH

RSI with Rocuronium is fine. I use it all the time. The RSI dose is 1.2 mg/kg but pushing the dose even higher like 1.5 mg/kg gives a faster, more liable onset. If you want to match SUX in quality and speed then go with the 1.5 mg/kg. For me, I only need decent intubating conditions so a lower dose of Roc like 1.0 mg/kg in the OR and 1.2 mg/kg in the ER is fine.

We use a lot of SUX in Trauma because it is fast, cheap and reliable. The drug lasts around 3 minutes compared with 60-70 minutes or so for ROC 1.2 mg/kg.

If you use ROC for intubation don't forget the Versed or propofol drip post intubation as the Etomidate will be long gone after a few minutes with only the paralysis on board.

http://www.ncbi.nlm.nih.gov/pubmed/11099426

 

[BLADEMDA]

Acad Emerg Med. 2011 Jan;18(1):10-4. doi: 10.1111/j.1553-2712.2010.00954.x. Epub 2010 Dec 23.

Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department.

Patanwala AE, Stahle SA, Sakles JC, Erstad BL.


Source

Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA. [email protected]


Abstract


OBJECTIVES:

The objective was to determine the effect of paralytic type and dose on first-attempt rapid sequence intubation (RSI) success in the emergency department (ED).

METHODS:

This was a retrospective evaluation of information collected prospectively in a quality improvement database between July 1, 2007, and October 31, 2008. Information regarding all intubations performed in a tertiary care ED was recorded in this database. All RSI performed using succinylcholine or rocuronium were included. Logistic regression was used to analyze the effect of paralytic type and dosing, as well as age, sex, body mass index, physician experience, device type, and presence of difficult airway predictors on first attempt RSI success.

RESULTS:

A total of 327 RSI were included in the final analyses. All patients received etomidate as the induction sedative and were successfully intubated. Of these, 113 and 214 intubations were performed using succinylcholine and rocuronium, respectively. The rate of first-attempt intubation success was similar between the succinylcholine and rocuronium groups (72.6% vs. 72.9%, p=0.95). Median doses used for succinylcholine and rocuronium were 1.65 mg/kg (interquartile range [IQR]=1.26-1.95 mg/kg) and 1.19 mg/kg (IQR=1-1.45 mg/kg), respectively. In the univariate logistic regression analyses, variables predictive of first-attempt intubation success were laryngeal view (more success if Grade 1 or 2 compared to Grade 3 or 4 of the Cormack-Lehane classification, odds ratio [OR]&#8195;=55.18, 95% confidence interval [CI]=18.87 to 161.39), intubation device (less success if direct laryngoscopy, OR=0.57, 95% CI=0.34 to 0.96), and presence of a difficult airway predictor (OR=0.55, 95% CI=0.31 to 0.99). In the multivariate analysis, the only variable predictive of first-attempt intubation success was laryngeal view.

CONCLUSIONS:

Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study.

 

[Rendar5]

I am 2/3+ through IM and I have about 95. Have an anesthesia month at the end and 2 CCM months left so hoping to be around 150.

Count yourself lucky you have EM style procedure numbers. I'M residents at my old residency did like 10 tubes and 10 lines in 3 years. Anaesthesia did all codes including ICU codes

 

[BLADEMDA]

Hmmm. I have never seen this dose of roc given before. Is there any Literature on it or just trial/error over a career and user preference? (not that that doesn't mean its a great option)

The correct text book answer for an RSI using rocuronium is 1.2 mg/kg. So, you are correct about the dosage. The real world range is 1.0 mg/kg to 1.5 mg/kg depending on the speed and quality of the Vocal cord relaxation needed for the intubation. If you truly want to match the quality and speed of a SUX 1.5 mg/kg IV dose then pushing the Roc up to 1.5 mg/kg is pretty reasonable. I've never given more than this amount of Roc (1.5 mg/kg) for an intubation.

Remember, the Roc comes as 10 mg/ml in 5 ml or 10 ml vials. It's fairly easy to draw up a 100 mg dose.

