Paralytics for ICU intubations?

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europeman

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Anyone here routinely use paralytics for ICU intubations in patients with an indication for rapid sequence intubation? Double dose rocuronium for example (since so many ICU patients can't/shouldn't get succs?)

The ER airway guys:gals at my institution are very good and always do and I have noticed their intubations Att much much much smoother
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There's a great "pro-con" lecture/debate by Scott Wingart and Paul Mayo regarding NMB in the ICU.

http://emcrit.org/podcasts/paralytics-for-icu-intubations/
(scroll down a bit past the papers to find the lectures)

I am EM-trained, so I am biased, but for tubes that aren't going to be awake (or "ketamine-awake"), I say high-dose roc all the way.

HH
 
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Great debate. I've heard this and in my opinion it's a no-brainer that the pro-paralytic is better.... But I recognize people are trained differently and also that its not a black/white issue.

So what are the thoughts on the rest of u??
 
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I have attendings who do both, intubations without paralytics are harder, I prefer paralytics unless I'm thinking its going to be a hard tube that I can bag.
 
If you are trained at emergency airways and the failed airway and have a good failed airway algorithm then I would go paralytics all the way.

If you have intubated occasionally, or don't feel you can get the tube either A. call for help, or B. DO an awake intubation (which usually means you have time.)

If you have time an awake look is great, we have an entire awake intubation box set that we use for topicalization and then use ketamine (+/- a little versed) for an awake look.

If you don't feel confident with an airway I advocate not pushing paralytics, and you should grab someone who is and maybe spend some time in the OR with anesthesia for anticipated difficult airways.
 
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My practice as a critical care physician for everything but awake intubations, which I do rarely:

Induction: fentanyl versed; fentanyl propofol; or fentanyl +/- versed + ketamine
Paralysis: succ, or if contraindicated, rocuronium 1.2 mg/kg

Then intubate
 
i dont understand the logic of pushing induction agents on sick patients without paralytics. that airway is going to collapse and the pt will stop breathing. its all or none in my book. commit to asleep with paralytics or awake with brutane.

remember the LMA if you get in trouble.
 
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I also think it is prudent to have a glidescope/fiberoptic nearby or ON HAND for most intubations because you can nevere be too prepared for surprises!
 
Because it's sometimes safer. Once you push a neuromuscular blocker, your somewhat-hard-to-bag patient loses all pharyngeal muscle tone and now you can't bag him at all. Patients under deep sedation can still protect their airway and generate respirations. Don't push drugs your patient doesn't need, especially ones with side-effect profiles like paralytics.
 
I'm an ER guy.

I agree with VentdependenT, ORL 10, sluggs, and HH.

If a guy needs an emergent intubation in the ICU, that guy should either get an awake tube, or get an RSI, and the data is pretty clear that intubating conditions are optimized during RSI when the patient gets a paralytic.

The Weingart/Mayo debate is worth reviewing and has cemented my practice to avoid sedative-only intubations in the ICU (where I'm called at night to intubate) and in the ED.

I agree with ariwax that you shouldn't push drugs your patient doesn't need -- that's why I push paralytics. That loss of pharyngeal muscle tone allows me to get that ETT between the cords.
 
ariwax said:
Because it's sometimes safer. Once you push a neuromuscular blocker, your somewhat-hard-to-bag patient loses all pharyngeal muscle tone and now you can't bag him at all. Patients under deep sedation can still protect their airway and generate respirations. Don't push drugs your patient doesn't need, especially ones with side-effect profiles like paralytics.
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i have had the complete opposite experience. deeply sedated Patients cannot protect their airway. thats why even patients receiving MAC need empty stomach and experienced personell by for airway. laryngospasm sucks. again if you put to sleep then paralyse.

giving 25ucg and 1 of versed will stop a sick tachypnic pt from breathing or worse will cause them to obstruct while still breathing. then pt vomits. not paralysed? bummer. cric pressure wont help now. then you know what you get? brain damaged pt. screw that.
 
VentdependenT said:
i dont understand the logic of pushing induction agents on sick patients without paralytics. that airway is going to collapse and the pt will stop breathing. its all or none in my book. commit to asleep with paralytics or awake with brutane.

remember the LMA if you get in trouble.
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Exactly
 
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Ariwax..... In my experience its actually easier to bag valve mask a patient once they are paralyzed. That is, if you know how to do a proper two hand jaw lift Bvm technique properly.

Is there any evidence out there to the contrary?

