nmb in diff vent
TRANSCRIPT
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Paralyzed with Indecision
What is the best option forintubating patients who are low
probability for difficult ventilation?Calder, I. Could safe practice be compromising
safe practice? Should anaesthetists have todemonstrate that face mask ventilation ispossible before giving a neuromuscular
blocker? Anesthesia 2008 63 (113-5)
Turlough OHarePGY5 McMaster Anesthesia
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Prior to administering an Anesthetic
Answer 2 questions:
Potential trouble with ventilating?
Potential trouble with intubating?
Unanticipated difficult ventilation
Attempt intubation First attempt best
Use NMBA or attempt mask ventilation first?
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What would you do?
Hx snoring and BMI 31 (175cm, 95kg)?Hx 60yo with beard and BMI 31?Hx OSA, thick neck and BMI 31?
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What would you do?
GR 3 MV GR 3/4 MVand DI
BMI 30
Jaw protrusion
snoring
Beard
Thick neck
MP 3/4 Sleepapnea
57yo
Odds ratios
RF 3MV 3/4MV DI
1+ 6 5
2+ 10 11
3+ 20 17
4+ 35 23
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What would you do?
Odds ratios
RF 3MV 3/4MV DI
1+ 6 5
2+ 10 11
3+ 20 17
4+ 35 23
Hx snoring and BMI 31?
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What would you do?
Odds ratios
RF 3MV 3/4MV DI
1+ 6 5
2+ 10 11
3+ 20 17
4+ 35 23
Hx 60yo with beard andBMI 31 (175cm, 95kg)?
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What would you do?
Odds ratios
RF 3MV 3/4MV DI
1+ 6 5
2+ 10 11
3+ 20 17
4+ 35 23
Hx OSA, thick neck andBMI 31?
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What should we do?
1. if tracheal intubation is planned in a patientin whom difficulty with FMV is a possibility,should we give NMBA drugs as soon aspossible?
2. not all such patients can be identified inadvance
should NMBs be given routinely immediately afterinduction?
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5 points on the use of NMBAs priorto intubation
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1. Cant ventilate, then what?
In practice, patients are not woken up if wecant ventilate them
We try to obtain an airway
Catastrophic hypoxia is likely to ensue if we areunable to obtain patency
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2. Horns of a Dilemma
Enough hypnotic to mask-ventilate
Minimize hypnotic to maximize return ofconsciousness
Fear may result in under dosing
vs.
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3. Is masking easier with a NMBA?
reluctance to give a NMBA when FMVproves to be difficult is more likely to resultin FMV that is difficult, compounding anydifficulty resulting from a relatively low doseof induction agent.
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4. should difficulty occur
the absence of neuromuscular blockademay hinder rescue of the situation
There is a considerable body of evidence tosupport the proposition that NMBs makeintubation easier
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5. Whats the real problem?
NMBAs can resolve some problems with
BMV such as laryngospasm
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5 points on the use of NMBAs priorto intubation
1. common practice when a cant ventilate scenarioensues is to attempt intubation
2. optimal revival and optimal intubating conditionsare in conflict
3. the addition of NMBA to our anesthetic likelyimproves mask ventilation
4. the addition of NMBA to our anesthetic likelyimproves intubation success
5. the lack of NMBA may result in inappropriatetreatment of a patient who is difficult to ventilatedue to lack of relaxation (i.e. bronchospasm)
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What would Calder do?
if tracheal intubation is planned in a patientin whom difficulty with FMV is a possibility
1.give NMBA drugs as soon as possible
conditions for intubation are optimized
2.not all such patients can be identified inadvance
So, NMBs should be given routinely immediatelyafter induction
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What would you do?