 

[BLADEMDA]

There is a misconception about Sux and high potassium. Clinically, the potassium needs to exceed 5.5 or even 6.0 before the issue of Sux induced hyperkakemia becomes an issue. The Sux does cause about a 0.5 increase in the potassium levels on average. Hence, many of us use Sux as our first line drug for trauma.



http://www.acep.org/content.aspx?id=43644

Does anyone see the factual error in this link? It is the summary at the bottom of the page

 

[BLADEMDA]

http://www.edtcc.com/blog/2012/3/18/ed-rsi-rocuronium-vs-suxamethonium-succinylcholine.html

For those of you who prefer Rocuronium over Sux in the ER there are many reasons to do so.

 

[tkim]

Ketofol can replace Etomidate in almost every situation. There is also no "theoretical" risk of increased morbidity/mortality due to Adrenocortical suppression like you get from Etomidate.

Perhaps, you have learned something about using Ketofol for induction on a routine basis.

I've used ketofol - well, prop then ketamine, as I would like to titrate both to effect, for procedural sedation, but never for induction. It's always been etomidate/sux, or prop/sux, but more roc lately as they come out so fast before the maintanence meds kick in. I'm going to try ketofol on the next tube.

 

[deleted109597]

http://www.edtcc.com/blog/2012/3/18/ed-rsi-rocuronium-vs-suxamethonium-succinylcholine.html

For those of you who prefer Rocuronium over Sux in the ER there are many reasons to do so.

I wholeheartedly agree with this. The only reasons I don't use Roc are 1. if we are out of it, and 2. if it's someone else's patient and they don't want it (trauma).

If I'm intubating someone, it's not elective. Thus, I can't just wait for them to wake up. And if it's a difficult airway, the fact that they aren't going to start moving after procedure 2 is huge for me. Plus, it makes it easier to scan. You just have to remember to choose appropriate sedation as well.

 

[Apollyon]

Does anyone see the factual error in this link? It is the summary at the bottom of the page

They turned around the fasciculating and defasciculating aspects - said one did, and the other didn't - when it's the other way around!

 

[fahimaz7]

Unfortunately our neurosurgeons will throw a tizzy if we use any ketamine for any patients with possible head injury.

It's a pity, as the literature suggests this belief is false, and none of our ED staff agree with them.

We use ketamine all the time in our head injury patients, as even a brief episode of hypotension = way worse prognosis.

 

[BLADEMDA]

http://prehospitalmed.com/2012/10/1...he-direct-laryngoscope-star-by-dr-rob-bryant/

Those of you who prefer the VL should try the Parker tube. For grade 2 and 3 views the Parker tube makes intubation much easier wth a VL.

 

[Bostonredsox]

Count yourself lucky you have EM style procedure numbers. I'M residents at my old residency did like 10 tubes and 10 lines in 3 years. Anaesthesia did all codes including ICU codes

Eww. Sounds like a few of my friends. They went to fancy top tier ACGME programs and wore pretty bowties and carried clipboards and saw the rarest of rare cases. They also put in like 8 lines in 2+ years waiting behind army's of CC fellows, gas residents, surg residents, etc etc. I had the option to transfer to such a program halfway through intern year.

I decided to trade the rare cases and "prestigious IM training" for a community shop that allowed me to do 10 months of MICU and far fewer months of wards, and 350+ procedures and counting....

I may have piss-poor knowledge on complement deficiency and the pathophysiology of gitelman's syndrome, to name but a few things,.....but I can work my way through just about any shock pt door to door without calling for help unless its to go to the OR or the cath lab.

To each their own.

And as for the original thread topic...we are trialing a Glide that has to go back soon. I have been using it as first line for all of my recent tubes. (first 50-60 or so of my short career I did pure DL with bougie as backup) I love the glide. Very smooth and great for teaching purposes. Once it goes back and we get our Mcgrath Mac (the rep didn't know we had committed to buying the McGrath before he left us the glide to trial, I didn't bother to tell him ) I will go back to DL with a standard mac3/4 as my first line and carry the McGrath with me to all of my codes to use as a backup. I do not like it as much as the glide and have sort of relegated it to my backup "I cant see cords on DL so lets switch to VL" strategy. This is probably the best way of doing it anyway in terms of people with <500 tubes in their career (me) to really work proficiency of DL to the max, in case you are ever somewhere without VL as a backup.

I am very much against IM residents training with VL until they have demonstrated excellent proficiency with DL and thus I do not let my interns use VL very often. just my 2 cents.

 

[BLADEMDA]

You should try this ETT when using the Glidescope. Google it. I recommend the Parker tube over a standard ETT for VL.