While I totally hear you on the logic that "once u give a paralytic, you are screwed if you can't bag them" because even some anesthesiologists go by this logic, it just doesn't make sense to me. Again.... The biggest reason is because its easier to manipulate their jaw when they are paralyzed! They are certainly are not protecting their airway if you give them an induction dose of. Etomindate or propofol!
 
ariwax said:
Because it's sometimes safer. Once you push a neuromuscular blocker, your somewhat-hard-to-bag patient loses all pharyngeal muscle tone and now you can't bag him at all. Patients under deep sedation can still protect their airway and generate respirations. Don't push drugs your patient doesn't need, especially ones with side-effect profiles like paralytics.
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Not trying to pick a fight, just honestly wondering:

What is your base training?

IM/general surgery or EM/anesthesia?

HH
 
ariwax said:
Because it's sometimes safer. Once you push a neuromuscular blocker, your somewhat-hard-to-bag patient loses all pharyngeal muscle tone and now you can't bag him at all. Patients under deep sedation can still protect their airway and generate respirations. Don't push drugs your patient doesn't need, especially ones with side-effect profiles like paralytics.
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Disagree 100% with everything you said:)
 
I'm an IM resident, but being at an opposed IM program we cover the ICU as well any codes or "rapid responses" that happen on the floor or unit and thus get quite a bit of experience with airways.

I would say most of the time I use paralytics, mostly sux, sometimes roc. Most of of our pts don't have contraindications to sux and it's readily available quickly in our RSI kits... sometimes Roc takes a little longer to get. Recently had a case where I knew it was going to be a very difficulty airway (hx prior trach that was a difficult/small trach per report) and since it was for hypercapnic resp failure and the guy was still spontaneously breathing and oxygenating well so I elected not to paralyze. But for most of our RSI on the floor or unit we use paralytics.

Induction wise lately it's mainly been midazolam. We used to use etomidate a fair bit but we've had a shortage of it for a while and midazolam is kept in our RSI kits. Other option I'll use is propofol. Don't use it as much as while our nurses can push just about any other drug they can't push propofol. There have been times when I needed some sedation and that was the only med available at the time so I would have to push it. And a fair bit of our pts needing emergent intubating are hypotensive to begin with so I tend to shy away from it. I'm certainly not comfortable with push dose pressor use but it's something I'm trying to read up on more. Ideally I'd like to become comfortable with it so that if I choose to use propofol I can have a stick of Neo standing by. Usually though our pts are already semi sedated from whatever pathology is occurring and I can get away with a little midazolam or 20-40mg of propofol and not have huge BP issues.

In the ICU propofol is so quick/easy for nursing to get and they're comfortable using it so half the time by the time we're set up to intubate they already have a bottle hanging and it's easy just to draw a few cc up to push.

We also have a couple glidescope machines around so at least if it's an anticipated difficult airway in the unit I'll have the glidescope ready.

Have had a few nightmare airway cases recently and realized we need to make a difficult airway kit. Last time had to send someone running to the OR for a small cuffless ETT and would also like an LMA or iLMA handy if needed.

At night and at times during the weekends we're the only docs in house, besides the ER attendings, but they don't respond to codes or rapids on the floor or ICU, just us. Needless to say it means some interesting and harrowing experiences, but we try to develop these skills early on during our ICU and anesthesia months.
 
I don't understand how u are managing airways but don't have LMAs readily available. That's an extremely important took in a standard airway algorithm which can save u 90% of the time in the can't ventilate/can't oxygenate patient.
 
europeman said:
I don't understand how u are managing airways but don't have LMAs readily available. That's an extremely important took in a standard airway algorithm which can save u 90% of the time in the can't ventilate/can't oxygenate patient.
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No I agree and a recent case brought this issue to light. We can easily get them but had to have someone run to the OR. I guess we didn't realize that RT didn't keep some handy and didn't keep any in their RSI kits.
 
If you are heavily sedating someone (propofol for example) what is your argument to not giving a paralytic? I think you have all the dangerous without any of the benefits of paralytics.

If you are doing an awake intubation with ketamine I have yet to see a patient become apneic, even sick ones, which is why I like ketamine. I do this for anticipated difficult airway patients in whom I have some time. There are a million ways of doing this, but you don't have a lot to lose by trying this, you can always go to RSI but not the other way around.

If you are in an ICU and you are intubating without multiple backup devices available you are rolling the dice each time. Don't get me wrong I love to play craps and if anyone will be in vegas for AAEM next month let's get a table. You should probably make a difficult airway box, ours has s a bougie (these cost dollars), multiple sizes of LMA's (also cheap), a video laryngoscope (whatever you like, we have a glidescope) and cricothyrotomy kit accessible for every intubation. If you don't know how to use those backup devices you should probably call someone who does.
 
