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Pharmacologic Management of Rapid Sequence Intubation (RSI)

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Title: Rapid Sequence Intubation (RSI) Author: James Gibson Last modified by: jv3 Created Date: 3/8/2012 1:37:18 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Pharmacologic Management of Rapid Sequence Intubation (RSI)


1
Pharmacologic Management of Rapid Sequence
Intubation (RSI)
  • James Gibson, PharmD
  • PGY1 Pharmacy Practice Resident

2
Learning Objectives
  • List the six Ps of RSI.
  • Discuss historical rationale for LOADing
    patients undergoing RSI.
  • Understand the rationale for use of one induction
    agent over another.
  • Identify the contraindications to succinylcholine
    administration and how to manage patients who are
    not candidates.

3
Rapid Sequence Intubation (RSI)
  • Induction of a patient using simultaneous
  • Sedatives
  • Rapid-acting paralytic agent
  • Goal to avoid assisted ventilation due to
    elevated risk of aspiration
  • Un-fasted patient
  • Pharyngeal/laryngeal manipulation

4
The Six Ps of RSI
  • Preparation
  • Pre-oxygenation
  • Pretreatment and induction
  • Paralysis
  • Placement of the tube
  • Post-intubation management

5
Preparation
  • Assess patientdifficult airway?
  • IV access
  • Monitor (tele, pulse ox)
  • Gather
  • Equipment for intubation
  • Post-intubation medication(s)
  • Pertinent patient history
  • Supplies for surgical airway (just in case!!)

6
Pre-Oxygenation
  • Goals
  • Establish O2 reservoir
  • Maximize time for intubation
  • Prevent need for bag-mask ventilation
  • Methods
  • 3-5 minutes of 100 O2 via face mask
  • 4 (or 8) vital capacity breaths on 100 O2

7
Pre-Oxygenation
http//www.ncsrc.org/2_newsletters_2008_2.shtml
8
Pretreatment
  • Goal
  • Mitigate adverse physiologic reactions to
    intubation
  • Sympathetic pressor response
  • Bronchospasm
  • Increased intracranial pressure (ICP)
  • Muscle fasciculation
  • Begins 2-3 minutes PRIOR to induction/paralysis
  • LOAD
  • Not routinely done in practice

9
Pretreatment
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating agent
  • Dose 1.5 mg/kg IV
  • To prevent rise in ICP by
  • Preventing cough
  • Blunting pressor response
  • May reduce reactive bronchospasm in asthma

10
Pretreatment
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating agent
  • Fentanyl 3 mcg/kg IV
  • Provides analgesia
  • Lessens pressor response
  • Limits ICP increase
  • More effective than lidocaine

11
Pretreatment
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating agent
  • Dose 0.02 mg/kg
  • To prevent bradycardia caused by airway
    manipulation and succinylcholine
  • Historically used in pediatrics
  • May be more beneficial with repeated doses of
    succinylcholine (i.e. OR setting)

12
Pretreatment
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating agent
  • Fasciculations occur in gt90 of patients given
    succinylcholine
  • Muscle pain
  • Increase intragastric pressure ? emesis
  • Increase ICP (?)
  • Prevention
  • Higher doses of succs (1.5 mg/kg vs 1 mg/kg)
  • Non-depolarizing NMB (1/10th of paralytic dose)

13
Induction Agent(s)
  • Given as rapid IV push immediately before
    paralyzing agent
  • Ideally provides
  • Rapid loss of consciousness
  • Analgesia
  • Amnesia
  • Stable hemodynamics

14
Induction Agents
Drug Dose
Thiopental 3-5 mg/kg IV
Methohexital 1-3 mg/kg IV
Fentanyl 5-15 mcg/kg IV
Midazolam 0.1 mg/kg IV
Ketamine 1-2 mg/kg IV
Etomidate 0.3 mg/kg IV
Propofol 2 mg/kg IV
15
Induction Agents
  • Etomidate
  • Ultrashort-acting non-barbiturate hypnotic
  • Rapid onset30 to 60 secs
  • Hemodynamic stability
  • Hydrolyzed in liver and plasma
  • ? ICP with minimal effects on cerebral perfusion
  • NO analgesia
  • ADE Myoclonic jerks, ? cortisol production

16
Induction Agents
  • Fentanyl
  • Short-acting, potent
  • Minimal histamine release
  • Hemodynamically stable
  • Sedation is rate- AND dose-dependent
  • Combined with other induction agents for
    analgesia
  • ADE muscle rigidity, grand mal seizures (rare)

17
Induction Agents
  • Midazolam
  • Sedative, amnestic, muscle relaxant
  • NOT analgesic
  • Less cardiorespiratory depression vs. other
    benzos
  • ?BP ?HR
  • Use lower dose in hypovolemic, elderly, or
    traumatic brain injury patients (0.05 mg/kg)
  • Does NOT contain propylene glycol

18
Induction Agents
  • Ketamine
  • NMDA-antagonist ? dissociative anesthesia
  • Analgesic, amnestic, anesthetic
  • Dissociation occurs at threshold of 1-1.5 mg/kg
    IV
  • 4-5 mg/kg IM (more emesis)
  • Catecholamine reuptake inhibition (? HR, BP, CO,
    ICP)
  • Maintains respiration and airway reflexes
  • ADE Emergence delirium (30)Premed midazolam
    0.07 mg/kg
  • Emesis (highest in adolescents 9yo)
  • CI schizophrenia (schizoaffective) lt3 months
  • (relative) Asthma exacerbation CVD

