Podcast 104 – Laryngoscope as a Murder Weapon Series – Hemodynamic Kills

smacc-hemo-kills

The Airway Moratorium is Over!

In this podcast I talk about how not to kill the shocked/hypotensive patient in the peri-intubation. I gave this talk at SMACC 2013.

This lecture is part of the Laryngoscope as a Murder Weapon Series:

Literature

Best Review Article

Anaesthesia 2009;64:532

Hypotension in the peri-intubation is bad and is a source of mortality

Hemodynamically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367) and (Heffner et al. J Crit Care 2012 Aug;27(4):417)

Etomidate

Etomidate is probably safe in moderately shocked patients (Acad Emerg Med 2006;13:378)

Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)

Ketamine

Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79), in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404) and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)

Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability

A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.

Cats did fine (Canad Anesth Soc J 1975;22(3):339). However if you give 10-100-fold doses to canine heart tissue then maybe (J Cardiovasc Pharmacol 1986;8:414) and (Anesthesiology 1992;76:564), in the latter, dogs got infusions at 25-100 mg/kg/hr.

Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)

Ketamine in ICP (Emerg med australia 2006;18(1):37-44)

Two RCTs of etomidate vs. ketamine showed both are equally hemodynamically stable, but this was full dose ketamine (Am J Emerg Med 2013;31:1124 and Lancet. 2009 Jul 25;374(9686):293-300). Middle dose may be even better.

Paralytics

Anesth Analg. 2000 Jan;90(1):175-9.

Other References Reviewed

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Comments

  1. Great post Scott!

    I had a few thoughts:
    1) What about topical lidocaine or IV lidocaine? The last hemodynamically unstable pt I intubated (critical AS with hypoxia/resp failure and hypotension) I only used lido spray and 0.1mg epinephrine to intubate. A quick topicalization and suction can smooth over some of the analgesic and lack of paralysis (laryngospasm) that may occur from underdosing.

    Also, my limited experience with IV lidocaine is that it acts basically as a GA agent, and it reduces the dose of other induction agents you may need. It seems to be fairly cardiac stable, and may have some additional benefit in TBI/ICP patients.

    2) If you are giving high-dose sux or high-dose roc, why not just give the roc? There is no chance of MH-reaction, and also less risk of masseter muscle spasm and sux is the most commonly implicated agent for histamine release or anaphylactoid reactions.

    • IV lidocaine would be a v. bad idea; it will definitely lower the BP. SPray is fine, but not sure how much it is bringing to the table. Only advantage to Lido in TBI is blunting sympathetic tone–exactly what we don’t want in this circumstance. even there, it is of questionable benefit.

      Only reason to give sux is if you want to be able to do post-tube neuro exam, i.e. multi-trauma with potential TBI.

  2. Question? Could you give a small dose push dose pressor epi since there is likely some hypotension to develop…working in small increments to prevent the hemodynamic instability before it actually occurs…

    • you could definitely give 1/2 ml (5mcg) of the Push-Dose Mix (1:100000) with the induction meds, v. little change of sig. overshoot with that dose.

  3. Hi Dr. Weingart,

    Awesome podcast to listen to after intubating a septic patient last night. If patient does not have a central line, when they need to be intubated, do you suggest still having norepi at the bedside during peri-intubation? And giving it via peripheral line if necessary?
    Do you give your push dose pressors via peripheral lines?
    In the peri-intubation period, with the norepi at bedside, how long do you wait for fluid response before starting norepi? If MAP is not at 65 after intubation, are you just starting norepi along with keeping fluids going? Even if you have not given 2 liters of NS?
    Thanks a million.
    Awesome lecture.

    • This will depend on your institution. At the Janus, we would start the norepi peripherally and put a central line in as soon as pt is intubated to spare them the discomfort. This is assuming they have a reasonable peripheral line. You can always start pressors and then titrate them off as you give volume resus post-tube.

  4. Hi Dr. Weingart,
    With Ketamine what is your middle ground dosing? I heard the dissociative dose of 1-2mg/kg but do not think you mentioned the middle groound dose. Thanks!

