Podcast 129 – LAMW: The Neurocritical Care Intubation

head-explode

This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.

Who is this For?

Semi-elective intubations for patients with presumed or known elevated ICP

In TBI severity of brain injury doesn’t predict the lack of need for pharmacological blunting of increase in MAP or ICP (23511147)

The prototypical case requiring this treatment is a high-grade SAH prior to securing the aneurysm

This is the same way we would intubate an aortic dissection patient

Preoxygenation

Ap Ox and high-flow fiO2 for the full 3 minutes or longer

ETCO2

Put it on the BVM

Non-Pharmacologic Methods to Blunt Reflex Response

Limit time of laryngoscopy and atraumatic laryngoscopy

Leave the patient upright until the last possible moment, then intubate in 20 degrees head-up

No-touch intubation with video laryngoscopy by the best intubator

Pretreatment

Control the BP BEFORE the intubation

Lidocaine

While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.(11696494) Literature is pretty good on endotracheal suctioning, but nothing on patient-important outcomes during intubation. Not hemodynamically active in this one study, but I have experienced radical drops in BP. (22633717)

Local is more effective than IV. (10861151)

Lidocaine References (11696494), (17358099), (23683444), (7772359),

Fentanyl

Dose 5 mcg/kg (6318605), (7032347)

All equipment meds must be prepared before administration. Someone must be watching the pt. You need to have push-dose epinephrine drawn up at the bedside if you are going to use fentanyl in these doses.

Remifentanil

Remifentanil can also be used, but I don’t have so I can’t speak about it

Esmolol

Dose 1.5-2 mg/kg ~ 3min beforehand

Combo of Esmolol and Fentanyl (1363221) (7788827) (9084524),(1672488)

Nicardipine

Dose 20 mcg/kg (average 1.4 mg)

(21696933) and (10553821) and Review Article (16978041)

Other Group’s Recs

At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead

Osmotic Therapy

Probably a good time to give a dose of hypertonic saline

Induction Agents

Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.

Muscle Relaxants

Rocuronium or Succinylcholine at full dose

Post-Intubation Sedation

Propofol and Fentanyl

Post-Intubation Ventilation

Shoot for 95% saturation, use PEEP only if necessary; but if it is necessary it is safe to use

Increase Respiratory Rate until ETCO2 of 35 mm Hg; then send a blood gas

Other Situations

Basilar Stroke and Stuttering Stroke-lower bp=screwed

Review Article

Has anyone found a good one for ICP

Here is a great article for the high-risk vascular intubation

Rich Levitan’s Airway Course

Go here to get the scoop

Now on to the Podcast…

Bibliography

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Comments

  1. Jamie Lan says:

    Alfentanyl 20-30mcg/kg 30 seconds prior.
    Remi on infusion as it wears off too quickly to time it well with laryngoscopy.
    Lower dose of lipophilics and higher dose of neuromuscular blockers for peripherally shut down patients.

    Regards,
    Jamie
    ED trainee
    Australia

    • Ahh nice call on the alfent, but I don’t have that either. Remi with induction agent/paralytic should be timed directly to the laryngoscopy’s reflex surge. Not sure of the relevance of the shut down stuff–see the hemodynamically unstable lecture for that stuff.

  2. Volker Schulte says:

    Great post – as always
    ONS – Optic Nerve Sheath is a great tool to identify patients at risk for critical ICP. Especially if you take in account young patients who have a normal looking CCT. As they have no reserve space for swelling they will deteriotate fast.
    If you have ever changed a tube or performed a tracheostomy while the patient is under ICP monitoring then you see how fast the numbers can raise up. So the techniques described in the podcast can also be used for elective procedures on a NICU.
    In Germany we use urapidil as our drug of choice to lower blood pressure.

    Ciao
    Volker
    Neurointensivist
    Osnabrück, Germany

    Kleffmann, Jens, et al. “Effect of percutaneous tracheostomy on intracerebral pressure and perfusion pressure in patients with acute cerebral dysfunction (TIP Trial): an observational study.” Neurocritical care 17.1 (2012): 85-89.

