Cite this post as:
Scott Weingart, MD FCCM. Ketamine ……. then Rocuronium, DSI & The Timing Principle. EMCrit Blog. Published on April 25, 2017. Accessed on April 24th 2024. Available at [https://emcrit.org/emcrit/ketamine-rocuronium-dsi-timing-principle/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: April 25, 2017
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Ummmm. High dose roc has an onset similar to succ. So waiting 15-20 sec until pushing the induction agent could be awful for the pt. I do anesthesia for a living along with a background in flight, ICU and ED nursing. Sometimes people give 5-10mg roc up front before induction with agent/ succ. Watch people struggle to catch their Breath, look panicky, and get the floppy fish look, etc….and this happens with a small deplorazing dose. Thank goodness some give preop Midaz which helps block some of that memory. An RSI dose of roc well before giving your anesthetic agent… Read more »
Cindi, did you listen to the audio or are these comments based solely on the sparse text of the actual post.
I own that. Only listened to part of it….My bad. I will listen to the entire podcast and readdress the subject after that.
Thanks for some nice insights. The practical aspects you’ve explored (e.g. omitting the flush and pauses in administration) are probably just as important as the pharmacokinetic nuances. The drug order is primarily important in patients with severe hypoxemic respiratory failure. For most patients it doesn’t matter. The rest of this comment focuses on severe hypoxemic respiratory failure. Let me define three states that a patient could be in prior to intubation: State #1: Agitated, unable to comply with preoxygenation State #2: Anxious but able to comply with preoxygenation State #3: Dissociated by ketamine, still breathing, able to comply with preoxygenation… Read more »
Ahh so much good stuff to parse here: Your stage 2 patients are the crux. Tachnypnea does nothing for oxygenation, it is a purely ventilatory driver. Hyperventilation may be a maintainer of recruitment, but I think that is fairly theoretical that ketamine will both decrease the pt’s Vt and this will have effects on their oxygenation. But let’s pretend that is the case. If that happens after your ketamine admin. then that is a fantastic thing to know. It gives you time to put the patient on CPAP before you push the NMB. Whatever you are seeing at that point… Read more »
Such a great discussion. So the original problem is that a paralytics (Roc or Sux) induce apnea for a significant period of time before they have induced optimal intubating conditions. – the “apneic period” Anything that further prolongs this apneic period just exacerbates this initial problem. Pushing sedative before paralytic in traditional RSI, makes patients apenic *even longer before* optimal intubating conditions. And so I think in critical patients there can be a real issue with pushing sedatives like Etomidate and Propofol before the paralytic…. and the more critical the patient, the more relevant this problem becomes. So what’s the… Read more »
I pushed roc prior to the induction agent for years, until once I got distracted while pushing the induction agent and didn’t notice that the syringe had become disconnected from the IV tubing, so I pushed the ketamine onto the patient’s bed instead of into the patient’s veins. That scenario was awful enough that I won’t push paralytic first again; there are other ways beyond being careless that could lead to paralytic on board without sedative and the theoretical benefit Josh speaks of isn’t worth it, in my opinion. I’ve moved to a modification of RSI which I explain in… Read more »
Don’t forget: roc hurts a lot in the vein.
Yeah, I didn’t know this until a boss pushed the roc in fast in an elective case (post-midaz and fent, pre propofol) and he nearly jumped off the bed.
copy message to colleagues here: This is an important post, I’m listening to it twice, for starters. There is an immediately prev original post on this subject, to which this is a reply. 2 super smart experienced guys who don’t agree- who is right? Most of our patients we end up intubating will be the profoundly hypoxemic Should we, if safety first, then be giving paralysis first, sedation second? Josh Farkas’s reasoning is simple and clear – but is it true? Scott W’s reasoning is further downstream and depends on (and he says it) giving the ketamine slowly to avoid… Read more »
you’ll have to clarify Kevin, you lost me in that last paragraph
I agree with your thoughts on the timing principle and I have started using it myself, but I miss some documentation with rocuronium doses of 1,2mg/kg. This is what I use when doing RSI with rocuronium (as I almost always do). In the articles you have posted there is no higher dose than 0,6mg/kg. As rocuronium will have faster onset when given at higher dose it would be nice to have some documentation on this dose too when using the timing principle. I have never myself experienced any awareness when using this dose.