Post intubation sedation

[SpecialK]

Personally I think the distinction is reasonable.

Our airway management approach has changed fundamentally over the past 20 years or so. In the olden days, people who needed more oxygenation than supplemental oxygen could provide automatically meant they needed to be intubated, and if they had a level of consciousness too great to allow them to be intubated easily then they just got given midazolam until basically they were obtunded enough to be intubated.

Since then we have evolved significantly including carrying nasal airways, LMAs, PEEP, having RSI, formally adding DSI and rocuronium only RSI, and at some point in the future CPAP and mechanical ventilation (they cannot be added at the moment because of the cost).

And if I can send somebody off to oblivion with a bit of ketamine (and a mg or two of midazolam maybe) and oxygenate them no I wouldn't intubate them unless hospital was a very long way away or they needed a physically secure airway.

 

[VentMonkey]

Since then we have evolved significantly including...rocuronium only RSI

How on earth does this work, and/ or constitute evolving? Is this only in a "crash airway" scenario?

FWIW, I agree with your post overall, and you guys are light years ahead of my service.

 

[SpecialK]

How on earth does this work, and/ or constitute evolving? Is this only in a "crash airway" scenario?

It's always been possible whether with rocuronium, or the older long-acting neuromuscular blocker which was vecuronium, but up until now it's been a bit "off the books" or, how to say, not formally written into the CPGs.

There are many contraindications to suxamethonium so there may be patients who could benefit from RSI but whom cannot be administered suxamethonium. Rocuronium only RSI is an alternative for these patients because well, they are going to benefit from the procedure, and an alternative is available to suxamethonium.

Many hospital personnel are now only performing RSI with rocuronium.

 

[Handsome Robb]

I'm assuming your implying substituting roc for sux in addition to the sedation/analgesia?

We only use roc, no sux anymore.


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[SpecialK]

I'm assuming your implying substituting roc for sux in addition to the sedation/analgesia?

Still.give the patient a general anaesthetic yes. The neuromuscular blocker is just different.

 

[TXmed]

http://emcrit.org/podcasts/post-intubation-sedation/

 

[StCEMT]

http://emcrit.org/podcasts/post-intubation-sedation/

I had just opened this when I started this post. Buuut I wanted to see where the topic would lead here. The opposing view points and varied experiences that resulted are nice to see for someone in my position. Got exactly what I wanted.

 

[TXmed]

Im not exactly a fan of adding a pressor just for the purpose of higher sedation with propofol. I prefer to add a ketamine drip/fentanyl drip to the propofol (i like to mix &match rather one med). But that is preference and there are patients where its somewhat appropriet *grits teeth*

 

[Tigger]

Since then we have evolved significantly including carrying nasal airways, LMAs, PEEP, having RSI, formally adding DSI and rocuronium only RSI, and at some point in the future CPAP and mechanical ventilation (they cannot be added at the moment because of the cost).

Disposable CPAP units are inexpensive and effective. Ours (attached) are like 50 USD per unit. I work at a place with the SureVent as well, it is not a ventilator but is much better than a BVM and inexpensive.

Incidentally our Ketamine protocol was not clearly written so it seemed appropriate to use 2mg/kg for both induction and continued sedation. It seemed to work great as sedation (n=a few) however the state determined that is not an allowed use of Ketamine so back to fentanyl and versed for us.

 

[Carlos Danger]

Im not exactly a fan of adding a pressor just for the purpose of higher sedation with propofol. I prefer to add a ketamine drip/fentanyl drip to the propofol (i like to mix &match rather one med). But that is preference and there are patients where its somewhat appropriet *grits teeth*

I almost never use ketamine alone. I use it as part of my non-narcotic general anesthetic technique, and I also use it during tricky sedation cases as a propofol-sparing agent, when it is important to maintain airway reflexes. Very generally speaking, I can just about cut my propofol dose in half with 25mg of ketamine front loaded.

 

[SpecialK]

Disposable CPAP units are inexpensive and effective. Ours (attached) are like 50 USD per unit. I work at a place with the SureVent as well, it is not a ventilator but is much better than a BVM and inexpensive.