ORL10 said:
If you are heavily sedating someone (propofol for example) what is your argument to not giving a paralytic? I think you have all the dangerous without any of the benefits of paralytics.

If you are doing an awake intubation with ketamine I have yet to see a patient become apneic, even sick ones, which is why I like ketamine. I do this for anticipated difficult airway patients in whom I have some time. There are a million ways of doing this, but you don't have a lot to lose by trying this, you can always go to RSI but not the other way around.

If you are in an ICU and you are intubating without multiple backup devices available you are rolling the dice each time. Don't get me wrong I love to play craps and if anyone will be in vegas for AAEM next month let's get a table. You should probably make a difficult airway box, ours has s a bougie (these cost dollars), multiple sizes of LMA's (also cheap), a video laryngoscope (whatever you like, we have a glidescope) and cricothyrotomy kit accessible for every intubation. If you don't know how to use those backup devices you should probably call someone who does.
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I find propofol is more often than not unavailable as many of the people I am tubing are already significantly hypotensive. Etomidate/succ is my go to if succ is an option. If their k+ prevents me from using succ I quite often just use fentanyl and versed. If they are too spastic and out of control and I can't use succ than our protocol is Vec. But we have have to have anesthesia present to use it. We also do not have a glidescope and I am not yet capable of crich'ing. Both are on the horizon. But I have to say versed and fentantyl do work well in the case I cant use propofol or paralyze them.
 
Bostonredsox said:
I find propofol is more often than not unavailable as many of the people I am tubing are already significantly hypotensive. Etomidate/succ is my go to if succ is an option. If their k+ prevents me from using succ I quite often just use fentanyl and versed. If they are too spastic and out of control and I can't use succ than our protocol is Vec. But we have have to have anesthesia present to use it. We also do not have a glidescope and I am not yet capable of crich'ing. Both are on the horizon. But I have to say versed and fentantyl do work well in the case I cant use propofol or paralyze them.
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Why cant you use succ if they are "spastic/out of control?"
 
Why dont u have rocuronium? Vec is not good emergency drug.
 
Not sure to tell you the truth. our emerg boxes were designed by anesthesia. I have never needed to use vec or roc thus far. I am sure a time will come when I will though. Dont have much experience with roc/vec/panc and the other non depolarizers.
 
If your patient is hypotensive, all sedatives will drop your pressure, not to mention putting a patient on PPV (reduced venous return and reduced CO) will cause your hypotensive patient to become more hypotensive. It is a myth that etomidate or versed will maintain BP during induction in the critically ill patient. One strategy we often employ is reducing the dose of the induction agent and bolusing IVF prior to induction +/- push dose pressors.

Hypotension itself is often very sedating, especially in the patient with acute hemorrhage. Try half the dose of your induction agent, propofol, ketamine, etomidate or whatever you like. Just know that in patients with poor effective circulating volume all sedatives will drop your pressure, not just propofol.

Also, it's sort of strange you don't have rocuronium and you use vecuronium for paralysis. Do you sedate and then just leave them with a nasal cannula and a NRB mask on until the vecuronium takes effect, I would think you would need to bag these patients peri-intubation? Or do you give the vecuronium then a minute or two later give your sedative?
 
Bostonredsox

Double dose roc takes 45 seconds to work... It's effectively as quick as succs.

You sound like you have genuine interest in airway but the way you are managing them without backup equipment (boogie, Lma, ability for surgical backup immediatey for cric or at least needle with jet ventillation) means every time u are managing an airway, u are Doing it, frankly, in a very dangerous manner.

Since you haven't been trained to use paralytics then you presumably have to sedate your patient very well to get a tube in.... Otherwise they are fighting you, aspirating, and becoming hypertensive.tachy as you try and time a tube through moving vocal cords (not ideal).

Try listening to all the www.emcrit.org airway podcasts (there are several) as he has a lot of resources for you.
 
europeman said:
Bostonredsox

Double dose roc takes 45 seconds to work... It's effectively as quick as succs.

You sound like you have genuine interest in airway but the way you are managing them without backup equipment (boogie, Lma, ability for surgical backup immediatey for cric or at least needle with jet ventillation) means every time u are managing an airway, u are Doing it, frankly, in a very dangerous manner.

