Midazolam for intubation (Have U used midaz. anaesthesia?)

[BlueSkies]

I know this thread is old but I do love RSI since it is basically our bread and butter in the Aeromedical world so let me throw my two cents in on this one and see what you think!!!

First off, I have never seen or heard of anyone using Versed (Midazolam) as an induction agent. It is simply a bad choice. Number one it is a Benzo and it has predictable effects but it's not reliable. While it does provide the amnesic effect it does not effective kill the urge to vomit which is exactly what we are looking for when we use the term RSI. Remember that the "I" in RSI stands for Induction, not intubation as we are inducing a coma.

Propofol has a great place but in the rotor wing environment it is hard to keep up with, we have so many tubes and machines in a small space it is not a good situation if someone is snowed with Propofol and your line kinks or you lose your IV and the patient wakes up and starts kicking the pilot in the neck!!!

Let's talk about Ketamine for a second, great drug, great profile, easy to dose, good for kiddos and adults but it is not the wonder drug it is made out to be. Look at the side effects, number 1, it causes hyper salivation so if you're using Ketamine without the premeditating of your patient with Atropine then you may want to think about approaching your Medical Director for a change in your RSI protocols. Number 2, Ketamine if give to a sympathetically exhausted patient will cause hypotension, bradycardia and death if your are not careful. Reminder that Ketamine's mechanism of action is to use your catecholamine stores and if they are depleted your patient is screwed!

I have seen a lot of the peeps here talking about Suxamethazone which if you're not familiar with it is nothing more than how they package Succinylcholine outside the US. Been there done that when I did medivacs in Mongolia for over 2 years

Succs has some lethal and well known side effects such as being a trigger for malignant hyperthermia, increases potassium, can't use it in renal failure patients or patients with increased ICP or Increased intraocular pressures, penetrating eye trauma, blah blah blah

Now let's talk about my new favorite drug!!! SUGAMMADEX (Bridrion) it has been available in the US since Dec 2015.

This drug has effectively replaced Sux in my RSI and Difficult airway protocol. It's mechanism of action is to encapsulate Rocuronium at the nicotinic and muscarnic receptor sites and make it moot. 

So, in the near future you will see most of your RSI protocols changing to include Sugammadex as soon as the price goes down lol

Basically what your protocol may change to is something like this:

Pre Medications such as Atropine, Lidocaine (you can remove your defasciculation doses now since Sux will be gone)  

Versed, Propofol, Fentanyl, Amidate (My favorite because it is the only one with a linear relationship, 100 secs of induction for every 0.1mg/kg)

Rocuronium (your typical dose of 1mg/kg)

Intubate

Continue in with analgesia and pain control

See!! No SUX anywhere!!!

What happens if you miss the intubation and you run into a can't ventilate can't oxygenate situation? Of course the answer is Surgical Cryc lol but before you get there you can admin Sugammadex and the effects of Roc will be reversed in typically less than 3 minutes.

Great studies have already been released in the US, the UK and Aussie, check it out for yourself if you don't believe me and as I always say, don't take my word for it, go learn it for yourself!!!

Look up the new Difficult Airway Algorithms that have been released here in the US, you will see on them that it leads you to the "wake the patient up." option, This is actually referring to using Sugammadex to reverse the neuromuscular blockade! Sugammadex works with Vecuronium also but not nearly as well as it does with Rocuronium. 

It is still expensive as it is only marketed by MERCK and so far it is $100 for a 200mg vial and the average dose if 4mg/kg which would be 400mg for a 100kg patient at a cost of $200 dollars for your service. The good news is it is not needed for every RSI case if you can pass the tube through the chords  

Well this has been way more fun for me than it should have but I look forward to the replies on this thread so return fire at will!

 

[kohlerrf]

I routinely use Midaz for RSI. Usualy I will give 5mg Midaz fast push IV, the pt usualy goes down enough to intuabte with out a problem. If that does not work next I use Etomidate and because I used midaz first I don't have to worry about myoclonus ( an untoward side effect of Etomidate). if that does not work my next step is Sux.

Anecdotally I have seen that the rate at which you administer Midazolam the deeper the sedation (all be it short lived) a fast push of 5 or 10 mg is usually enough to knock the pt down you will be able to tell this because when you initially stick the Blade into the mouth pt  pulse rate will remain unchanged. If you notice an increase in rate your pt is not sedated enough. Same with the use of Sux if the pt pulse rate rises under Sux it usually means your pt has awoken but remains paralyzed!

[Spock]

Sugamadex is not the answer to a failed intubation.  While it will reverse neuromuscular blockade from a non-depolariizing agent such as rocuronium, it does not reverse the induction agents administered such as versed, fentanyl, etomidate, propofol, or any combination of those medications.  I've used sugamadex several times when a surgical case ended much sooner than expected and it reverses the blockade in about 30 seconds.  The best approach for prehospital RSI should include video laryngoscopy along with the usual induction agents including succinylcholine which is safe in the vast majority of patients.  Solid QA medical oversight along with operating room time to maintain skills are also required for good RSI outcomes.     

As I cited before, versed alone as an induction agent for RSI is not supported in the literature and the drop in BP can be lethal.  That does not negate the anecdotal experiences of many folks including myself, but it is not a good option.

Spock

[BushyFromOz]

Would be interested to know what doses of midazolam people have been or think people have been using for induction, and if it was given in isolation or in combination with something else