Your question regarding Sux versus Rocuronium for RSI is a cause of much
debate, between PEM and anesthesiology. I am very comfortable with Sux and
its profile. I still believe that its short duration of action provides me
with the added comfort that god forbid I make a wrong selection of patient
for paralysis in RSI and end up with a "CVCI" situation., the patient will
resume spontaneous ventilation within 10 minutes while a maintain
transtracheal oxygenation through an alternate route like a cric.!!.
The opponents of sux have concerns about the reports of asystole in younger
infants. I usually administer atropine if I am doing RSI on a child,
especially if less than 2 years. Also, there is the potential of
incurring the risk of administering it to an infant with undiagnosed occult
myopathy and making matters worse.
There was an extensive discussion on the list about this debate. You might
want to check the archives of a few years back. I think it was Dr. Gerardi
who had another interesting point at that time; basically saying that this
issue of "short" duration of action is a redundant one. Whether it is 10
minutes or 40 minutes with Roc....if you are in a CVCI situation you are up
the creek anyway!! Hence why not choose the one with the safest profile.
May be that is true, but I am not willing to give up Sux yet.
I refer you to Mazurek AJ et al. "Roc vs Sux. Are they equally effective
during RSI of anesthesia?" Anest Analg. 1998 Dec 87; 1259-1262. This paper
compared the pharmakokinetic profiles of the 2 drugs for emergent (i.e.
full stomach) intubations of patients needing to go the OR from the ED.
This population is what we are likely to encounter as opposed to the
traditional elective well prepared OR intubation under controlled unhurried
I was curious if the 3 infected wounds s/p dermabond closure, that you
cited, had a pre-closure profile that would have made them prone to
infection anyway?? To be specific, did they have a "dirty" mechanism? Had
they presented > 8 hours since injury? Were they on less vascular areas
like extremities, as opposed to face or scalp? Was there a missed FB?
etc.....I am not aware of any specific literature reporting a higher
incidence of wound infection with tissue adhesives. Did Dr Trott cite any
new data at the "Hotlanta" meeting? He had actually reviewed cyanoacrylate
tissue adhesives in JAMA 1997 May where if I recall rates of wound
infection were not statistically higher as compared to suture closure. May
be the folks from Australia and South America who are using it for a while
now may have a different spin on this.
Thanks for listening. Did not intend it to be so wordy!!
Jay Pershad, MD
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