  3. What about pretreatment with fentanyl and induction with ketamine? These older articles suggest this combination disturb HR and MAP the least.

    1. Katz et al. Hemodynamic stability and patient satisfaction after anesthetic induction with thiopental sodium, ketamine, thiopental-fentanyl, and ketamine-fentanyl. J Clin Anesth 1993, Mar;5:134-40.

    2. Katz et al. Haemodynamic stability and ketamine-alfentanil anaesthetic induction. Br J Anaesth 1998, Nov;81(5):702-6.

    A good review article from 1996:
    Kovac AL. Controlling the hemodynamic response to laryngoscopy and endotracheal intubation. J Clin Anesth 1996, Feb;8(1):63-79.

    But practically, from a semi-elective intubation standpoint, you could have infusions of propofol, fentanyl, labetalol / esmolol already set up and running, then bolus the desired amounts with the syringe pumps and add the paralytic agent. Since you are going to sedate with proposal / fentanyl anyway, why bother with other induction agents, or even ketamine for that matter?

    • most EDs and ICUs lack syringe pumps, they use bag roller pumps. It is much safer on these pumps to draw up sticks of medication

  4. Wilhelm Wallquist says:

    You didn’t say anything about setting up an arterial line, something I consider almost necessary in order to control blood pressure in these situations. Did I miss something, or do you think non invasive blood pressure is good enough?

    Thanks for the excellent podcast

    Wilhelm Wallquist
    Anesthesiologist and critical care physician
    Sweden

    • its a great point! All these patients get a-lines in my place, but we usually wait until after. It would be nice to have before intubating, though I think the non-invasive BP is fine for the elevated BP situations. I find they fail in hypotension. You just need to make sure the rep. time is reasonable.

  5. Always interesting, Scott. A couple of thoughts. First of all, fentanyl (or any other opiate) is almost always a good choice. I would caution, however, that CO2 can rise if the pt is not being ventilated adequately (why is the patient being intubated in the first place?) which is not good for the brain. Also, nicardipine is ok, but has been shown to have a higher incidence of hypotension compared to other agents (esmolol?) in part due to its relatively longer half life, making it a little more difficult to rapidly titrate. (Yes, a pre-induction a line would be key). However, better to go with the agent you know than to try something new emergently. Also, for aortic dissection one is not only concerned about the MAP but the pressure wave (dP/dt) that is propagating the dissection; hence lowering inotropy is beneficial, which is why my choice for aortic dissection would be esmolol rather than nicardipine, which theoretically might increase dP/dt by reflex because it relatively spares cardiac contractility. Maybe it’s the Italian sepsis study (which I don’t believe, by the way), but I’m liking esmolol more and more, and have resorted to doing more esmolol pushes vs gtt. Anyway, nice topic.

  6. I can’t help but cringe a bit at your suggestion for “push dose nicardipine,” especially as a remedy in case the provider “screws up” a push dose pressor such as epinephrine. Having physicians mix up these push dose vasoactive agents at the bedside is just asking for a disastrous error. Unfortunately, epinephrine is one of the only drugs I’m aware of which has its concentration still expressed in ratio strength (e.g. 1:10,000 or 1:1000) instead of mass concentration. There’s loads of documentation in the literature related to dosing errors with epinephrine, and we know that physicians don’t do particularly well with calculations when ratio strength is involved (see Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med 2008; 148:11-14.). To me, recommending off-label dosing of one drug (nicardipine) to remedy the untoward effects of another drug (epinephrine) if dosed/administered inappropriately, all mixed up at the bedside of a critically ill patient just seems incredibly unsafe. I’m sure you have had much more experience with these practices, and I’m sure I’m a bit more biased toward the worst-case scenario when medication errors happen. Just makes me a bit nervous when one of my providers is going to try this when I’m on shift (or potentially worse, when I’m not).

