病房插管小筆記 (note about rapid sequence intubation)

INTUBATION Yuan Chieh Chang

2016. September

插管時機

病人無法Matintain Airway

通氣和氧合不足預期病程發展

• Gag reflex ：at risk

• GCS• 應綜合評估

• SaO2• PETCO2

例:• SCI 需要配合及輸送• 預期進行手術等治療

一次就要插上

• Complications ： once in every 8 patients

• adverse event rate Ｘ3• 1 attempt: 14.2% vs >1 attempt: 53.1%

Difficult Airway

Time + Coperation ?

Time avalilable

Surgical and rescue

Awake intubation

N

Delayed sequence intubation?

Rapid sequence intubation

Y

Y

N

Y

N

Time + Coperation ?

Surgical and rescue

Awake intubation


Y

Y

N

Difficult Airway

Time avalilable

N Rapid sequence intubation

Y

N

Difficult Airway

Time avalilable


Y

Time + Coperation ?

Surgical and rescue

Awake intubation


Y

Y

N

Difficult Airway

Time avalilable


Y

N

Difficult Airway

Time avalilable


Y

Difficult Airway

所以…要如何判斷？

Look

Evaluate

Mallampati

Obstruction

Neck mobility

Difficult Airway

Look

Evaluate

Mallampati

Obstruction

Neck mobility

Look

外觀：是否有外傷等不適合使用喉鏡插管的狀況

Look

Evaluate

Mallampati

Obstruction

Neck mobility

Evaluate

Look

Evaluate

Mallampati

Obstruction

Neck mobility

Evaluate

3-3-2 Rule躺著時，可以把嘴完全打開後，拉出舌頭，用喉頭鏡的光預測

Look

Evaluate

Mallampati

Obstruction

Neck mobility

Mallampati

Bag-Mask Ventilation 失敗？

Cricothyrotomy 也可能失敗？

• 手術(Surgery)影響解剖構造

• 佔據空間的病灶(Mass): 血腫

• 碰不到呼吸道(Access)：極度胖，外部固定等

• 放射治療(Radiation)

• 腫瘤(Tumor)：影響凝血

-10 min

-8 min

-3 min

0

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment

Paralysis and Induction

Posotioning

Pass the tube with Verification

Post intubation care

7 Ps of Rapid Sequence Intubation

-10 min

-8 min

-3 min

0

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




-10 min Preperation

• Team: • “Appropriate Nurses”, RT• Back up

• Equipment:• Peripheral Line x 2• Fluid x 1 先掛起來• 升壓劑：Bosmin, Phenylephrine • BP monitor, EKG monitor

Ringer

IV

-10 min

-8 min

-3 min

0

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




-8 min Preoxygenation

• FiO2=90 NRM 要開到 30 lpm 才有• 3 mins of tidal breathing; either 4 or 8 rapid deep

breaths of FiO2 = 1.0 • 時間不夠：

• 4 or 8 maximal breaths over 30 to 60 seconds

Nitrogen washout

-10 min

-8 min

-3 min

0

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




-8 min Preoxygenation

• FiO2=90 NRM 要開到 30 lpm 才有• 3 mins of tidal breathing; either 4 or 8 rapid deep

breaths of FiO2 = 1.0 • 時間不夠：

• 4 or 8 maximal breaths over 30 to 60 seconds

Nitrogen washout

Preoxygenation

好了好了撐多久？

• 93%< critical desatureation• Critical Patient

-10 min

-8 min

-3 min

0

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




• 在特定的病人避免過度的刺激pharynx • ACS, ICP, ICH

• 並無很強的證據支持使用

-3 min Pretreatment

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment

0 Paralysis and Induction

Posotioning





facilitate laryngoscopy, prevent laryngospasm, and enable passage of the ETT

Ideal Intubating Conditions, Prevent Hemodynamic Instability, Analgesia and Amnesia

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

Etomidate

• Minimal cardiovascular effect• No↑ myocardial O2 comsumption

• Neuroprotective• Lower ICP

• Adrenal insufficiency• Inhibit 11 β-hydroxylase enzyme• critical ill septic patient• No solid proof of an absolute morality

GABA Not BZD

Metabolism (Portency): primarily hepatic strongly protein bound

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

Tendency to cause:• Hypotension: up to 30%• Myocardial depression• Limited use in intubation

BronchodilatorNeuroprotectiveImmunosupression

Propofol

hepatic Conjugation Renal excretionCI 會影響代謝速率

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

• dissociative anesthetic + analgesic• sympathomimetic effects

• ↑HR, BP, ICP• Bronchodilator• ↑ Airway secretion, preserved reflex

• neuroprotective when• in concert with other agents (BZD, Prop.)• ↓ICP

Katemine

M

Opiod

NMDA

Metabolism : hepatic P450 Excretion by kidney (inactive)Not a significant concern

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

• Sedation + Amnesia + Anxiolysis + muscle relaxation (some)

• Rapid onset• 10%↓BP (SVR); ↑HR• apnea

• independent of neuromuscular blocker

Midazolam

• Metabolism: P450 system• Excretion: kidney

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

• rapid onset of action• neuromuscular blockade for 6 to 10 minutes• Adverse effects

Succnylcholine

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Etomidate

Propofol

Midazolum

Katemine

Succnylcholine

Rocuronium

• nondepolarizing NMB • rapid onset of action (60 seconds) • paralysis for up to 60 minutes

Rocuronium

1 Min 4 Min0 2 Min 3 Min 10 Min

> 1hr

1 Min 4 Min0 2 Min 3 Min 10 Min

> 1hr

別這樣出現空窗期...

In Sepsis Patient

23sec DesaturationLimited TIME

HypotensionShock

MetabolismOrgan Failure

In Sepsis and unstable Patient

Ketamin Etomidate

小心CAD的病人，會增加心臟負荷

Adrenal insufficiency的風險要準備好，肝臟疾病或蛋白質代謝都會影響強度

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




15-30 sec Posotioning

Sniff position

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




+45 sec Pass the tube with Verification

Cormack and Lehane

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Cormack and LehaneCormack and Lehane

Gr. III Gr. IV

迅速思考替代方案

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning





Cormack and LehaneCormack and Lehane

Check positionPE: not collectively reliableMost accurate: PETCO2

Ultrasound

-10 min

-8 min

-3 min

15-30 sec

+45 sec

+90 sec

Preperation

Preoxygenation

Pretreatment


Posotioning




+90 sec Post intubation care


induction agentsLaryngeal manipulation

hypoxia hypercapnea

negative to positive pressure ventilation

UnstableCondition

Myocardial depression↓vascular tone in lower extremities

Hypotension

Normal : 0.5- 0.7More than 0.8 predict Hypotension

shock index = Heart rate / SBP

• Fluid Resusitation• Avoid in Congestive patient

• Pure Vasocontrictor: Phenylephrine

Other complication

• Tachycardia• Bradycardia• Hypertension

Keep Light Sedation

Vital sign changes do Not correlate with pain experienced by intubated patients

and are unreliable in determining the need for pain medication

Referance

• Emerg Med Clin N Am 34 (2016) 97–127 Airway Management of Respiratory Failure Michael C. Overbeck, MD

• Book: Sepsis - An Ongoing and Significant ChallengeEdited by Luciano Azevedo, ISBN 978-953-51-0780-4, 420 pages, Publisher: InTech, Chapters published

• Imange: FreeImages.com

病房插管小筆記 (note about rapid sequence intubation)

Healthcare