I recently spoke at a symposium at the Greater NY Hospital Assoc's with the title: Controversies in Critical Care. I debated Paul Mayo, MD on the topic of whether paralytics should be used for ICU emergent intubations. Of course, I took the pro side of the debate. Dr. Mayo based his con side on an amazing study that came out of his ICU at LIJ hospital in NY.
Here is the abstract of that study:
Seth Koenig, MD; Viera Lakticova, MD*; Abhijeth Hegde, MD; Pierre Kory, MD; Mangala Narasimhan, DO; Peter Doelken, MD and Paul Mayo, MD
The Safety of Emergency Endotracheal Intubation Without the Use of a Paralytic Agent
Here is some literature you may want to cast a more informed vote:
Mort on Complications of Repeated Laryngoscopic Attempts
Here is the article I wrote with Rich Levitan on Preoxygenation for Intubation:
- Weingart, S. Levitan, R. Preoxygenation and Prevention of Desaturation During Emergency Airway Management (In Press, For Review Only)
Update
- Annals ATS. First published online 26 Feb 2015 as DOI: 10.1513/AnnalsATS.201411-517OC Neuromuscular Blockade Improves First Attempt Success for Intubation in the Intensive Care Unit: A Propensity Matched Analysis Jarrod M Mosier , John C Sakles , Uwe Stolz , Cameron D Hypes , Harsharon Chopra , Josh Malo , and John W Bloom Read More: http://www.atsjournals.org/doi/10.1513/AnnalsATS.201411-517OC#.VPN3bOFGxsk
- BMC Anesthesiol. 2014 Jan 1;14:39
Need an audio only version:
Mp3 of the Paralytic Debate (right click and choose save as)
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Scott Weingart
An ED Intensivist from NY.
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Hey Scott
You seriously got ambushed on that debate – completely agree with your assertion in the post-game review: Dr Mayo has shown that a highly drilled team can perform difficult intubations with a similar complication rate to the “elective or anaesthesia-department rates”. He did not show that paralytics are bad, or that sedative-only approach is better / less complications.
Here is my take on the debate: Paralytics allow your average “wild man” ED, GP or trainee type to maximise their success rate. You could argue that there is a constant “trial” going on in the community hospitals which shows that using sux (or Roc) makes and average doc equal to a highly drilled team of ICU residents using Propofol only.
The clincher is this: there is no way you can achieve a 42-point checklist in most crashing patient intubations – it may actually be faster to read the Wall St journal! We just don’t have the manpower.
Casey
PS: I reckon you should have asked for a second round…thought the lap-lap pic was a nice touch though – nice thighs – you been workin’ out?
Hey buddy,
I agree checklist is tough on crash tube, but in a podcast later this month, I will put forth the argument that very few intubations should be crash.
We have a checklist that is rarely used, but then the other day one of my residents forgot to turn on the O2 for the BVM.
The sicker the patient, the more likely we are to be stressed and forget something key. When you think of the tasks that we actually accomplish pre-tube 42 is probably an understimation. Best way is to probably assign a nurse or junior to run through the list silently and only call out missing items/steps.
checklists and doctors..man we are an egotistical bunch. Some of my colleagues absolutely oppose the idea of checklists, whether it be for ventilator setup or RSI. They argue medicine should not be rigidly boxed into protocols and checklists.
get over it people. pilots have to use checklists in their daily job or they lose their licence.
Recently as last fortnight in Melbourne Australia, there was a medical error that made the headline news. An in utero abortion of twin pregnancy went wrong. The baby with unsurvivable heart defects was supposed to be euthanased in utero. They accidentally got the wrong twin.
Checklists I agree can be time consuming but even in prehospital RSI, there is always time to do them. Even in the crashing patient, they can always get BVM whilst you are setting things up.
I think I heard somewhere that a rapid sequence induction has at least 162 steps or critical decisions. Not all of them need to be on a checklist though, as a correctly written checklist can check several points at a time…
You can see the one we use here (EDICT). It was primarily the work of Reuben Strayer. I am in the process of making a streamlined one to be read out at the beginning of the set-up by a nurse or attending. They only need verbalize the ones that
I take Scott’s side- use the paralytics and give yourself the best view possible. You said every argument I would have used in the situation. One quick point- one argument against paralytics (or using suxs instead of roc) is that patients can “wake up” and breathe on their own. As you said- this is shennanigans. Why are you intubating most of these people in the first place? You are intubating them because they aren’t oxygenating or ventilating well to begin with! The only time I could make a cogent argument for not using paralytics or for using suxs instead of roc is the young drunk and rowdy trauma patient who is oxygenating and ventilating just fine but you have to put them down to do your CT scans and/or resuscitation. You can make an argument that these patients are breathing fine at baseline and will wake up to normal respirations if you can’t get a tube in. However, aren’t you still putting them at risk for aspiration because you aren’t paralyzing their musculature to prevent vomiting? Otherwise I can’t think of any other possible reason to forgo the paralytics. If Dr. Mayo wants to do a truly valuable study, the… Read more »
agree Steve! I almost think they wasted an epic study by going down the sedative only road. If they had just billed this as a paper outlining a training approach to reduce complications during ICU intubation, it would have been landmark.
