List Archives

Wed Jan 24 23:52:11 GMT 2007

Hi Simon, have to agree with all that you and Ian say. Not a big fan of etomidate, especially as a sole agent for intubation or in the critically ill.

As for ANZICS 2007.....I cannot recommend the Rotorua hospitality highly enough and I would encourage list members to attend. However, not sure about the Tweed for the white water rafting, bungee etc although I suppose that it won't show the brown 'adrenaline stains'!

Regards to all the team
Mark F
UK

----- Original Message ----
From: Simon Scothern <Simon.Scothern at lakesdhb.govt.nz>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Wednesday, 24 January, 2007 3:59:23 AM
Subject: tweed sux

Interesting isn't it? We have quite a lot of data on suxamethonium
having high side effect rates (these are relative of course, in absolute
terms, severe/fatal problems are not common) because it's been around
for so long. You may argue from comparative data that problems with
other NMBA's (e.g. Rocuronium) are more common than we initially
thought. 

A quick search hasn't changed my opinion that sux has the highest rate
of anaphylaxis. I've certainly been involved with a number of cases of
(? potassium related) cardioplegia/cardiac arrest. 

As we've both indicated, it comes down to personal preference and
experience (hopefully with a bid of evidence based medicine). 

Now, re the tweed jacket!! As you know, the ANZICS ASM is in Rotorua in
October this year. Tweed provides good protection whilst running the
world famous luge tracks, I think it should come - along with it's
owner, of course - we'll take an action photo for the list. (I'll bribe
the fashion police). Your panty hose and sanitary towel may be useful
too!!

The same goes for the rest of the list if you'd care to attend a good
conference and amazing party in one of the most beautiful places on
earth. 

Yours (still full of cheer)

Simon Scothern
FRCA, MRCP
ICU Clinical Director/Consultant Anaesthetist
Rotorua Hospital
Pukeroa Hill
Private Bag 3203

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ian Seppelt
Sent: Wednesday, 24 January 2007 4:04 p.m.
To: Simon Scothern; trauma-list at trauma.org
Subject: RE: Prehospital Etomidate

Nothing wrong with thio/sux [big syringe, little syringe!!]. I still use
thio, pancuronium and isoflurane for my long spinal fusions -
sevoflurane and desflurane are on the backbar but I find the whole
concept irresponsible for a 6 - 8 hour multilevel procedure, when there
is no purpose to a 'rapid clear headed wakeup' and if anything the
patients appreciate being a bit drowsy in the postop period. Before I
stopped public hospital anaesthesia I despaired of registrars who could
use nothing but propofol, rocuronium and sevoflurane -- they reacted at
times like I was a dinosaur (I'm only just 40!!) but we then had fun
deliberately doing 'non standard' things like pretending a particular
drug was not available and conpensating for its non availability,
mounting an isoflurane vapouriser in circuit and doing some drawover,
etc etc. Unfortunately too much anaesthesia is non thinking service
mentality.

For the public hospital ICU, where I am mainly NOT doing things myself
but rather supervising trainees, often from a distance, simplicity,
safety and standardisation are important - thiopentone and sux are
standard [the sux is kept in a plastic box with a list of the obvious
contraindications in BIG LETTERS on the lid] and the important thing is
teaching the trainees to get the dose of thio right [NOT 5 mg/kg per
textbook for the shocked patient in respiratory failure].

I do have a tweed jacket at home though [haven't worn it in ages].

Concerning your comments below I firstly challenge the "high side
effect profile" of sux and secondly please note I did not refer to 5 -
10 minutes wear off time for "can't intubate/can't ventilate" but
deliberately referred just to "can't intubate". The most common scenario
is a junior who can't intubate, but can still manage the airway - if
they learn a failed intubation drill that includes 'call for help', and
the patient is otherwise stable then the safest thing is let the sux
wear off and wait for skilled help. True 'can't intubate/can't
ventilate' is much rarer and is always going to be ugly. We supply (and
teach) LMA, preferably ILMA, as technique of choice for Plan B, and the
Melker cric kit is there (and every registrar goes through these on my
manequins early in the term).

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> Simon.Scothern at lakesdhb.govt.nz 24/01/2007 1:09pm >>>
Hi All,

I agree with Ian re. the myths with suxamethonium and ketamine etc. I
"grew up" in the days when propofol was not validated as a rapid
sequence drug and thiopentone and etomidate were the RSI hypnotics on
the menu. I find propofol to be the superior agent in my hands and
don't
seem to see the much reported cardiovascular depression except in
cases
of severe hypovolaemia (where etomidate and thio achieve similar side
effects).  I might use ketamine in these circumstances. 

There's a lot to be said for "operator - drug familiarity". There's
also
some logic in sticking to one agent when putting together a team
Standard Operating Procedure. Drug availability/manufacture has
effected
our decisions in the past (e.g. we had difficulty getting thiopentone
for a while).  

As far as I'm aware, suxamethonium still causes the most problems in
practice for which there are preposed reasons

*         the errant practice of attempting to intubate as soon as the
fasciculations resolve i.e. failing to wait for the whole minute to
peak
effect

*         the high side-effect profile

*         possibly the assumption that 5- 10 minutes wear-off time is
acceptable in cases of "can't intubate/can't ventilate" situations.  

