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:
Eleni Salakidou's SmaccBYTE Entry
Nickson's Hierarchy of Resus Airway Needs
Literature
Best Review Article
Anaesthesia 2009;64:532
STC Review Article
Curr Anesthesiol Rep 2014;4:225
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)
Heffner et al. J Crit Care 2012 Aug;27(4):417
Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. (PMID 25402500)
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
Nickson's Pyramid
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Scott Weingart
Latest posts by Scott Weingart (see all)
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Scott, I have a question about the reduction of dose for Propofol in the shocked patient. What mechanism in the shocked patient causes Propofol to be effective at only 10% of its normal dose? Why wouldn’t we use that lower dose all the time? Working air-med where inductions are often performed with sub optimal hemodynamics. Thank you for all the information. JC, FP-C
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.
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.
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.
[…] EMCrit on intubating patients in shock […]
[…] This article fits in nicely with an EMCrit episode just released on Hemodynamic kills in the Laryngoscope is a Murder Weapon series by S… […]
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!
0.5 mg/kg generally. I mentioned this in the podcast in the section of what I actually do.
I’d like to say…thankyou
: )
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.
: )
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.
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.
Ditto on the “Thank-you and cool graphics”.
thanks Don
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.
absolutely
[…] 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 […]
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.
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!
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.
[…] 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. […]
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?
I would do a similar dose reduction for all of them. If you are concerned, that the dose is inadeqaute, titrate the sedatives prior to administering the paralytic.
[…] Laryngoscope as a Murder Weapon Series – Hemodynamic Kills […]
[…] EMCrit podcast on peri-intubation […]
This is fantastic! We still use allot of “normal dose” thio around these parts, which, oddly enough, leads to quite a bit of hypotension.
I’ve finally gotten around to translating this into “Kiwi” It would be great to hear your comments.
http://www.thesharpend.org/eeacc-5-airway-pharmacology
great stuff, Andy
Hey Scott, I’m a resident from UT Houston interested in your take on proposal in lower doses for shock patients. References here didn’t have much to support the maintained cerebral concentrations without hypotension, found one study that looked at 16 sheep given either 1mg/kg of 10mg/kg and then looked primarily at CV effects as outcome. Wondering if there is any literature you can share. Appreciate the feedback.
[…] For more discussion of this strategy for intubating the hemodynamically tenuous patient, see Scott Weingart’s podcast. (3) Image credits: Speedometer image from freeimages.com. This entry was posted in […]
[…] a “hemodynamic kill” from intubation; further discussion of avoiding this may be found on the emcrit site. 6: Immediately determine contraindications to thrombolysis using a […]
Scott,
I love what you are doing, keep on doing it man! So as a third year at my program at henry ford, we do evidence based lectures. My topic is podcasts as teaching tools. Some push back I get from older attendings is “well they are not peer reviewed” and “how do you know they are evidence based?” One of my favorite ‘casts of yours is the hemodynamics kills (intubating the shock patient) one. So what I have chosen to do as part of my lecture is break down your podcast and look at the evidence you use to support this. Regarding this I have 2 specific questions:
1) You saw all induction agents will drop the pressure in shock patients. I love your analogy of NIN to bob marley! Theoretically, it makes sense. While you present evidence for and against this, it is by association. Do you have any direct causation evidence (i.e., looking at physiologically there is a loss of sympathetic surge once these patients are “induced”)?
2) your choice to use a lower dose of ketamine than the standard. any direct evidence or more anecdotal?
Thanks Scott!
Eric Einstein
1. have to go back to the ref sheet linked in this post. problem is this group is notoriously understudied
2. anecdotal. but i’ve started doing hemodynamic DSI and now have 6 patients where I could actually witness the response to these doses, they dissociate.
[…] Weingart S. Podcast 104 – Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills. https://emcrit.org/podcasts/intubation-patient-shock/ […]
[…] When the time comes for the intubation, I would use RSI with ketamine as the induction agent. Ketamine may be more hemodynamically stable than other induction agents (although any agent can result in hemodynamic collapse due to loss of sympathetic tone). I would use a slightly lower dose than normal, starting at 0.5mg/kg. Due to poor muscle perfusion, normal doses of paralytics may be ineffective. I would use a higher dose of paralytic than usual (rocuronium 1.6mg/kg or succinylcholine 2mg/kg). For a more in depth discussion of intubating the hypotensive patient, see Scott Weingart’s SMACC talk “Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills” […]
What induction agent do you use for post cardiac arrest patients? Does the sympathetic surge from ketamine increase the risk of further dysrhythmia?
All depends on their pressure. If low or on pressors, ketamine is fine. If high would avoid. If normal, ketamine is prob still fine, but need to be careful.
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[…] Weingart has described this as the ‘nine inch nails to Bob Marley transformation’. (See intubating the patient in shock from SMACC 2013). Decreasing the dose of sedative, and having pressors / push dose pressors ready […]
[…] [3.] https://emcrit.org/podcasts/intubation-patient-shock/ […]
Dr. Weingart, thanks for your continued great work; CA-2 anesthesiology resident here, just wondering about your comments during the podcast regarding choice of pressor (neo, ephedrine, and epi) during the peri-intubation period; I was unable to find the reference you mentioned discussing epinephrine’s advantage with respect to induction/paralytic agents delivery, etc. Would you be able to point out which resource contains that information? Thank you!
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[…] For hypotensive patients (or patients at risk of becoming hypotensive) etomidate and ketamine are the most commonly used medications. However, it is essential to recognize that all of the drugs we use can result in hemodynamic instability. The dose of the agent chosen is probably more important than the actual agent used. For patients in shock, use much lower doses than usual, and titrate up as necessary. As a general rule, half the induction drug and double the paralysis dose. For a more in depth discussion on the topic, refer to Scott Weingart’s talk. […]
Hi Scott,
one issue with middle dose ketamine I experienced is that some patients are still awake during the intubation period. They eventually received an additional small dose of etomidate and are fine. I prefer Ket because I haven’t seen any periintubation hypotension patient since I started using it instead of eto.
But what is the issue here with patients receiving Ket at your recommended dose and being awake?
I do all of these patients as hemodynamic DSI–give ketamine and wait 30 sec. if they are still awake, give more. when dissoc. and the bp has not dropped, then push paralytic
[…] Weingart has described this as the ‘nine inch nails to Bob Marley transformation’. (See intubating the patient in shock from SMACC 2013). Decreasing the dose of sedative, and having pressors / push dose pressors ready […]
[…] Podcast 104 – Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills […]
[…] HOp Killers por Scott Weighart, MD: https://emcrit.org/emcrit/intubation-patient-shock/ […]
[…] doses. This will be a future post here, but for now I would refer to EMCrit’s excellent post on how to intubate a patient with hypotension. Practically, this means I am using 0.5mg/kg of ketamine and 1.5mg/kg of rocuronium as my initial […]
[…] Weingart has described this as the ‘nine inch nails to Bob Marley transformation’. (See intubating the patient in shock from SMACC 2013). Decreasing the dose of sedative, and having pressors / push dose pressors ready […]
[…] RSI Meds (Great Explanation HERE) […]
Hello Scott,
I am a paramedic in upstate NY and MA. Both the agencies that I run with do not carry ketamine out of medical director fear over the “emergence reactions” seen in patients, and that contrary to your statements, they have positive experiences by utilizing midazolam and etomidate in their drug repertoire. Can you comment on this? One of our agencies is endeavoring on a prehospital RSI program that does NOT include ketamine- only etomidate and midazolam. I see a safety issue here.
Martin
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