I find it interesting that the ICU team for the high alert procedure does not include the attending. Just the Fellow who received intensive high fidelity training. Many Internal Medicine programs do not include intubation training during their 3 years. So therefore the real question is would you have your intern or 2nd year EM resident after their anesthesia rotation intubate with RSI without you in the room?
Is that the real reason that paralytics are an uncomfortable portion of the RSI in the ICU?
I guess that is the real question–if someone less than an attending is doing the tube, is it better to give them muscle relaxants or not. At the end of the discussion period, Paul and I agreed if the intubator doesn’t know difficult airway algorithms, maybe best not to paralyze. But it is unclear to me who they call in the event of a difficult airway.
this part I dont understand. if the intubator does not know difficult airway algorithims why are they doing the intubation. It is not a totally benign procedure. there are much safer airway interventions
The interesting thing is why does the high alert dangerous procedure not have an attending physician on the team?
With IM training many programs do not have intubation as a skill set that is developed during the 3 years. ABIM has cut way back on required procedures for IM graduates. So the Fellow may have never intubated much prior to their ICU fellowship. Would you be comfortable with your EM intern or 2nd year performing RSI intubations in the ED after their anesthesia rotations without you in the room?
Perhaps that is part of the root of the concern over paralytics in the ICU intubation.
Ok Ok Ok I have been reading through the comments with much attention as I am Paul Mayo’s partner in crime in the ICU. When we argue we must get our facts straight. Of course an attending is present when ALL intubations take place in the ICU. ALL intubations have an attending present. There I said it. Another comment. The idea that you could read the Wall Street Journal faster than the 42 point checklist. Hmmm. Firstly I don’t read the WSJ…I wish I had that much time. The checklist takes under 2 minutes! I agree that almost ALL intubations have at least that amount of time till the tube needs to go in. Also remember that there is a thing called effective BVM. Now lastly if you were to see the way patients are intubated in my ER…….hmmmm
Folks, We are luck enough to be joined by Dr. Koenig, 1st author of the study, which Dr. Mayo speaks about during the debate. He is an intensivist at Long Island Jewish Medical Center in NY.
Hi Seth In Dr Mayo’s lecture slides it does actually state that an attending supervisor is present for all ICU intubations..so it was already declared during the debate..if not verbalised. I keep reviewing the recording as it is one of the best debates/lectures I have heard in a long time. Its good to challenge always what we do and how we do it. In fact your study does challenge us with the notion that in critically ill patients a graded sedative only approach to intubation is not an unreasonable primary strategy, and if things do not go well then you can always use a paralytic and have an attending on hand to assist. So I have to ask. In your study, if things were going badly with the intubation attempts, at what point did you decide to do something else and perhaps use a paralytic? Dr Mayo argued that the problem with RSI with paralytics was the ill conceived assumption that intubation will be successful. Equally you could argue that with a sedative only approach, you are assuming as well that intubation will be successful..otherwise why did you allow 3 or more attempts to occur for intubation, with sedative alone?… Read more »
It’s funny because when anesthesia residents respond in most hospitals, they too aren’t allowed to use a paralytic unless they are with their attending or are with another senior resident. Why is that?
One thing no one touched on in the debate was ventilating a patient! It’s much easier to ventilate a patient once they are paralyzed. Sure sometimes their tongue falls back, but it’s also easier to position them and put an airway in them once the roc has kicked in. The patient who is spontaneously “breathing” (i.e. gasping, etc, and not able to maintain oxygenation/ventilzation on their own) is much harder to assist with a BVM. Plus they are at more risk of aspirating since your bag is not in sync witht them, air goes into the stomach, etc.
I honestly don’t even understand how there is a debate.
Leon
Yep-the anesthesia resident thing has always struck me as odd as well. The idea is that if they need paralytics, then an attending should be present, but what if the pt crumps prior to that in a situation where lytics would have allowed successful tubes.