Since you haven't been trained to use paralytics then you presumably have to sedate your patient very well to get a tube in.... Otherwise they are fighting you, aspirating, and becoming hypertensive.tachy as you try and time a tube through moving vocal cords (not ideal).

Try listening to all the www.emcrit.org airway podcasts (there are several) as he has a lot of resources for you.
Click to expand...

You are correct on much of your statement. I am an IM resident at a community shop planning a pure critical care future. I have around 70 or so airways but the greater majority are codes which frankly are usually easy as everything is flopped open and no one is fighting you. Our shop is not a large academic institution so I have learned what I know basically by my own tiral and error. Our intensivist isnt here full time and hospitalists run the unit quite frequently, some good, others not so much. Either way, I have tubed about 5x more people than the hospitalists so they cannot help me much. I should clarify, we do have an LMA, we do have and I have myself used a bougie. We have airtracts which I dont have much practice with. We have a glidescope but the CRNAs keep it locked up in the unit and they are not the most helpful. Supposively we are getting our own glidescope this year. We do not have reliable surgical backup in house. I cannot yet cric. I am planning on taking one of the advanced airway courses with a fellow senior resident in chicago this summer so I can become proficient in Cric myself. So to be honest, I think I have done pretty well for basically teaching myself everything I know about an airway. In general a Mac4 an 8.0 succ/etomidate and a bougie in case i fail and im usually solid. But you are correct, I do have more than a genuine interest in airways. I plan to be an intensivist at a mainly rural community hospital back home. So i want to be the definitive airway, hence the planned cric training. But I defintely need more training in advanced airway manuevers and non depolarizing paralytic use. SO any direction you can point me in is most helpful. It has been not the easiest road learning critical care in this setting. My procedural skill has benefited as frankly, there is no one else to perform the procedures and most of my fellow residents are not interested in critical care...they want to 'make money?' or something like that so they are headed GI/Cardio. So for all you guys with experience, JDH, europe Hernandez, send me pointers and important articles. Need to learn!
 
So I read the whole thread and some of the links Arch put in and it seems to me I have been doing quite a few things wrong. For one I rarely start with RSI on patients for the feared cant ventilate/cant intubate situation. I tend to pre-oxygenate, push an induction agent, etomidate most often, and then have a look in the airway. If the cords are open, I slide in the tube. If they are closed or they spasm when I get close but I can DEFINITELY see them, I back out, push succ, wait 30 sec and then intubate. I have been very leary to RSI right off the bat as I can't cric and dont have a glidescope, nor do I have years of practive with difficult airways, again only about 70 tubes thus far. The floor codes I obviously use nothing and just slam an 8.0 in and be done. But I have to say I have been fearful of showing up to the stepdown unit for an 'impending resp failure' and then RSI'n them. Been doing a bit of reading and it seems you are all a fan of ketamine for awake tubes. Assuming I have BP room and can use propofol, and yes I know they all cause some hypotension, is their any reason I should be using ketamine over propofol or etomidate before looking into the airway? Or do I need to just let my balls drop and start RSI'n people unless they truly look like they are going to be difficult...because the idea of once you have induced, youve created an unprotected airway why not paralyze makes perfect sense to me.
 
ariwax said:
Because it's sometimes safer. Once you push a neuromuscular blocker, your somewhat-hard-to-bag patient loses all pharyngeal muscle tone and now you can't bag him at all. Patients under deep sedation can still protect their airway and generate respirations. Don't push drugs your patient doesn't need, especially ones with side-effect profiles like paralytics.
Click to expand...

I don't know that I've EVER turned a "hard to bag" patient into one I couldn't bag at all once I pushed NMB's. Really??? Lost "pharyngeal muscle tone??? That's what oral/nasal airways are for. Sounds like more practice with mask airways would be helpful.

And on a critically ill ICU/ER patient, deep sedation is pretty much general anesthesia. Don't fool yourself.
 
Ariwax,

Understandably this is how u were trained.

But once you train with paralytics and Learn how to really take over your patients airway, you will probably discover how much safer it is (quicker intubations, less traumatic, less aspiration, less vital derangements, less stress, etc).
 
Bostonredsox said:
I cannot yet cric.
Click to expand...

I beg to differ. If you can intubate someone, if you can do a central line, or pretty much any procedure involving sharp objects, you can do a cric. When I did my first, I was alone and had never seen one live. There are excellent online resources and it is a very simple procedure if you do the scalpel-bougie method.

The key is mental preparation. You have to KNOW each step and rehearse it in your mind every so often. Probably the most important thing to know is the indication...usually we do these too late, but also know that if you do one there will be a lot of scrutiny and Monday morning quarterbacking from every corner of your hospital.