 

[southerndoc]

On a related note, observed an intubation by a resident this week. Used 100 fentanyl, 5 versed, 20 etomidate. Thought this was a rather unusual combination. Haven't seen anyone use this combo in the past. Has anyone here been using something similar?

We have a pulmonologist that does this as well. Never heard of the combo before.

 

[Hamhock]

I am very much against IM residents training with VL until they have demonstrated excellent proficiency with DL and thus I do not let my interns use VL very often. just my 2 cents.

I would re-consider this.

The VAST majority of intubations can be easily performed with only a little training with VL.

The same can not be said for DL. (yes, most can be performed with DL by experts, but not folks with only a little training).

There is a small number of tubes that require DL (some bloody trauma, UGIB, etc.), but I suspect that the average -- if not most -- IM residents will not or should not be intubating these patients without back up or without being the "airway expert" (rare for an IM resident).

I would argue that most or nearly all IM residents (exceptions CCM and some gung-ho IMers like Boston) will never have enough intubations to be the "airway expert" and will not have enough to master DL.

However, many IM residents can become proficient with VL (using good BVM and LMA as back-up until an "airway expert" arrives).

Why prevent an IM resident from becoming proficient in a skill (airway management with BVM, LMA, and VL)?

Most are never going to be "masters" of airway management and if you force them to use DL, they will end up being incompetent (or inappropriately overconfident) with both DL and VL.

HH

 

[ihearttriangles]

I would re-consider this.

The VAST majority of intubations can be easily performed with only a little training with VL.

The same can not be said for DL. (yes, most can be performed with DL by experts, but not folks with only a little training).

There is a small number of tubes that require DL (some bloody trauma, UGIB, etc.), but I suspect that the average -- if not most -- IM residents will not or should not be intubating these patients without back up or without being the "airway expert" (rare for an IM resident).

I would argue that most or nearly all IM residents (exceptions CCM and some gung-ho IMers like Boston) will never have enough intubations to be the "airway expert" and will not have enough to master DL.

However, many IM residents can become proficient with VL (using good BVM and LMA as back-up until an "airway expert" arrives).

Why prevent an IM resident from becoming proficient in a skill (airway management with BVM, LMA, and VL)?

Most are never going to be "masters" of airway management and if you force them to use DL, they will end up being incompetent (or inappropriately overconfident) with both DL and VL.

HH

So, how are EM/IM residents trained in intubation? My assumption was that before you are allowed to intubate the crashing patient in the ED or unit you should have spent at least a couple weeks in an OR intubating in a more or less controlled environment. And I would think a couple of weeks should at least net you ~30 tubes (at least 3/day x 10 days) which seems like a fairly good start to becoming competent at DL intubation. During my paramedic training I got 3 days in the OR and 3 weeks in the ED which net me around 12 tubes. Hardly ideal but that's what I got and then I just had to start doing it for real in the field. Now, I'm sure some people will snicker and say,"she probably sucks ass at intubating." Well, you'll just have to take my word for it that I don't. Another reason I don't like the idea of only learning VL is that, and here I hope I'm not just being macho (people have accused me of being a tomboy before), you want to be like a boy scout, be prepared. I know as VL becomes cheaper and cheaper it will become more ubiquitous but it will be a long time before it makes it's way to resource poor environments (prehospital, developing world, wilderness). And how much of a little b#$ch are you gonna feel like if you are someplace that only has DL and you don't know what to do? Same reason I train martial arts and have health insurance. Unlikely I will have to use either one but if I do I will thank my lucky stars I came prepared.

 

[BLADEMDA]

So, how are EM/IM residents trained in intubation? My assumption was that before you are allowed to intubate the crashing patient in the ED or unit you should have spent at least a couple weeks in an OR intubating in a more or less controlled environment. And I would think a couple of weeks should at least net you ~30 tubes (at least 3/day x 10 days) which seems like a fairly good start to becoming competent at DL intubation. During my paramedic training I got 3 days in the OR and 3 weeks in the ED which net me around 12 tubes. Hardly ideal but that's what I got and then I just had to start doing it for real in the field. Now, I'm sure some people will snicker and say,"she probably sucks ass at intubating." Well, you'll just have to take my word for it that I don't. Another reason I don't like the idea of only learning VL is that, and here I hope I'm not just being macho (people have accused me of being a tomboy before), you want to be like a boy scout, be prepared. I know as VL becomes cheaper and cheaper it will become more ubiquitous but it will be a long time before it makes it's way to resource poor environments (prehospital, developing world, wilderness). And how much of a little b#$ch are you gonna feel like if you are someplace that only has DL and you don't know what to do? Same reason I train martial arts and have health insurance. Unlikely I will have to use either one but if I do I will thank my lucky stars I came prepared.