Seth & Paul’s study I think does show that if the anesthesia resident pushes a TON of propofol, the pt will probably be close to the same intubation success likelihood as with lytics.
Yes, bagging is much safer with muscle relaxation in a sick pt.
Now the debate on whether in an elective case they should have atrial of sedative bagging before paralysis is a going back and forth in the anesthesia lit right now. I am not going to be the arbiter of what is right in their world. My opinion of course is paralyze without the BVM check, but you intuited that already.
Scott,
Interesting debate. Thanks for putting it up.
A tangential point that I thought might be worth some more attention is that of the checklist. As Casey mentioned above, a 42-point checklist is unrealistic in the crashing patient. But as Atul Gawande discusses in “The Checklist Manifesto”, even pilot’s who’s planes are crashing are now using checklists with improved outcomes. Checklists have been shown to improve outcome in many high-risk, high-pressure situations. Particularly at teaching institutions where not everyone involved will have adequate experience prepping for and performing intubations and where the make-up of the team shifts constantly, it seems like there might be room for a brief checklist before emergency intubations.
Curious to hear your thoughts and those of other listeners.
Nick
I’m all for checklists (when appropriate – I am a fierce opponent of cookbook or protocolised-medicine). However my RSI checklist is not 42 points long and has a neuromuscular blocking agent on it.
I reckon a re-match is called for…
COI : “Wild man” rural doctor
thankyou for a truly engaging and thought provoking debate! In my view, it was almost a draw but SW took it by a narrow lead. Dr Mayo’s study is remarkable in design and I will be keen to review the peer reviewed paper in detail. I particularly support the notion of a highly drilled team approach to high risk airway management. The checklist concept is well grounded in sound human factors research..42 points does seem like overkill but I will look forward to reviewing the list. IN my own service we have instituted a 7 point checklist and many prehospital/HEMS units have similar checklists for prehospital RSI. I also totally agree with his view that OR/anaesthesia rules do not apply in the MICU..in fact I believe they do not apply in the ED , prehospital or anywhere outside the OR. Has Dr Mayo debunked the traditional concept of RSI in emergency airway management? yes and no. He argues that if he has shown equivalent complication rates and overall intubation success using a sedative only approach then that is ergo the superior technique as less drugs are used. I disagree. It will be interesting to review the details of vasopressor/inopressor use… Read more »
Interesting debate, thank you. The thing that’s been missed when talking about an emphasis on physiology is that what’s described does not equate to normal physiology. Propofol + vasopressor does not equal normal cardiac output or perfusion. I doubt anyone familiar with sedatives and relaxants would deny that you need less sedation if you are using muscle relaxants, therefore reducing the disturbance of cardiac physiology. I’m a bit confused by Dr. Mayo’s description of the airway team. While it seems like a lot of effort is made to use training, debrief and simulation (all good), two interns and a fellow are directly involved in the airway management, with a fourth person supervising their decision making. This means that no one person actually knows what’s going on in the airway- why in the laryngoscopy difficult, why is BVM difficult, what can be done to improve it? And why deliberately by policy exclude anaesthesia from the procedure? Even if you don’t think they are as good at manageing the whole induction, there can be little doubt that they are the best at the technical intubation and facemask ventilation… Why not let them at least handle the airway, while an intensivist or emergency… Read more »
I agree Tim. It does seem an odd strategy to have different people doing different things on the same airway. And excluding anaesthesia staff makes it seem even odder. To try to demonstrate that in MICU you do not need to do RSI or have anaesthesia staff on hand to manage an emergency airway does seem a complicated exercise and you have to wonder the aim of it all.
in the prehospital setting, we are used to not having anaesthesia staff , let alone many staff at all. We have found checklists useful and effective in improving intubation performance as well in the prehospital setting. in general we do not have the time nor controlled setting of titrated sedation to work with securing an emergent airway. we generally don’t want to take more than 1-2 attempts, we want to get it over and done with and move on.
Minh,
perhaps you can post a pic of the brilliant mat on which your folks lay out their equipment–a zero-time checklist of sorts.
Here’s one from MAGPAS (part of the UK BASICS scheme)
http://www.sjtrem.com/content/17/S3/O26/figure/F1
The RFDS ones are similar, printed out on a yellow clinical waste bag – so serves well as a RSI kit dump and for clearing up afterwards
Love it, such a clever idea
I am emergency medicine trained. Clearly RSI is the most effective method to rapidly secure an airway in the ED, ESPECIALLY in the critically time sensitive scenario.
