ICU doc: “Peri-intubation arrest is incredibly rare”

[u/Ineffaboble]

AITA?

I had a patient with a very bizarre presentation of flash pulmonary edema brady down and arrest after a crash intubation for sats heading down to 65% and no clear reversible cause at the time.

My nurses filed a critical incident report for completely unrelated reasons.

The ICU attending now looking after her tagged in and said “peri-intubation arrest is incredibly rare, and the medical management of this case should be examined.”

I know for a fact that this ICU sees mostly stable post surgical and post stroke patients and my friend who has been a nurse there for a year said she has never seen a crash intubation, let alone one led by this doc.

I also know that his base specialty is anesthesia.

I replied, “happy to discuss, bearing in mind that the ICU context and the ER ‘first 15 minutes’ context are radically different.”

I acknowledge that peri-intubation arrest is not super common, but neither does it imply poor management, especially in an undifferentiated patient where we don’t even know the underlying etiology.

[u/Hi-Im-Triixy]

What do you choose for push? Phenyl?

[u/hilltopj → u/Hi-Im-Triixy]

Personally I cycle the pressure twice and if it's not reading then they get a quick push of phenylephrine before sedation and roc. Or potentially consider ketamine in the appropriate setting.

Also, if you don't have a good pressure and you're considering push dose, have a nurse pull and hang norepi because the phenyl wears off fast.

[u/Former-Citron-7676 → u/hilltopj]

Just be aware that ketamine can induce/aggravate hypotension in catecholamine depleted patients…

[u/Ineffaboble → u/Former-Citron-7676]

I just scream “open wide” and do the Iron Sheikh yell to induce a catecholamine surge.

[u/hilltopj → u/Ineffaboble]

I do have a potentially dumb question I was always too afraid to ask in residency: Why dilute the push dose before hand instead of just pushing 1cc of code epi or phenyl followed by a flush? I've always been taught this is the way and I take time to prep it if I think things are going to go bad but is there any reason to not just give the undiluted form?

[u/Former-Citron-7676 → u/hilltopj]

Someone explained that here

[u/hilltopj → u/Former-Citron-7676]

This seems to be explaining why the IM anaphylaxis dose (1:1,000) epi needs to be diluted to the code dose concentration (1:10,000) for codes. But my question is why, for push dose in peri-arrest, does the code dose need to be diluted by putting 1cc into 9cc saline instead of just giving straight 1cc of the 1:10,000?

[u/Former-Citron-7676 → u/hilltopj]

As the last poster says: it is so the full dose reaches circulation. It’s a simplified answer, but it’s what it comes down to. Short half-life of epinephrine, also plays a role.