Annals of Emergency Medicine. 57.5 (2011) 449-461
19
Neuromuscular Blocking Agents (NMBAs)
  • Quaternary ammonium compounds that mimic
    structure of ACh
  • Depolarizing vs non-depolarizing
  • Allow complete airway control
  • Higher success (100 vs 82)
  • Less aspiration and airway trauma
  • Enable lower doses of sedative
  • Better hemodynamic stability

Acetylcholine
Succinylcholine
Roberts Clinical Procedures in Emergency
Medicine. 5th. Philadelphia, PA Elsevier, 2010.
99-109
20
Succinylcholine
  • Depolarizing NMBA
  • Non-competitively binds ACh receptors ? initial
    membrane depolarization
  • Longer degradation time than ACh
  • Paralysis in 60 sec. DOA 3-5 min
  • Prolonged in pseudocholinesterase deficiency
    (genetic, hepatic/renal failure, pregnancy,
    cocaine)
  • Repeat doses prolong paralysis
  • May increase bradycardia/hypotension
  • DOC for RSI

21
Succinylcholine
  • Dose 1.5 mg/kg IV (infants 2 mg/kg IV)
  • Use ACTUAL body weight
  • Rapid bolus follow w/ 20-30 mL saline flush
  • ADEs
  • Muscle fasciculation ? myalgias
  • Hyperkalemia, ? CPK
  • Bradycardia/hypotension
  • Mild increase in ICP
  • Malignant hyperthermia

22
Succinylcholine
  • Hyperkalemia
  • Typical K increase lt 0.5 mEq/L
  • Up to a 5 mEq/L K increase in certain settings
  • Contraindicated in
  • Conditions with up-regulation of ACh-receptors
    (see table)
  • Known/suspected hyperkalemia
  • Personal/family hx of malignant hyperthermia

23
Non-Depolarizing NMBAs
  • Competitive antagonists of ACh at neuromuscular
    junctions
  • Higher doses faster onset, longer duration
  • Reversible
  • Alternatives to succinylcholine
  • Long-acting vs intermediate-acting

Agent Dose (mg/kg) Onset (min) Duration (min)
Succinylcholine 1.5 1 3-5
Rocuronium 1 1-1.5 30-110
Vecuronium 0.1 0.25 3 1 30-35 60-120
Pancuronium 0.1 2-5 (60-100)
Roberts Clinical Procedures in Emergency
Medicine. 5th. Philadelphia, PA Elsevier, 2010.
99-109
24
Non-Depolarizing NMBAs
  • Pancuronium
  • Long time to onset
  • ? HR and BP (vagolytic effect)
  • Histamine release ? bronchospasm/anaphylaxis
  • Active metabolites
  • Accumulates
  • Renal dosing required
  • NOT recommended for RSI

25
Non-Depolarizing NMBAs
  • Vecuronium
  • Slower onset than rocuronium
  • Non-vagolytic no histamine release
  • Active metabolites
  • Often requires priming dose
  • 0.01 mg/kg during pre-oxygenation phase, then
  • 1.5 mg/kg given 3 min later for paralysis

26
Non-Depolarizing NMBAs
  • Rocuronium
  • Onset similar to succinylcholine
  • Non-vagolytic no histamine release
  • No active metabolites
  • Preferred alternative to succinylcholine in RSI

27
Post-intubation Care
  • After endotracheal tube is placed
  • Provide continued sedation/analgesia
  • Propofol drip (No analgesia)
  • 120 kg begin infusion at 20 mcg/kg/min
  • 121-150 kg begin infusion at 15 mcg/kg/min
  • gt151 kg begin infusion at 10 mcg/kg/min
  • Bolus fentanyl and midazolam
  • Fentanyl (analgesia)
  • LD 25-100 mcg IV q15 min PRN (max 300 mcg in
    first hr)
  • MD 25-100 mcg IV q30 min PRN (max 200 mcg/hr)
  • Midazolam (sedation)
  • LD 1-4 mg IV q15 min PRN (max 16 mg in first hr)
  • MD 1-4 mg IV q1 hr PRN

UWMC Form U2914
28
References
  • Claudius, C, LH Garvey, J Viby-Mogensen, et al.
    "The Undesirable Effects of Neuromuscular
    Blocking Drugs." Anaesthesia. 64.1 (2009) 10-21.
    Print.
  • Fleming, Bethany, Maureen McCollough, et al.
    "Myth Atropine should be administered before
    succinylcholine for neonatal and pediatric
    intubation.." Can J Emerg Med. 7.2 (2005)
    114-117. Print.
  • Green, Steven, Mark Roback, et al. "Clinical
    Practice Guidelines for Emergency Department
    Ketamine Dissociative Sedation 2011 Update."
    Annals of Emergency Medicine. 57.5 (2011)
    449-461. Print.
  • Hopson, Laura, and Richard Schwartz. Roberts
    Clinical Procedures in Emergency Medicine. 5th.
    Philadelphia, PA Elsevier, 2010. 99-109. Print.
  • Martyn, Jeevendra, and Martina Richtsfeld.
    "Succinylcholine-induced Hyperkalemia in Acquired
    Pathologic States." Anesthesiology. 104. (2006)
    158-69. Web. 8 Mar. 2012.
  • Walls, Ron. Marx Rosen's Emergency Medicine. 7th
    ed. Philadelphia, PA Elsevier, 2010. 3-22.
    Print.
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