>With all due deference, I don't quite follow the link between shortened
>length of paralysis and ease of active airway management. If youparalyzed
>a patient because 1) he needed to be intubated and 2) you wanted optimum
>intubating conditions, how will it help you if he returns to his
>unparalyzed, needing-intubation state? My failed-intubation algorithm
>probably works better if the patient is still relaxed.
>Will you really need PPV less? If the sux wears off, you have a patientwho
>is breathing badly enough to need intubation. Won't they get just as much
>PPV as the one who is still paralyzed?
OK, here's how it helps.
Take the situation where you have paralyzed a patient with a long acting
drug. Suppose that your initial attempts at intubaiton fail. What's the
The proponents of the theory that length of paralysis does not matter must
believe that you should continue flailing away at attempts to intubate.
To me the next logical step is to re-oxygenate the patient. That goal
will be much easier if the patient is breathing spontaneously. It may
avoid the necessity of prolonged PPV. This may buy you enough time to get
your most experienced intubater (say your collegue or anesthesia) into the
ED. A spontaneously breathing patient also opens up the possibility of an
alternative airway tool: blind NTI which is much more difficult if the
patient is apneic.
Also what if you cannot ventilate the patuient with PPV at all? This may
happen in some patients with obstructive or severe restrictive lung
disease. Is it really still your position that the patient is better off
apneic in this situation than with some, albeit inadaquate, respiratory
My theory is based upon the logic that some ventilation (even if
suboptimal) is better than none at all. One would think that this would go
without saying, but apparantly not.
The proponents of the "it doesn't matter how long you're paralyzed" theory
also overlook that fact that ventilatory or oxygenation failure is not the
only indication for intubation. We intubate people all of the time with
semi-emergent indications. Those with alterned levels of consciousness in
whom we want to protect the airway, patients with severe head trauma or
stroke, the polydrug overdose who will not be readily reversed, those with
multiorgan trauma who will be going to the OR, etc. etc. Granted, these
people need a tube but they do not necessarily need a tube this minute.
Let me give a real recent example of a situation where prolonged paralysis
would have been detrimental: A collegue of mine was seeing a patient in
status asthmaticus. Because of progressive CO2 narcosis she decided to
intubate him. She elected to do this under sedation but without the use of
paralytics. The intubation failed. I was called into the room
to assist and I was uable to intubate either. A third EP attempted
intubation unsucessfully. (Incidentally, between us we had 45 years
experince working in EDs, all board certified and two were residency
trained). I then talked his doctor into letting me try BNTI. On the second
attempt I was able to pass the tube uneventfully. Had he been paralyzed
the likelihood of sucessful BNTI would have been much lower. (As an aside,
he was seen one week later in our fast track area for a minor injury
sustained during an altercation and recognized the doctor who had taken
care of him in the ED a week earlier).
Now I will concede this much. The younger the child is the less relevant
the issue of the length of paralysis becomes. There are two reasons for
this: 1) 5 minutes of apnea without PPV really is far too much for any
child (under,say, 5 or 6 years of age) to tolerate anyway
and 2) any child under the age of 8 or 10 is not really a good candidate
for BNTI. So for that age group the case can be made to go with
rocuronium. Since length of paralysis becomes less of an issue and side
effects of sux are more prominantt in the younger group I can see the
rationale of the other side of the argument.
Anyway, I've exceeded my 15 minutes of fame and I'm getting out of here.
I'm like a fush out of water in this forum. Feel free to dissect the
argument. I'll let you have the last word.
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