However, one problem has occurred at our tertiary care ICU. In the setting of an RSI that goes sour, we have found that relatively simple adjuncts such as the gum elastic bougie are not always stocked on the icu airway carts. In the ER we take for granted the availability of a full set of backups (LMA’s and fiberoptic toys), though the ICU may not have these luxuries (at our institution).
For this reason, I usually proceed with a topicalized/sedated approach for most ICU intubations despite my comfort with RSI. With that said, there are a few ICU circumstances wher sedating to intubate is unethical (severe hypotension, increased ICP) and in these cases I still paralyze. Just my 2c!
Joseph-Makes sense. When I was taking shifts in the ICU, I used to have a bougie, an intubating LMA, and a #11 scalpel in my backpack. These days I’d probably add a king vision scope. WIth those items, I have everything I need for shock trauma algorithm.
One suggestion here
Check out http://www.airwaycam.com
Its Dr Levitan’s website
He sells a ready prepared emergency airway kit/tray called the PEAK
I bought one a while ago and its great. Comes with FAstrach disposable kits, blades, handles, bougie, even an Airtraq optical device, ETT, nasal airways
When you do your ICU shift, you can take it with you and place it on the airway cart. end of shift it leaves with you and you can stick it in the boot of your car.
As someone who bought and used it, I can definitely recommend it for the need of someone who has to go and work in different locations and wants to have standard kit come with them
MP3 please?
A couple of thoughts…
if you have time to do a 42 point checklist, you should have time to think about the situation enough to anticipate if the airway is going to be difficult, what the difficulties/potential complications could be, etc. These don’t sound like they were crash intubations.
And then 21% require >2 attempts, 15% have esophageal intubations, 11% desat’d to less than 80%, and two people died (yet their intubations were still apparently “successful…”)
While I’ll be the first to admit I’m unfamiliar off-hand with the rates of these in the emerge literature, my personal experience is that when we RSI, these rates are much lower – locally anyways.
I don’t know if based on these numbers I’d say that using propofol only gave “acceptable safety,” and I wonder if these numbers would have been better if a paralytic was used.
Aaron, I agree with all of that. The most recent NEAR study shows lower rates for ED performed RSI. The >2 attempts (which could be 8 attempts; and I don’t even know what was considered an attempt) and the desat rates scare me a bit.
Good. For a while there, I thought it was just me that was uncomfortable with those numbers.
Neuromuscular blockade to facilitate RSI/EEI might not be a benign manouvre, but I can’t imagine an increased dose of hypotension inducing sedative and therefore prophylactic vasopressor is either. It’s just swapping one set of potential adverse effect for another. That’s fine, as long as the practitioner has enough experience to understand and manipulate the differences. I agree with Minh’s earlier remark that sedative only RSI is not the first choice to teach to juniors, because they will need to be comfortable with the back-up of using the NMB.
Is this study more that intensive simulation, emergency crisis resource management and 42 point checklist is good way for novice intubator’s to increase there success at intubation in a safe way?
I think that is what they have proven–and it is no small thing to prove. I wish they had titled the paper, “A path to achieve safe intubations in an ICU” or similar and then it would have been a game-changer. I worry that this aspect may get lost whenever someone does a pubmed search.
interesting latest prehospital paper in Resuscitation on ETI
kinda suports what Mayo and Seth claim in their paper. non “expert” intubators in this prehospital HEMS Belgium service had statistically the same intubation success rates as “expert” anaesthetist doctors, with 46% intubations using sedatives alone( non expert doctor) vs 4%(expert doctor). Incidence of defined “difficult ETI” was statistically higher in the sedative only group though. They did not examine complication rates like aspiration nor hypoxia.
Breckwoldt J, et al. Expertise in prehospital endotracheal intubation by emergency medicine physicians—Comparing ‘proficient performers’ and ‘experts’. Resuscitation(2011),doi:10.1016/j.resuscitation.2011.10.011
@ leon and SW:
It isn’t easier to ventilate the “cant ventilate” patient with paralytics on board.
The article “Prediction and Outcomes of Impossible Mask Ventilation, Anesthesiology 2009; 110:891–7” describes 77/53041 patients, all but 3 had muslerelaxants but couldnt be ventilated. On the other hand an unknown number of patients could probably be ventilated due to the paralytics.
I believe my interpretation would be that 74 of them were difficult to ventilate despite muscle relaxants. I think this study offers a superior answer:
Anaesthesia, 2011;66: 163-167
agree x 2
My observation is that unstable patients die mostly from undue haste and cardiovascular decompensation, not inability to intubate them after paralytic.