Thanks, mate. Your CPAP looks interesting, I agree USD50 doesn't sound like much but if we look at stocking one medium and one large to each ambulance and not even counting response cars the initial cost of is USD50,000 approximately (excluding any bulk discount) plus whatever ongoing cost to replace expendables used however I imagine that wouldn't be very much.

There is a firm commitment from the ambulance service to introduce some form of CPAP when it can be afforded.

Like I said before, bloody fire service sits on its bum and does nothing and is flush with insurance levy money yet ambos who are 4x as busy have to beg and grovel for every cent of the health budget because it comes from taxes!

 

[Tigger]

Thanks, mate. Your CPAP looks interesting, I agree USD50 doesn't sound like much but if we look at stocking one medium and one large to each ambulance and not even counting response cars the initial cost of is USD50,000 approximately (excluding any bulk discount) plus whatever ongoing cost to replace expendables used however I imagine that wouldn't be very much.

There is a firm commitment from the ambulance service to introduce some form of CPAP when it can be afforded.

Like I said before, bloody fire service sits on its bum and does nothing and is flush with insurance levy money yet ambos who are 4x as busy have to beg and grovel for every cent of the health budget because it comes from taxes!

Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially if you aren't able to intubate patients.

 

[NomadicMedic]

Fixed that for ya...

Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially if you'd rather not intubate patients that can be better served with less invasive means.

 

[VentMonkey]

@SpecialK is it just the cost and/ or budget that's creating a delay in such a practical and inexpensive device? Is your medical director on board with it? Is it commonly used before going to intubation with respiratory patients in-hospital?

As advanced as the rest of the world is in regards to prehospital medicine, I find it remarkable your service has yet to add it to your scope.

 

[Tigger]

Fixed that for ya...

Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially if you'd rather not intubate patients that can be better served with less invasive means.

I am told that prior to CPAP's implementation that many/most CPAPed patients would just be intubated.

 

[SpecialK]

@SpecialK is it just the cost and/ or budget that's creating a delay in such a practical and inexpensive device? Is your medical director on board with it? Is it commonly used before going to intubation with respiratory patients in-hospital?

As advanced as the rest of the world is in regards to prehospital medicine, I find it remarkable your service has yet to add it to your scope.

Yes, it is the cost.

Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially if you'd rather not intubate patients that can be better served with less invasive means.

Define "large"? We have approximately 500 ambulances and another 100 or so other response-capable vehicles so every one of them would need to get it not to mention the ongoing cost plus the cost of the oxygen (although I don't imagine it being a significant user of additional oxygen considering if we use a bag and mask with PEEP it's at 15 lpm aready).

The government gives zero funding for anything beyond the basic operating costs of the ambulance service which in reality probably means salaries and fuel. Capital, vehicles, and equipment are financed through donations and sponsorships. You simply have to look in the media to see how uninterested the government seem to be about it. A "review" has been promised for almost a year but nothing has been achieved so far and I doubt anything meaningful will come in the near future anyway.

 

[VFlutter]

plus the cost of the oxygen (although I don't imagine it being a significant user of additional oxygen considering if we use a bag and mask with PEEP it's at 15 lpm aready).

CPAP uses significantly more oxygen than a BVM @ 15 lpm. Depending on the mask leak it could easily pull 25+lpm.

 

[SpecialK]

CPAP uses significantly more oxygen than a BVM @ 15 lpm. Depending on the mask leak it could easily pull 25+lpm.

Well then it's even less likely! The ambulance has one portable C and one bulk D oxygen.

Now that I remember, I know somebody who works down country a bit and they sometimes do interhospital transfers with CPAP; the hospital has a spare oxygen cylinder in ED for them to take because they aren't allowed to use the ambulance oxygen.

 

[VFlutter]

Well then it's even less likely! The ambulance has one portable C and one bulk D oxygen.

Now that I remember, I know somebody who works down country a bit and they sometimes do interhospital transfers with CPAP; the hospital has a spare oxygen cylinder in ED for them to take because they aren't allowed to use the ambulance oxygen.

Based on my calculations a jumbo D tank would last 26mins assuming 25L of flow. So that portable C isn't going to get you far.

There are plenty of stories of people underestimating their oxygen consumption and running out on transfers.

 

[Carlos Danger]

You can cut WAY down on oxygen flow requirements by just using a ventilator that has an internal blender. The LTV1200 does, and I assume most newer vents do as well.