    • Meghan, I think I understand your viewpoint. Unfortunately it is this viewpoint that may be contributing to the lack of experience on the part of physicians in the ED and ICUs on mixing up these drugs. Have you worked in an OR as part of your work experience? If not, it may be worth hanging out with the anesthesiologists for some of their high risk cases (or even the routine ones). I think you will find a very different approach to push-dose medications and to how those medications are mixed up. I will also refer you to the blog of one of your brethren.

  7. Chris Ackerman says:

    At the beginning of the podcast, you make a comment about Lidocaine and Fentanyl in TBI and “killing those patients”. We frequently use both of these medications (and as an ICU/Flight RN we are at the mercy of our medical control physician) in PAI for head injury patients. As our protocol committee chair, journal nerd, and FNP student, I have not seen any literature that puts our patients at higher risk for untoward outcomes when used properly. Is there evidence that these meds are potentially harmful? The only thing that I have found is that opioids may increase or contribute to the increase of ICP, but this condition appears to be rare and the evidence is older than dirt. Any guidance would be appreciated.

    I understand this question is NOT what the podcast is about, but the comment caught me off-guard.

    Chris Ackerman
    Flight/ICU RN
    AeroCare
    Lubbock, TX

    • Chris, you lost me. the comment was regarding giving these meds to hypotensive patients–that is indeed a very effective way to kill these patients.

  8. great podcast. curious why you make it a point though to mention “no peep unless necessary, but if necessary its safe to use”?

    I think what some people interpret as “low peep” or “high peep” varies drastically. At my shop, the anesthesiologists ROUTINELY have people on zero peep. So, if one of them were reading this page, I fear him/her would do what you say and do a beautiful intubation, put the patient on zero peep, and then have the icu pay the price a couple hours later.

    I, on the other hand, routinely start standard, run of the mill, people – just about everyone – at a peep of 10. I recognize that many others do 5. All arbitrary, I understand… but I think the idea that peep in any way raises ICP is not valid. We know this from the APRV world whereby moderate doses of Phigh (eg peep of 30) don’t affect ICP negatively at all (in fact I have seen it recruit lung, thereby allowing better right heart function and decreased ICP – may even have something to do with stenting the verts/jugulars open and allowing more efficient drainage but who knows). Not to mention one measurement is in cm of water and the other in cm of mercury – so it’s adding another comparison of apples and oranges.

    I think with a bad head intubation, the WORST thing you can do is have an episode of hypoxia – and then have to dig yourself out of it. Hence, I think, at least in my opinion, a statement such as “start with a moderate peep just as you would any other patient – keep in mind that oxygenation is paramount in these patients” may be better. what do you think

    • in poorly compliant lungs, PEEP will not affect the ICP and is beneficial for the reasons you have mentioned. In patients with normal lungs, there is a PEEP level that will increase ICP and potentially limit venous return and CO-worsening CPP. The rule for these intubations should be the same as in all others-use whatever PEEP you need to get the best cardiopulmonary situation. I have sent you a powerpoint by email.

      s

  9. Adam Bloom says:

    The review article you have posted sites the wrong dosing of esmolol…they recommend a dose of 1-2mcg/kg for pretreatment which is a thousand fold difference from the correct 1-2mg/kg dose.

    Also, looking critically at most of the literate here, there is usually a drop in blood pressure below baseline following successful intubation after pretreatment. However, most of the studies done were with thiopental. Which do you think is worse; hypotension or hypertension for these patients and do you ever drop the dose of fentanyl/esmolol or just use a single agent to prevent RSRL?

    Thanks,

    Adam Bloom

    • Adam, Not sure if you are going by the show notes or have listened to the episode. I don’t recommend esmolol at all as a prophylactic agent. I just use the fentanyl unless blood pressure already through the roof. Just as you say, many of these pts drop their BP in the post-induction.

      • Adam Bloom, ER Resident says:

        Ahh, just listened to it again and caught that part. Thank you very much for the quick reply.

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