Hence, I strongly support the checklist (and the first item on mine is: 1. PACE – announce that nothing will happen for > 5 minutes so that everyone slows down) , I always have dilute adrenaline drawn up and I always use paralytics because I want the tube to go in fast the first time and my backup plan does not include waking the patient up.
agree with all those points
Hi Greg and Scott. I agree mostly with the comments. never say never.whilst waking the patient up is usually not the best option in the critically ill or injured, it is an option. This case from Scotland highlights the issue in the elective patient
http://www.scotcourts.gov.uk/opinions/2010FAI15.html
there is one common emergency situation, actually already discussed in another post on emcrit, whereby you might choose to do RSI, yet if you do encounter unexpected difficulty, waking the patient up is a valid strategy.
Letting the patient wake up is an excellent option in anesthesia. Letting the patient wake up in the ED is great when it happens. Gearing your pre-intubation airway strategy with the patient waking up as you rescue technique will lead to bad decisions.
Scott, its a fine line to draw. If an elective patient turns into a failed airway and emergency with critical hypoxia, are they not then a critical patient? If waking them up is a practical option, its worth considering. Should you base your whole airway strategy/planning on this option? Of course no. But its reasonable to ask the question during your decision points. in fact you should ask the question several times if you are struggling in controlling the situation. The common emergency situation in the ED and small rural hospitals is the out of control combative agitated mental health patient, whom RSI is an option in controlling the situation and preparing them for air transport to a higher level care. If you encounter a very difficult unpredicted airway, apart from a range of options to quickly consider, waking the patient up is a valid option in my view. It might return you to the same problem as you had at the start but at least you know more information now about the airway and what level of risk you want to take in managing the acutely agitated patient. Now if you choose to use rocuronium as part of your… Read more »
i think we agree that if the reason for intubation was a non-pulmonary indication the wake-up option is more valid. If the patient was having hypoxemic failure as the reason for intubation, I’m going down the whole airway algo in 2 minutes post standard intubation failure.
yes thats a good summary of it, Scott. I think Richard Levitan put it best when he told me “the closer the patient is to dying, the less worry I have about pushing RSI drugs and getting the airway secured” and in fact in the critically hypoxic patient the longer you wait to make the decision to crack on and secure the airway, the harder you make it for yourself.
Find a good Flight or ground medic that has field experience and let them teach these people. Sorry doc’s but you have a great defined base of knowledge at your disposal and in many states they were trained by anesthesia and not only understand this procedure better than most. But many times are very experienced with much more success at it. These are the ones in rural areas with no help to speak of and do this in the most inhospitable environments.
Inspired by “The Checklist Manifesto” and by the “Airway 911 card” of Dr Braude, here’s my checklist for RSI (and more as you can see). I sort through this checklist whenever I’ve got time ahead and we give a copy to every medical student/intern that comes across our hospital. Although my “aide-mémoire” is in french, I’m sure you can decipher that I’ve put passive oxygenation in the checklist based on your article “Preoxygenation and Prevention of Desaturation During Emergency Airway Management”… thanks!
https://www.evernote.com/shard/s100/sh/9a0d376a-856c-4f7e-be2d-cd905d77b0b0/d82317e84f2c18f8c43ce55d560c80b0
P.S. we don’t have nicardipine in Canada 🙁
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Hi Dr Scott. .Thank you for putting up this useful debates . Actually we are doing a paper about RSI vs non paralytic RSI especially in patient with severe metabolic acidosis …and I’ll be very thankful if u could provide us with some references to go with.
I’m looking for information regarding paralytic use post intubation. My organization is leaning more towards analgesics ando sedation only, unless we need to use paralytics. Any information on this?
https://emcrit.org/podcasts/post-intubation-sedation-2014/
Just from a trainee’s perspective (internal medicine – critical care) When I began as a fellow in 2013 I was super excited to learn how to intubate and this is how it was taught….. -Lay them flat -100 fentanyl/2 of versed -Patient gagging and burping -100 fentanyl/2 of versed -becoming hypotensive – pressure bag 1 liter of crystalloid -rinse wash repeat until a harrowing intubation occurs or anesthesia arrives This crazy sequence of events is what led me to this site, because I thought something was missing, there has got to be a better way to do this. And thank you scott for showing me that there is and leading me to rich levitan (went to airway course in yellowstone this past year to keep fresh). Now its a resuscitative intubation, its my life as an attending is so much better and gave me ability to be independent and efficient/proficient Also, 2 of my 2 new co-attendings came from a place without paralytics and whose intubations were always supervised by anesthesiology, who took have their intubations. The terror in these guys is incredible. Bad mindsets, no mental checklist, and fear of paralytics make their lives so hard. It really looks… Read more »
here here