Yeah, but we don't have Ronaldo .... so no wonder we are now out of the World Cup. I must say we have spent a fair amount of time infront of the telly at work watching the highlights of Ronaldo hmmmmmmm
How much midaz are you using? I am not so much concerned about the 1mg or so you give somebody who is traumatically brain injured with a GCS of 3 vs the amount you are going to have to pour into that catatonic asthmatic who is still conscious so he won't remember.
We used to use midazolam but now we use 1.5mg/kg of ketamine (unless the patient is traumatically brain injured or has neurogenic cause for coma with GCS < 10)
Mind you I am no anaesthetics consultant (one day......) but I hear that midazolam is great for wrecking people's blood pressure and other nasty things when given in any significant dose.
Although you are using sux too so it's probably only a small dose to give amnestic effect rather than any serious neuromusclar relaxation.
*Brown goes back to reading his anaesthesia textbook in an effort to obtain more knowledge
(On the football - AH but what you showed was you don't need Ronaldo to be competitive. Beside look where it got Portugal? The guy score one goal in the whole tournament).
On the RSI stuff. RSI has been one of MICA's biggest successes in decades.
The sux is for tube placement in the traumatic or non-traumatic head injured pt with intact airway reflexes or trismus and GCS <10. Hence the need for paralysis. Its not for sedation. The Midaz and Fentanyl are for that (plus the fentanyl provides analgesia as well) - Paralytics and sedation are a hand and glove - never one without the other.
For the RSI we use Midaz 0.1mg/kg IV or half dose for age, low BP etc. We also add 8mg Panc after induction. In the HI trauma pt this is the key. The RSI is really for MAP control and therefore cerebral perfusion pressure control - None of those nasty spikes in BP (like when you stick a bloody big layryngo blade down the pts gullett without any paralysis on board which kills off more brain cells). You can cover secondary brain injury issues by controlling ventilation ETCO2/SPO2 etc after induction.
Sedation continues post intubation and Panc - Morph and Midaz infusion here 30and 30.
Your'e right about the Midaz trashing BP - most Benzos do when given in large IV doses. So there is a healthy 10ml/kg fluid load prior to the procedure. This covers both the Midaz hypotension side effect and also covers hypovolaemic issues - almost guaranteed in the multi-trauma pt.
We are only using Ketamine for analgesia in long bone fractures post Morph management - a trial at this stage. There's been no talk about using it for induction/sedation in our guidelines.
For the asthmatic pt who gets tubed - well if they are that far down the track i.e hypoxic - a late sign in severe asthma - then they need a tube and will need sedation to pass it. The hypoxic asthmatic is a stones throw from pushing up the daisies. We never paralyse an asthmatic - if you can't get the tube they are dead - no ventilations of their own.
Having said this the preference is not to tube the asthmatic if avoidable as management of the pt with a hyperinflated obstructed chest becomes problematic and dangerous. A pneumothorax is an easy complication of high pressure ventilation. It's also difficult to manage Co2 with ventilation measures in the asthmatic pt.
But life threat is life threat. Sedate to tube can certainly be lifesaving in such pts. I've seen it many times. The midaz is never an issue really.
Now I have to wait 4 more years for the Roos and Whites to play in the world cup but play they will. My tip for this one is Argentina or maybe Germany (if they beat them tonight).
Speaking of which, it's 20mins to kick off so I need to grab a beer and a chair and settle in.
MM
h34r: