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RSI, A Stepwise Approach

Introduction to Rapid-Sequence Intubation in adults
by

Amar Patel

on 20 March 2014

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Transcript of RSI, A Stepwise Approach

A 72 year-old, 80 kg male with pneumonia presents with respiratory distress and is not responding to nebulizer treatment. The patient is still awake but is becoming confused and tiring. A decision has been made to undergo intubation...
BY: AMAR PATEL
PHARM.D. CANDIDATE 2014
OSU/OHSU COLLEGE OF PHARMACY

RSI, A STEPWISE APPROACH
RSI benefits...
Objectives:
Rapid Sequence Intubation
A technique where a potent
sedative or induction agent
is administered almost simultaneously with a paralyzing dose of a
neuromuscular blocking agent
to facilitate rapid tracheal intubation.
Definition:
Protection against aspiration
Access to the airway for intubation
Permits pharmacologic control of adverse responses to illness, injury, and to intubation itself
P
reparation (0-10 min)
Evaluate patient
Plan approach
Establish IV access
SOAPME
S
uction
O
xygen
A
irway
P
harmacology
M
onitoring
E
quipment
P
reoxygenation (0-5 min)
100% oxygen 10-15 L/min x 5 minutes if spontaneously breathing
Provide reservoir of oxygen during intubation
Nitrogen wash-out
Provides maximum of 70% FiO2
P
retreatment (0-3 min)
L
idocaine
O
piates
A
tropine
D
efasiculating Agent
P
aralysis with induction
Administration of a
sedative
followed by a
paralytic
(neuromuscular blocking agent [
NMBA
]), usually a couple minutes after premedications.
Types of NMBA's:
Succinylcholine
Dose:

Use Total Body Weight

Adults: 1.5 mg/kg
Adolescents: 1 mg/kg
Infants/small children: 2 mg/kg

Notes:
Rapid onset, short duration of action
Rocuronium
Dose:

Use Ideal Body Weight
1 mg/kg

Notes:
Used when succinylcholine is contraindicated or for lengthened NM paralysis post-intubation
Slightly longer onset and duration of action
Vecuronium
Dose:
0.1-0.2 mg/kg

Notes:
Less desirable due to longer onset of action and longer duration.
Does not exacerbate hyperkalemia
Pancuronium, Atracurium &
Mivacurium
Not used in the ER
since they can often cause
histamine release
and possibly cause autonomic
ganglionic blockade
.
Depolarizing
Non-Depolarizing
P
lacement &
P
roof (0-45 sec)
Confirm tube placement
after laryngoscopy
Direct visualization
Auscultate
Where, when, order?
Capnometer
How many breaths?
References:
P
ost-Intubation Management (0-90 sec)
Secure
endotracheal tube
Ventilate
and
oxygenate
Physician order for ICU long-acting
sedation
of ventilated patients
Chest radiograph
P
rotection &
P
ositioning (0-30 sec)
Can assist with
visualization
of the glottic opening for
laryngoscopy
Sellick maneuver (
cricoid pressure
)
Does not reduce the risk of aspiration
Thumb and index finger apply cricoid pressure
7 P's to Successful Intubation
P
reparation
P
reoxygenation
P
retreatment
P
aralysis with induction
P
rotection & Positioning
P
lacement & Proof
P
ost-intubation Management
Induction Agents
Etomidate
Dose:
0.3 mg/kg (if > 10 years old)

Notes:
Rapid onset, short duration, cerebroprotective, not associated with hypotension, hemodynamically neutral compared to other agents.
Midazolam
Dose:

2-5 mg in adults/adolescents
0.1 mg/kg (6mg max) in children

Notes:
Possibility for hypotension, and fewer adverse events, better amnesia, and greater potency compared to diazepam
Ketamine
D
ose:
0.5-2 mg/kg

Notes:
analgesic properties, bronchodilator, may increase intracranial pressure. Used for asthmatics or anaphylactic shock.

Avoid:
Patients with aortic dissection, abdominal aortic aneurysm and acute MI.
Fentanyl
Dose:
2-10 mcg/kg
Propofol
Dose:
1-2.5 mg/kg

