i do not understand why they use 1,5 mg/kg of sux… some studies even suggest that 0,6 mg/kg is enough to intubate with less side effects

am i wrong ?

Thanks for posting on an interesting topic, but I’m afraid it misses the key points and there are notable misconceptions.

Opiates are actually rarely omitted in RSI inhospital; the reason they are not administered more in the prehospital setting is primarily due to logistical difficulties of controlled drug use. Opiates should NEVER be omitted on the basis the potential for failed intubation – if you think you won’t be able to intubate the trachea then don’t! If you undertake intubation you should have plans for failed intubation and CICV. In reality if a critically ill patient needs intubation then waking them up is rarely an option.

The use of opiates is particularly important in the head injured patient (which is the primary indication for intubation in most trauma patients). Permissive hypotension is NEVER used to minimise increases in ICP; hypotension in the context of TBI lowers cerebral perfusion pressure and dramatically increases morbidity and mortality. The key is to avoid hypertension (and thus increases in ICP secondary to increased CBF) by obtunding the stress response to laryngoscopy: this is most easily achieved with short acting opiates (remi/alf), but lidocaine and esmolol are alternatives.

Permissive hypotension is a controversial area which I have reviewed recently in an editorial (http://onlinelibrary.wiley.com/doi/10.1111/anae.12249/abstract). Of note, all trials looking at its use excluded those with head injury. I have doubts of the efficacy of permissive hypotension and it is CONTRAINDICATED in patients with TBI.

Ketamine is the optimal drug for induction even in head injury as it prevents hypotension. If CO2 is controlled, ketamine has no effect on ICP. I find it hard to believe that people are continuing to use etomidate in the critically ill trauma patient in light of its effects on adrenal supression and subsequent increases in mortility. Ketamine produces the same intubating conditions for RSI without effects on the adrenal axis (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60949-1/abstract).

The study you cite is worrying to me as a neuroanaesthetist – the aim of a trauma RSI is to have no effect of BP, either hypo- or hypertension. This group have failed their patients in 79% of cases. In UK trauma (primarily blunt in nature, with a head injury rate of 40-60%) these data suggest the potential for harm.

It is important to document impact like this, both for future funding and spread of these programs, but also as a reminder for us in high resource/high tech settings of how powerful simple interventions can be.

Actually when the patient is leaking and shocked i’ve got a preference toward low concentration albumine (40g/l) and ringer/saline.

Of course i keep in mind that everythink leaks and one important point is to teach resident to titrate the volume expansion and not prescribing it like sore throat pills

In the OR i mainly use RL (90% of the fluid i use) If the patient bleeds we have the blood and plasma really quick in our universitary hospital so i do not use HES or gelatine anymore. We also do a lot of hepatic and oncologic surgery so albumin take its place in the operating theatre too

We do the same in our ICU: RL (mainly to avoid chloride overload) and albumin 200 mg/ml or plasma as volume expanders. The middle way. Still, I sometimes wonder how much volume expansion colloids provide in critically ill patients with leaking vascular walls…

In the OT and also in the ICU HES and other colloids are still used as volume expanders for low risk, not so sick, patients.

thank you for this post !

In our ICU we use a lot Ringer Lactate (i think it’s better than saline looking at the chloride issue) and albumin @ 200 mg/ml because we have a lot of malnourished patients with deep hypoalbuminemia.

Despite good evidence we are pretty happy with this combo (the pharmacist is not hapy with the cost of albumin) so i think there’s something to dig with the association of a balanced crystalloid and albumin. The middle way