Please, please, wait for the roc to start working :(

[J-Dubya]

(Please note this is posted in the passing gas forum for a reason).

So, I'm at yet another new clinical site. Overall, it's pretty good so far. The MDAs are very hands off for the most part (I'm used as staff here). Some of them will discuss the anesthetic plan with me, but for the most part they say "it's your anesthetic do what you want." Of course, I will be held accountable for the results of the plan, but there is pretty much no hand holding.

The only thing that is bothering me has been the inductions. I was told the first day that they only give sux here if there is an indication (full stomach precautions, motor testing, etc). It wasn't clear to me if this was due to the sux shortage or just this group of practitioners' preference.

So, we have been using roc for induction (there is no vec). The induction (to jump in at the point that we are ready to go to sleep) goes as follows:

MDA pushed the prop, I give a squeeze or two on the bag and report to him that I can ventilate. He then (without variation in terms of the dose) pushes 50mg of roc. Out of habit, I always look at my watch when the roc goes it. Then what happens is the MDA stares at me and then says " well, take a look." This is happening between 40-90secs (one time I remember thinking that even if we were using sux that this guy was jumping the gun). These are average to large sized patients.

If I were running the show, I would ventilate the patient for three minutes before DL (this text book number has, for me, been borne out when I have put the nerve stim on patients in the past). I would redose the prop at around 2 mins (probably 50mg for an average patient).

In the past, when I have realized that the MDA was either not going to let me wait 3min or was going to let me wait 3 mins but was not going to give more prop, I have turned on the sevo at 8% and given a few big breaths before DL. BUT, this place does not have sevo (just iso and des).

So, here's my choice:

-go early (30seconds after the roc is in) and intubate with prop alone. Not a bad option at all in many patients. However some of these patients don't have super easy airways and I might actually need the paralytic (and for these patients I want my first shot to be my best shot).

-go late, what for the roc to kick in and hope enough prop is left so that the patient is not to light. I do give versed, but I don't want to rely on that for amnesia in the setting of an elective intubation. Plus I don't want my first BP after intubation to be through the roof.

Unfortunately, what I think I'm doing most of the time is splitting the difference so I'm performing a DL on a light patient without the benefit of paralysis As a result I've run into closed cords and struggled with a few easy airways.

Not much I can do as a student, but I still felt like venting!

[LouisiAnimal]

Kinda had the same thing happen to me yesterday. Pt for emergent ex lap, preop k+ was 5.3. Doc pushes 20 amidate and 50 roc. Literally about 30 sec later he says "see what you got". I tube him, BP goes to 200's. Did I mention he had a 5.5cm AAA?

The life of a student

[jwk]

There's a big difference between your estimates of 40-90 seconds, as well as 3 minutes. I rarely watch the clock, and never use a nerve stimulator to see if the patient is relaxed enough for intubation. You kinda get a feel for these things with experience, but if I was timing it, I'm probably sticking the blade in at about the 45sec mark. I'd be pulling my own hair out if I waited three minutes, and you would rarely NEED to wait that long. It's not like the roc stops working when you start intubating, and if they're not quite relaxed enough, they will be shortly. If you can see that the cords are relaxed, that's all the relaxation you'll need.

BTW, I think that pressure of 200 is due to under narcotization, not tubing too quickly.

[LouisiAnimal]

You'd be correct jwk.....I told you exactly what was given. 20 amidate, 50 roc, no narc

[J-Dubya]

There's a big difference between your estimates of 40-90 seconds, as well as 3 minutes. I rarely watch the clock, and never use a nerve stimulator to see if the patient is relaxed enough for intubation. You kinda get a feel for these things with experience, but if I was timing it, I'm probably sticking the blade in at about the 45sec mark.

Again, IME (based on using the nerve monitoring) at 45seconds the roc is doing just about nothing (this is based on 50mg of roc to patient that weight over 70kg). I also find that when mask ventilating the patient I do not "feel" anything at 45second in terms of changes in compliance. I just don't think the drug is doing much at that time. I'd rather have them just not give the roc and I'll intubate with just prop.

As a SRNA, I have intubated many people without paralytic on board, but in my student experince, "when you need it, you need it." I just don't see the harm in waiting the 3mins for the drug to kick in. Sure you need to redose the induction agent, but is that such a big deal. IMHO, it's the same as not waiting 60sec for sux.

For me, if an extra 2 mins means less chance of an airway complication, I'm all for it. However, clearly these MDAs agree with you.

[squeege]

You can lift the mask off the face and with your left hand try (or look like you are trying) to move the mandible & say "still a bit tight" "not quite relaxed" and resume bagging until you are more comfortable for your first look.

Sq

[deliciousbass]

I agree in that some people are too impatient for 50 mg roc to work effectively. I try and wait 2 min with 150-250mcg fent on board and turn on some DES if I'm concerned of recall. Your propofol dose for induction is plenty to cover you for 3 min with versed and fent on board.

[SuccsDrugs&Rocuron]

"When Your Surgeon's THE FLASH":

wanna talk about a bad day (with a cool CRNA TG), gave total 50 Roc on a 8 MINUTE LAP CHOLE! No lie--the FLASH insufflated, we gave trendelenburg, left tilt, bada bing! Done!

Holy crap batman...no twitches...um, goin' to any Mardi Gras parades?...

[yoga]

Why not use the nerve stimulator to check relaxation. It is easy, handy and beats trying to make the clock go faster. I routinely intubate with cisatracurium (Nimbex) for my own reasons (no histamine release and nice to have extra relaxation time) and it is a slow onset muscle relaxant. So I wait the required time and intubate without problems. So glad I am working alone.

[Skeebum]

122636
In the past, when I have realized that the MDA was either not going to let me wait 3min or was going to let me wait 3 mins but was not going to give more prop, I have turned on the sevo at 8% and given a few big breaths before DL. BUT, this place does not have sevo (just iso and des).

OK, I'm with ya, intubating 3 minutes after Prop induction ............a little bump isn't a bad idea. But why not turn on the Des?? I'm willing to bet that you have placed an LMA after 200mg of prop and then turned on the Des. Yes??

As I read this my first thought was................ohhhhh, he's in the "mask induction" box. Yes you are in the process of inducing your patient, and yes Sevo is the preferred VA for mask inductions. Your patient is already induced (thanks to the Prop), you're maintaining. No contraindication comes to mind for using either VA (Des or Iso) while waiting for the Roc to kick in.

I think your 3 minute masking is a tad long, I've found that 90sec gets the job done.

ETA: Not hating the 3 minute mask: if the airway is good, ventilation in maintained, there are no containdications to masking, and you believe that is the best course of action..........Roc on (pun intended).

Just my 0.02

Skee