In setting up a system, my suggestion would be 

*         propofol and a rapid acting NMBA (rocuronium would be my
preference but I'd accept the argument for suxamethonium)

*         SOP for failed intubation +/- failed ventilation to be
drilled
into the team. My SOP's include the LMA, we use them very effectively.

Of course, this may vary depending on the level of standard staff
composition. 

(p.s Ian, I'm surprised you're a thio/sux man. Do you have a tweed
suit
in your wardrobe as well :-) ? )

Simon Scothern

FRCA, MRCP

ICU Clinical Director/Consultant Anaesthetist

Rotorua Hospital

Pukeroa Hill

Private Bag 3203

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ian Seppelt
Sent: Wednesday, 24 January 2007 12:27 p.m.
To: bensonblues at comcast.net; trauma-list at trauma.org 
Subject: Re: Prehospital Etomidate

An old myth .... There is NOTHING wrong with suxamethonium (succinyl

choline) for intubating a head injury. The problem with high dose

NDNMBAs (vecuronium, rocuronium etc) is that you need at least 3 x the

ED95 to get acceptable intubating conditionms at 1 minute, and you are

then stuck with the drug for 30 - 40 minutes or more. If you have a

'can't intubate' situation the patient is considerably better off if
the

sux goes away and spontaneous breathing resumes (usually 5 - 10

minutes), and you have some time to consider plan B in a well
oxygenated

breathing patient, than if you are forced into crash airway management
/

hypoxic cricothyrotomy etc etc.

As for choice of induction drug, the best is the one you are most

familiar with. I will always use thiopentone (in an appropriate dose)
in

trauma but there is nothing wrong with propofol, or vomidate, or even

ketamine if that is what you are used to. [Another myth - the

"contraindication" to ketamine in TBI, though for a number of other

reasons I don't use it]

The big problem with etomidate (aside from the guaranteed postop
nausea

and vomiting hence 'vomidate') is adrenal suppression. Bad drug for

intubating septic shock patients for this reason (concerns about

relative adrenal insufficiency, CORTICUS results notwithstanding) -

Annane's initial studies were seriously flawed because he did not take

into account the fact that a significant proportion had been intubated

with etomidate - etomidate should be an exclusion criterion from any

future RAI / steroid /sepsis study.

Cheers, Ian

Ian Seppelt FANZCA FJFICM

Senior Staff Specialist

Dept of Intensive Care Medicine

The Nepean Hospital, PO Box 63 Penrith NSW 2751

Clinical Lecturer, University of Sydney

>>> bensonblues at comcast.net 23/01/2007 4:45pm >>>

Dave,

Etomidate is a good induction agent (minimal CV effects), but in my

experience, paralysis with a neuromuscular agent may also be needed. I

used it once on a fellow to put him down for a shoulder dislocation,
and

he developed myoclonus and a weird lipsmacking face and neck

spasm-thing. I managed his airway with an s-tube and suction, but it

lasted about 10 minutes. For intubating trauma victims, I
co-administer

succinylcholine (or high-dose vecuronium for head injury). I think

propofol is a superior agent. What say the rest?

DB

--

trauma-list : TRAUMA.ORG

To change your settings or unsubscribe visit:

http://www.trauma.org/traumalist.html 

######################################################################

Attention: 

This message is intended for the addresses named and may contain 

confidential information. If you are not the intended recipient,
please

delete it and notify the sender. Views expressed in this message are 

those of the individual sender, and are not necessarily the views of 

Sydney West Area Health Service.

This e-mail has been scanned for viruses

######################################################################

--

trauma-list : TRAUMA.ORG

To change your settings or unsubscribe visit:

http://www.trauma.org/traumalist.html 

Attention:
The information contained in this message and or attachments is
intended only for the
person or entity to which it is addressed and may contain confidential
and/or privileged
material. Any review, retransmission, dissemination or other user of
this information, or 
taking of any action in reliance upon this information by persons or
entities other than the
intended recipient is prohibited. If you received this in error, please
contact the sender
and delete the material from any system and destroy any copies.
Lakes District Health and any of its subsidiaries reserve the right to
monitor all
e-mail communication through its networks.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

######################################################################
Attention: 
This message is intended for the addresses named and may contain 
confidential information. If you are not the intended recipient, please
delete it and notify the sender. Views expressed in this message are 
those of the individual sender, and are not necessarily the views of 
Sydney West Area Health Service.

This e-mail has been scanned for viruses
######################################################################
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html
Attention:
The information contained in this message and or attachments is intended only for the
person or entity to which it is addressed and may contain confidential and/or privileged
material. Any review, retransmission, dissemination or other user of this information, or 
taking of any action in reliance upon this information by persons or entities other than the
intended recipient is prohibited. If you received this in error, please contact the sender
and delete the material from any system and destroy any copies.
Lakes District Health and any of its subsidiaries reserve the right to monitor all
e-mail communication through its networks.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

List Archives

For your convenience, find the Trauma List Archive Below

tweed sux