Notes:
Rapid onset, short duration, cerebroprotective, decreases blood pressure and heart rate, antiemetic, and can be used in malignant hypothermia patients
Fentanyl
1.5 mg/kg
0.02 mg/kg
Dose: 2-3 mcg/kg
Describe indications, contraindications, advantages, disadvantages and complications of endotracheal intubation
Describe the indications and contraindications of the medications used for RSI.
Be able to prepare the necessary medications for RSI
Understand the necessary steps for RSI
10% of paralyzing dose
Rapid loss of consciousness
to facilitate ease of intubation
Hyperkalemia
Burns
Crush injuries
Intraabdominal sepsis
Malignant hyperthermia
NM disease
Caution:
1.
Rapid-Sequence Intubation. American College of Emergency Physicians Clinical and Practice Management Policy Statements. Apr 2012. Available at: http://www.acep.org/Clinical---Practice-Management/Rapid-Sequence-Intubation/. Accessed 03 Feb 2014.
2.
Caro D, Walls RM, Grayzei J. Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA;2014.
3.
Lafferty KA, Mosenifar Z, Filbin MR, et al. Rapid Sequence Intubation. Medscape Reference. 27 Nov 2013. Available at: http://emedicine.medscape.com/article/80222-overview#a16. Accessed 03 Feb 2014.
4.
Epocrates Rx Online [Internet database]. San Mateo (CA): Epocrates, Inc. 2014. Available at www.epocrates.com. Accessed 03 Feb 2014.
5.
Brunton LB, Lazo JS, Parker KL, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. Pg. 220-226. New York: McGraw-Hill; 2006.
6.
Mace SE. Challenges and Advances in Intubation: Rapid Sequence Intubation. Emerg Med Clin N Am. 26 (2008): 1043-68.
7.
Society of Critical Care Medicine and American Society of Health-System Pharmacists. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Am J Health Syst Pharm. 2002; 59:179–95.
8.
Rapid Sequence Intubation Drug Kit (RSI kit) and Code Box. St. Charles Redmond. 2014.
9.
Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest. 2005 Apr; 127(4): 1397-412.
10
.
Bauman KA, Hyzy RC. In: UpToDate, Manaker S (ED), UpToDate, Waltham MA. (Accessed 20 Mar. 2014.)
11.
American Association for Respiratory Care (AARC). Removal of the endotracheal tube 2007 revision & update. Respir Care 2007. Jan; 52(1): 81-93.
12
. Neligan P. Weaning and Discontinuation of Mechanical Venilation. Critical Care Medicine Tutorials. Accessed 20 Mar. 2014. Available at: http://www.ccmtutorials.com/rs/Weaning/index.htm.
Disadvantages:
Side effects
/complications related to drugs administered
Hypoxia
due to prolonged intubation
An "
emergent
" or "
crash
" airway
Indications
Patients with elevated ICP and impaired auto-regulation
Fentanyl and lidocaine
Major vessel dissection or rupture, or ischemic heart disease
Fentanyl
Reactive airway disease
Lidocaine
Pediatric patients (<10yo) and patients at risk of bradycardia
Atropine
Extubation Procedure
Extubation
involves the process of removal of an endotracheal tube from a patient.
Complications
Aspiration
Laryngospasm/bronchospasm
Pulmonary edema
Trauma to airways
Hypoxia/hypercapnia
Indications for Extubation
Patients who do not need further medical care (
PEEP </= 10 cm H20 and FIO2 </= 0.40
)
Adequate
respiratory drive
Respiratory muscle
strength
Cough
reflex
to clear secretions
Laryngeal function
Clearance
of NM blockers
Acute airway
obstruction
Consciousness
(airway protection not needed)
Equipment and Monitoring
Oxygen
Suction
Oral/Nasal airways
Ventilation system
Face masks
Endotracheal tubes
Intubation materials
Emergency surgical airway materials
Withdrawal Side Effect
Opioids
should be
tapered last
so the patient does not wake up in pain.
If a patient has been administered a
sedative/analgesic
for
< 7 days
, it is
okay to abruptly discontinue
.
There may be a
delay
between the reduction of the sedative/analgesic agent and
when the patient wakes
.
When the Patient
improves
A look into Extubation
Factors Warranting Extubation
Acute airway obstruction
Mucus or mechanical deformation
Prolonged Intubation
Sinusitis
Vocal cord injury
Laryngeal injury
Laryngeal stenosis
Tracheal injury
Hemoptysis
Pulmonary infection
Patients who are capable of
maintaining adequate ventilation
who
do not require high levels of positive airway pressure.
Weaning Criteria
Prior to Extubation
Need for
reintubation
No difficulties with intubation
Gas leak
around deflated cuff with positive pressure breaths
Stable, adequate
hemodynamic function
Stable
non-respiratory function
Normal
electrolyte
values
Post-Extubation Management and Assessment
Physical examination
Auscultation
Invasive/non-invasive measurement of arterial blood gas values
Chest Radiography
Document extubation complications
Assess need for reintubation
Noninvasive positive pressure ventilation
Pulse oxygen
Cardiac monitors
CO2 detectors
Ambu bags
BP, HR, O2 sat, RR
Turned off sedation
Medications Involved during Extubation
Sedative, Analgesic, and NMBA
Gradual taper of dose or abrupt discontinuation
Glucocorticoids
Conflicting data around efficacy in
preventing post-extubation stridor
If extubation is delayed due to a reduced cuff leak, may give a
short dose of glucocorticoid prior to extubation
Methylprednisolone 20 mg
Q4H for four doses
Methylprednisolone 40 mg
4 hours prior to extubation
Full transcript