nmb in diff vent

8/2/2019 Nmb in Diff Vent

1/17

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


2/17

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?


3/17

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?


4/17

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


5/17

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?


6/17

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)?


7/17

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?


8/17

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?


9/17

5 points on the use of NMBAs priorto intubation


10/17

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


11/17

2. Horns of a Dilemma

Enough hypnotic to mask-ventilate

Minimize hypnotic to maximize return ofconsciousness

Fear may result in under dosing

vs.


12/17

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.


13/17

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


14/17

5. Whats the real problem?

NMBAs can resolve some problems with

BMV such as laryngospasm


15/17

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)


16/17

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


17/17

What would you do?

nmb in diff vent

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