Watch Darren Braude's YouTube video. It's linked from the EMCrit cric episodes, also a must watch. Carry a #11 blade, and a bougie if they aren't in your code carts.
 
jwk said:
I don't know that I've EVER turned a "hard to bag" patient into one I couldn't bag at all once I pushed NMB's. Really??? Lost "pharyngeal muscle tone??? That's what oral/nasal airways are for. Sounds like more practice with mask airways would be helpful.
Click to expand...

I have seen it happen before.
 
pseudoknot said:
I beg to differ. If you can intubate someone, if you can do a central line, or pretty much any procedure involving sharp objects, you can do a cric. When I did my first, I was alone and had never seen one live. There are excellent online resources and it is a very simple procedure if you do the scalpel-bougie method.

The key is mental preparation. You have to KNOW each step and rehearse it in your mind every so often. Probably the most important thing to know is the indication...usually we do these too late, but also know that if you do one there will be a lot of scrutiny and Monday morning quarterbacking from every corner of your hospital.

Watch Darren Braude's YouTube video. It's linked from the EMCrit cric episodes, also a must watch. Carry a #11 blade, and a bougie if they aren't in your code carts.
Click to expand...

Good videos, very informative. Question, I noticed form some other posts that some of you carry a trach hook. There was a viedo showing a cric with a hook but Darrens videos had as you mentioned a scalpel with finger widening of incision followed by bougie and then tube. What is the utility of the trach hook with a bougie available?
And I snagged an 11 blade from the OR ;)
 
i'm a surgeon, so in the trauma bay we have a cric and tracheostomy set which includes all the instruments (including trach hook) one could possibly need. Frankly it's overboard. It's also available in any crash cric set in a PACU or if an ICU has them. it's not a totally necessary item, and, in fact, i think it could be dangerous if you aren't really trained how to use it.

i've two emergency crics. one with and one without the hook. both went fine; tube was in within 15 seconds of incision.

i agree if you are using a boogie, the hook might have less utility. IF you don't have a boogie though, then having the hook provides a nice means of counter-tension for when you are puting the tube in.

the main pearl to performing a crash cric is puting your first finger into the trach hole you made AS SOON as you make it, thereby not losing it to the blood/spit/fluids which will be in our field. but eventually your finger as to come out and a tube or something needs to go in... which is where the hook can be useful.

that said.... again, it's NOT necessary, and in fact, i would encourage you not to even use it.
 
Didn't have to wait long for the roc trial. Had a nasty Cdiff septic shock tonight, Creat around 10 with K of 7, no underlying renal Dz. Rapid sequenced with etomidate and High Dose Roc. Called CRNA to stand next to me in case she was for some reason difficult, though she had very favorable anatomy. Wanted to use ketamine but we are apparently on back order and SBP in the mid 60s so no propofol. Had her push em both, waited about 70 sec, took a peak, cords flopped right open in front of me about 15 sec later. Was a super smooth airway. Thanks for the advice.
 
Wow nice! You should also know how to make push dose Epi using the material in your crash cart. If its a 10cc Epi vial with 100mcg/cc.... Just take one cc and dilute it into 9cc of saline and now u can push dose 10-50cc (ie 10-50mcg) Epi. Sounds like this is a patient who, had u had this avail, would have made u more comfortable


Amazing how much more controlled the situation is once they are paralyzed. You got it in first try nice!


Regarding jet ventilation.... It's useless and doesn't provide ventilation so u are soon going to have a very acidotic patient! To do it get the plunger of a 3cc (or 5cc?) syringe and connect to needle. The other end will fit onto an ambu bag using the adaptor from a 7 or 7.5 et tube

Again just cut
 
Thanks for info on the pulse dose stressors. I had already thrown in an IJ in her and had levophed running so I had the nurse crank it up a bit expecting some bp drop with the etomidate. Good to know though for the patients not already on a pressor or who is too acidotic for them to work, she was near that which is why I tubed her.

I have been unsuccessfuly in getting a smalle wrappable bougie to carry with my 11 blade. All we have are the 3 foot long hard plastic ones in the straight sleeve. Supposively we have shorter "tube exchangers" but I have been unable to locate one. RT told me we keep a trach hook in the difficult airway box though, so I'm waiting for the opportunity to try it out.

I also met with Rx and anesthesia during last CC meeting about looking into swapping out vec for roc in our RSI kits. They are looking into it.
 
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