病房插管小筆記 (note about rapid sequence intubation)
TRANSCRIPT
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
Delayed sequence intubation?
Y
Y
N
Difficult Airway
Time avalilable
N Rapid sequence intubation
Y
N
Difficult Airway
Time avalilable
N Rapid sequence intubation
Y
Time + Coperation ?
Surgical and rescue
Awake intubation
Delayed sequence intubation?
Y
Y
N
Difficult Airway
Time avalilable
N Rapid sequence intubation
Y
N
Difficult Airway
Time avalilable
N Rapid sequence intubation
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
Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
-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
Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
-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
Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
-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
Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
• 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
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
Etomidate
Propofol
Midazolum
Katemine
Succnylcholine
Rocuronium
-10 min
-8 min
-3 min
15-30 sec
+45 sec
+90 sec
Preperation
Preoxygenation
Pretreatment
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
0 Paralysis and Induction
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
15-30 sec Posotioning
Sniff position
-10 min
-8 min
-3 min
15-30 sec
+45 sec
+90 sec
Preperation
Preoxygenation
Pretreatment
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
+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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
+45 sec Pass the tube with Verification
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
+45 sec Pass the tube with Verification
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
0 Paralysis and Induction
Posotioning
Pass the tube with Verification
Post intubation care
7 Ps of Rapid Sequence Intubation
+90 sec Post intubation care
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