Question
When is it best to avoid a neuromuscular blocking agent for intubation?
Answer
Well, I do not like to ever think of absolutes, but I will say that I certainly do my best to avoid them in patients who have a history of a difficult airway. For these patients, I might try to intubate with higher doses of hypnotic sedative agents like higher dose Propofol and avoid paralytic and take a look with a video scope or depending on the history, what do you mean to consider awake fiberoptic intubation, where I would use local anesthetics to numb up the airway and keep them breathing on their own. At the same time, I enter the trachea with a scope first. Another situation that I would avoid paralytics is in the case of an anterior mediastinal mass. Why? There's a potential for major airway and vascular or compression with these patients, and the paralytic dose could be fatal to them. Useful strategies to consider for these types of patients include awake fiberoptic intubation, maintenance of spontaneous ventilation as mentioned avoidance of muscle relaxants, intubation distal to the airway compression with the ENT team presence, positioning changes, immediate availability of rigid bronchoscopy, and you might even consider elective cardiopulmonary bypass in extreme cases. And then, of course, as mentioned in my talk, sometimes a patient is actively coding, and for those patients, they are usually already flaccid. There is no need for paralytics or drugs, period.
This Ask the Expert is an edited excerpt from the course, What’s Anesthesia Got To Do With It? presented by Steven Vela, MSNA, CRNA.
