An anonymous EM Intensivist writes:
I am writing to comment on a trend that I'm noticing among my residents, and I wonder if others are noticing a similar trend. I am an emergency physician and an intensivist at the University of XXXXXXX, and I have a number of EM residents who avidly listen to your podcasts.
Over the course of the last year, most of our residents have made the transition to using rocuronium for RSI (mostly based on recommendations from your podcast, I think). I use rocuronium preferentially as well, for many of the same reasons that you cite.
What has not accompanied the use of rocuronium, though, is an accompanying willingness to provide adequate sedation and pain control. I find that this is especially true with trauma intubations. I would say that the usual course of events goes something like this: etomidate and rocuronium for RSI, tube goes in, patient is hypotensive (trauma patient), so patient gets crystalloid or blood during emergent evaluation. After 5-10 minutes, blood pressure and HR start to trend back up, and most everyone in the trauma bay is patting themselves on the back because they have resuscitated a hypotensive trauma patient. They are going to CT.
In the old world order (the etomidate and sux days) — which I do NOT think was better — the clinical course would be the same … except. After 10-15 minutes, that hypotensive trauma patient would start coughing (with better vitals), then would sit up and give someone the finger while he was preparing to pull his endotracheal tube out. The janitor would peer into the trauma bay and would recognize a trauma patient who needs sedation, and sedation would be provided.
Now, everyone is hesitant to give long-acting sedative medications to our patients immediately post-intubation, because pts are “sedated” and we're worried about hypotension.
I think that this is an unintended consequence to the transition of moving to rocuronium as a paralytic agent for RSI. I think it's a great drug, but I think that when the tube goes through the cords, the intubator needs to announce to everyone in the room “I've given a paralytic drug that lasts for an hour, the sedative agent that I gave does not, so we are going to give ___ right now so that this guy does not wake up paralyzed.” Propofol infusion +/- fentanyl, bolus of midazolam and dilaudid — I don't really care what people use, but I think that the way that people are starting to practice is to unintentionally use pain and awareness as a pressor, and I hate to see this happen. I also think that people need to think to watch the vitals and respond with sedation as necessary. I had one case of a SAH that started with intubation and ended with a resident using labetalol IVP for HTN that started about 20 minutes after intubation. In many of these patients, propofol can be a very effective antihypertensive.
I have not done in depth analyses to see what our patients remember (perhaps we should), but I'm a little worried that someone out there is aware of their resuscitation while they are paralyzed because we are not rigorously applying the pharmacokinetics we know about the agents we are using. I think that in some cases, their physiology would suggest that they might.
Thanks for all the good work you do for our community,
This wee is my audio response. But to sum it up:
- If you are going to use roc, you better be starting sedation the second you are done securing the tube
- There is no patient so unstable that they do not deserve analgesia and sedation.
- For more see this previous post on post-intubation sedation/analgesia
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020
- EMCrit 287 – Thoracotomy Masterclass with Dennis Kim - December 10, 2020