  5. rfdsdoc says:

    I’d like to say…thankyou

  6. Wow. I thought I knew what to expect with this month’s cast but you went above and beyond my expectations. Additionally the graphics were a really cool treat. Thank you.

  7. Jens Michelsen says:

    Hi Scott. I like you prioritizing life before awareness, but what is the difference between memory and awareness???

    • The way many of the amnestics work is that you can be aware during the event, but will not lay down memory of it. When the pt emerges from their ICU course they will have no recollection of the intubation, no horrible memories.

  8. how you monitor blood pressure? we are used to go with 2.5 minutes interval. what do you think?

    • we hit stat which immediately retakes as soon as the first reading is done. don’t do this if the iv is on same arm until after meds go in. if pt is clamped down, they will need bp recycled 4 or so times before you get a real read.

  9. Don Diakow says:

    Ditto on the “Thank-you and cool graphics”.

  10. Peter Weimersheimer says:

    Great lecture. An additional reason to not use etomidate is that it cannot be used as an infusion. There is a false sense of security in relying on a short acting hemodyndamically “inert” induction agent and then often having an intubated patient without adequate sedation/analgesia out of fear of other using other agents in an unstable patient. Makes more sense to go through the initial intellectual exercise of selecting appropriate analgesics and induction agents for a specific case that can be titrated after intubation for an adequate analgesia/sedation package.

  11. Thanks Scott, Listening to this has given me alot more insight into a recent case. We had a 15month present to Janus Hospital in what looked like septic shock. She was RSI’d with ketamine and sux and promptly went into cardiac arrest requiring CPR. She had good CPR, and responded the the adrenaline, and went on to inotrope and vasopressor infusions. Turns out she had myocarditis. One of the discussions around this was that she already had a sympathetic overdrive, and the ketamine further pushed her sympathetic system, beyond its capacity and hence she arrested. And this was / is the main reason some of the intensivists I work with would not have used Ketamine. Realistically the dose of ketamine was more than you suggest and this is the likely mechanism. Do you think you would use ketamine in this situation? Is there basis to the above explanation?

    • far more likely was the shift from Neg to Positive pressure. When these pts code with ketamine they blame the drug, when they code with etomidate, they blame the pt.

      • Minh Le Cong says:

        yes I have seen this situation before. v tricky!
        Scott is right. V unlikely it was ketamine related. The child was responsive to adrenaline periarrest and then vasopressor infusions post, so why would ketamine cause too much sympathetic effect?!

        There is no ideal induction/RSI combo for this situation..just grades of risk! a low dose of ketamine is reasonable but still no guarantee.
        Pre RSI bedside cardiac USS might help here. If LV function looks terrible..beware pushing the induction drug! I would start a norepi or epi drip and preoxy like heck then see what LV function is like in ten min if you can wait that long. otherwise if got no time , use v low dose of ketamine along with epi drip running and prepare for arrest!

  12. Great podcast.

    I was hoping you could point me towards the references which would further explain a couple things:

    1. Normal or increased doses of etomidate are required for adequate anesthesia in shock patients, and
    2. Phenylephrine slows the onset of sedatives as compared to epinephrine

    Thanks for all the great info.

  13. Amazing podcast, thanks so much for putting it out.

    I was intrigued by the 90% reduction in propofol dose for hemmorrhagic shock. Have you come across any studies looking at sedative dosing in other forms of shock? Sepsis for example? If not what does your experience tell you?

Trackbacks

  1. […] EMCrit on intubating patients in shock […]

  2. […] This article fits in nicely with an EMCrit episode just released on Hemodynamic kills in the Laryngoscope is a Murder Weapon series by S… […]

  3. […] über den Teich: Scott Weingart aus dem Elmhurst Hospital in NYC hat in unverwechselbarer Weise diese Thematik in seinem Podcast dargestellt. Die entsprechende Literatur ist auf seiner Seite […]

  4. […] The intubation checklist that Scott Weingart proposes HERE is very good.  Have a listen to the podcast and look over the checklist.  We hope to introduce a very similar procedure in our department and will be rehearsing this during this sim session.   The link to the podcast on intubating haemodynamically unstable patients is HERE. […]

  5. […] Laryngoscope as a Murder Weapon Series – Hemodynamic Kills […]

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