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To maintain the presence of the endotracheal tube post-intubation; using paralysis in combination with sedation is likely much safer than using sedation alone [...]; and we'll be able to use a lower dose of sedation.

To the first:

Only if you screw up your sedation.

To the second:

Don`t really understand the point - either you do a sedation, or you don`t. What you proclaim, sounds like leaving the patient half-awake, while being paralyzed, which can`t really be the goal.

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Don`t really understand the point - either you do a sedation, or you don`t. What you proclaim, sounds like leaving the patient half-awake, while being paralyzed, which can`t really be the goal.

Both your points sort of lead to the same answer so I'll address them together

Ketamine only produces general anaesthesia for around 20 minutes after which time the patient is going to wake up. Ongoing sedation ensures the patient is not awake and aware they cannot move with a tube shoved down their gob.

Achieving a patient who is sufficiently sedated that we have blunted all their neuromuscular reflexes so they do not become agitated or restless and fight the tube is going to require a larger amount of sedation than a paralysed patient who needs a "don't remember" dosing.

My readings around anaesthesia and intensive care generally state the first requires anywhere from 0.3 to 0.5mg/kg and the latter 0.1mg/kg. Indeed 0.1mg/kg is the dosage used here for patients who have a neurogenic cause for coma with a GCS < 10 and require RSI.

Our Clinical Practice Guidelines say pretty much the same thing except for midazolam post-intubation it appears fixed bolus amounts are trendy down here; up to 3mg every 5 minutes (there are slightly lower dosages for patients who weigh <50kg). As an aside I'd be interested to see if a midazolam drip would be any better and might have a looksee around these here interwebz.

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Fighting the tube is often the result of poor ventilator management and poor analgesia & sedation IMHO. It's poor form to force the patient to accept our settings with paralysis. Patient-ventilator interaction and synchrony is very important and not possible when the patient is paralysed. Additionally, continued paralysis when it's not really indicated can lead to additional issues such as hypothermia among other problems.

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Achieving a patient who is sufficiently sedated that we have blunted all their neuromuscular reflexes so they do not become agitated or restless and fight the tube is going to require a larger amount of sedation than a paralysed patient who needs a "don't remember" dosing.

My readings around anaesthesia and intensive care generally state the first requires anywhere from 0.3 to 0.5mg/kg and the latter 0.1mg/kg. Indeed 0.1mg/kg is the dosage used here for patients who have a neurogenic cause for coma with a GCS < 10 and require RSI.

Our Clinical Practice Guidelines say pretty much the same thing except for midazolam post-intubation it appears fixed bolus amounts are trendy down here; up to 3mg every 5 minutes (there are slightly lower dosages for patients who weigh <50kg). As an aside I'd be interested to see if a midazolam drip would be any better and might have a looksee around these here interwebz.

Giving the patient a "don`t remember"-dosage, as you put it, doesn`t mean that he isn`t feeling something in the imminent present - having an effect on normal cardiovascular response mechanism (pain - tachycardia), that you don`t wanna have, leaving aside the ethical note on a patient experiencing pain, even if he can`t remember it in the end (and they sometimes do remember).

With the dosages named above, did you mean Ketamine?

Of course it depends on wether you use Ketamine or Esketamine - with Ketamine the general literature states around 0.25-0.5mg/kg (analgetic) and 1-2mg/kg (anaesthetic). You can ruthly divide those with 2 for the Esketamine dosages.

Edited by Vorenus
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Giving the patient a "don`t remember"-dosage, as you put it, doesn`t mean that he isn`t feeling something in the imminent present - having an effect on normal cardiovascular response mechanism (pain - tachycardia), that you don`t wanna have, leaving aside the ethical note on a patient experiencing pain, even if he can`t remember it in the end (and they sometimes do remember).

Excellent point mate, pain has a significant physiologic response as well as mental and physical aspects as well.

This is why sedation (midazolam) is combined with morphine (analgesia) in our post-intubation regimen.

With the dosages named above, did you mean Ketamine?

Of course it depends on wether you use Ketamine or Esketamine - with Ketamine the general literature states around 0.25-0.5mg/kg (analgetic) and 1-2mg/kg (anaesthetic). You can ruthly divide those with 2 for the Esketamine dosages.

Apologies; the dosages above were for midazolam.

Fighting the tube is often the result of poor ventilator management and poor analgesia & sedation IMHO. It's poor form to force the patient to accept our settings with paralysis. Patient-ventilator interaction and synchrony is very important and not possible when the patient is paralysed.

I respect you have substantial experience with automated ventilation and such; this is not something available pre hospital in NZ and is unlikely to become so in the near future. For now it's the trusty manual ventilator bag down here

Additionally, continued paralysis when it's not really indicated can lead to additional issues such as hypothermia among other problems.

Yes this is true. Something I think is often forgotten is the trusty ambo blanket and the problems having a proper body temperature can avoid. Apparently "hypothermia" is part of the "triad of trauma death" as it has some bad coagulojuju associated with it, I've yet to adequately research it. Everybody is on about cold fluids in post-cardiac arrest and traumatic brain injury but I am curious to have a looksee about warmed fluids and severe trauma.

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I respect you have substantial experience with automated ventilation and such; this is not something available pre hospital in NZ and is unlikely to become so in the near future. For now it's the trusty manual ventilator bag down here

You`re still bagging, too?

We`ll get a brand-new Medumat Transport with a digital display when the new NEF comes. ;)

Are having a pretty normal respirator right now, with my former service we had CPAP, which was pretty cool.

Yes this is true. Something I think is often forgotten is the trusty ambo blanket and the problems having a proper body temperature can avoid. Apparently "hypothermia" is part of the "triad of trauma death" as it has some bad coagulojuju associated with it, I've yet to adequately research it. Everybody is on about cold fluids in post-cardiac arrest and traumatic brain injury but I am curious to have a looksee about warmed fluids and severe trauma.

Everybody`s going on about post-arrest therapeutic hypothermia, but I`d say most places still lack the appropriate tools for establishing that and more importantly, sufficiently monitoring it, starting with the simplest thing: a decent thermometer.

I`m not that literate when it comes to therapeutic hypothermia, but what I seem to remember is, that cold fluid is really not such a great inducent factor of it. I`ve seen some pretty cool devices that were advertised in some EMS papers, but still waiting to see someone actually have/use them.

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You`re still bagging, too?

We`ll get a brand-new Medumat Transport with a digital display when the new NEF comes. ;)

Are having a pretty normal respirator right now, with my former service we had CPAP, which was pretty cool.

Bloody Germans so efficient :D

No CPAP here, not even the Bouginec (? sp) French one which connects onto the oxygen tank so no CPAP machine is actually required

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A question: Do we have any business performing RSI when we do not have adequate post intubation management education or resources?

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A question: Do we have any business performing RSI when we do not have adequate post intubation management education or resources?

So would you call this a scope of practice situation or a low resource problem?

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Hello,

Excellent discussion so far.

I read the thread and I was wondering if the code status and level of intervention was addressed?

Thank you,

DD

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