You sound great. FWIW, my karate is pretty bad so I carry a .38 SW snubnose, lightweight concealed or a HK45C with tritium sights or a Ruger .380 LCP.

As for DL vs VL I try to teach both to new CRNAs (Miller blade for the new CRNA) and several struggle with the VL at first. If you intubate less than 3-5 times per month I strongly suggest the VL with a Parker tube combined with a Rigid Stylet (comes from the manufacturer). Do not use a standard intubating stylet. If you decide to get all "macho" with the DL plan on just ONE attempt before switching to the VL. Learning how to bag mask certain patients requires significantly more skill than a DL so you need to be ready for plan "B" if your DL fails. I suggest a Supreme LMA or Standard LMA be available as well.

Be careful out there.

 

[joeDO2]

As for DL vs VL I try to teach both to new CRNAs (Miller blade for the new CRNA) and several struggle with the VL at first. If you intubate less than 3-5 times per month I strongly suggest the VL with a Parker tube combined with a Rigid Stylet (comes from the manufacturer). Do not use a standard intubating stylet. If you decide to get all "macho" with the DL plan on just ONE attempt before switching to the VL. Learning how to bag mask certain patients requires significantly more skill than a DL so you need to be ready for plan "B" if your DL fails. I suggest a Supreme LMA or Standard LMA be available as well.

Be careful out there.

Also, even if it isn't going to be a difficult airway.... just have the VL and LMA at the bedside. I've seen so many times people run scrambling for these items after taking a first look. It just looks disorganized / unprofessional when people are running around looking for equipment. You don't have to open it or anything but just have it there. I cringe when I see someone walk in to intubate someone with only a mac 3 and a tube in their hand.

 

[BLADEMDA]

Also, even if it isn't going to be a difficult airway.... just have the VL and LMA at the bedside. I've seen so many times people run scrambling for these items after taking a first look. It just looks disorganized / unprofessional when people are running around looking for equipment. You don't have to open it or anything but just have it there. I cringe when I see someone walk in to intubate someone with only a mac 3 and a tube in their hand.

These days I take a bougie and glidescope with me to the floor for intubations. The ER has the equipment ready to go but other locations are less likely. I rarely ever need anything other than the miller 2 blade but I like having my backup by my side (Smith and Wesson at home or Glidescope at work).

 

[Bostonredsox]

These days I take a bougie and glidescope with me to the floor for intubations. The ER has the equipment ready to go but other locations are less likely. I rarely ever need anything other than the miller 2 blade but I like having my backup by my side (Smith and Wesson at home or Glidescope at work).

I carry a bougie with me everywhere, along with an 11 blade. And I also carry the McGrath Mac to the floor codes as well. But often times when I get there, unless they look like a difficult airway, I just set the McGrath case to the side and intubate via standard DL with a Mac 3/4. This is partly because I don't like the McGrath nearly as much as a glide, which I will typically use right off the bat.

And to HH, I definitely see your point. Most of my counterparts have somewhere between 2 and 20 tubes throughout their entire IM residency. Just doing VL is probably best for them. None of them are planning careers in CCM besides me though so I guess the need for them to be proficient at DL isn't really there after all. Seeing as we bout a McGrath not a glide, cheap ass hospital, It will be harder for me to teach VL though. I find it difficult to stand to the side and direct an intern or other senior through the anatomy on the much smaller McGrath screen. I feel that tool is really a one man handheld glide for a proficient user. It is not nearly as easy to use it as a teaching tool.

 

[BLADEMDA]

It's a great teaching tool

 

[BLADEMDA]

I recommend you buy these stylets. They are reusable and make intubation via the glidescope smooth as a baby's bottom.

 

[Bostonredsox]

that is the exact model and stylet we used when it was on trial and I can attest, every intubation was smooth as buttaaa. loved that machine.