pharmacologic management of rapid sequence intubation (rsi) james gibson, pharmd pgy1 pharmacy...
TRANSCRIPT
Pharmacologic Management of Rapid
Sequence Intubation (RSI)James Gibson, PharmD
PGY1 Pharmacy Practice Resident
Learning ObjectivesList the six P’s 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.
Rapid Sequence Intubation (RSI)
Induction of a patient using simultaneousSedativesRapid-acting paralytic agent
Goal: to avoid assisted ventilation due to elevated risk of aspirationUn-fasted patientPharyngeal/laryngeal manipulation
The Six P’s of RSIPreparation
Pre-oxygenation
Pretreatment and induction
Paralysis
Placement of the tube
Post-intubation management
PreparationAssess patient—difficult airway?
IV access
Monitor (tele, pulse ox)
Gather:Equipment for intubationPost-intubation medication(s)Pertinent patient historySupplies for surgical airway (just in case!!)
Pre-OxygenationGoals:
Establish O2 reservoirMaximize time for intubationPrevent need for bag-mask ventilation
Methods:3-5 minutes of 100% O2 via face mask
4 (or 8) vital capacity breaths on 100% O2
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
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
Pretreatment Lidocaine
Opioid
Atropine
Defasciculating agent
Fentanyl 3 mcg/kg IV
Provides analgesia
Lessens pressor response Limits ICP increase More effective than lidocaine
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)
Pretreatment Lidocaine
Opioid
Atropine
Defasciculating agent
Fasciculations occur in >90% 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)
Induction Agent(s)Given as rapid IV push immediately before paralyzing agent
Ideally provides:Rapid loss of consciousnessAnalgesiaAmnesiaStable hemodynamics
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
Induction AgentsEtomidate
Ultrashort-acting non-barbiturate hypnoticRapid onset—30 to 60 secsHemodynamic stabilityHydrolyzed in liver and plasma ICP with minimal effects on cerebral perfusionNO analgesiaADE: Myoclonic jerks, cortisol production
Induction AgentsFentanyl
Short-acting, potentMinimal histamine releaseHemodynamically stableSedation is rate- AND dose-dependentCombined with other induction agents for analgesiaADE: muscle rigidity, grand mal seizures (rare)
Induction AgentsMidazolam
Sedative, amnestic, muscle relaxantNOT analgesic
Less cardiorespiratory depression vs. other benzosBP; HR
Use lower dose in hypovolemic, elderly, or traumatic brain injury patients (0.05 mg/kg)
Does NOT contain propylene glycol
Induction AgentsKetamine
NMDA-antagonist dissociative anesthesiaAnalgesic, amnestic, anesthetic
Dissociation occurs at threshold of 1-1.5 mg/kg IV4-5 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); <3 months
(relative): Asthma exacerbation; CVD
Annals of Emergency Medicine. 57.5 (2011): 449-461
Neuromuscular Blocking Agents (NMBAs)
Quaternary ammonium compounds that mimic structure of AChDepolarizing vs non-depolarizing
Allow complete airway controlHigher success (100% vs 82%)Less aspiration and airway trauma
Enable lower doses of sedativeBetter hemodynamic stability
Roberts: Clinical Procedures in Emergency Medicine. 5th.Philadelphia, PA: Elsevier, 2010. 99-109
Acetylcholine
Succinylcholine
SuccinylcholineDepolarizing NMBA
Non-competitively binds ACh receptors initial membrane depolarization
Longer degradation time than ACh
Paralysis in ~60 sec. DOA: 3-5 minProlonged in pseudocholinesterase deficiency (genetic,
hepatic/renal failure, pregnancy, cocaine)Repeat doses prolong paralysis
May increase bradycardia/hypotension
DOC for RSI
SuccinylcholineDose: 1.5 mg/kg IV (infants: 2 mg/kg IV)
Use ACTUAL body weightRapid bolus; follow w/ 20-30 mL saline flush
ADEs:Muscle fasciculation myalgias
Hyperkalemia, CPKBradycardia/hypotensionMild increase in ICPMalignant hyperthermia
SuccinylcholineHyperkalemia
Typical K+ increase < 0.5 mEq/LUp 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
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 0.10.25
31
30-3560-120
Pancuronium 0.1 2-5 (60-100)Roberts: Clinical Procedures in Emergency Medicine. 5th.Philadelphia, PA: Elsevier, 2010. 99-109
Non-Depolarizing NMBAsPancuronium
Long time to onset HR and BP (vagolytic effect)Histamine release bronchospasm/anaphylaxisActive metabolitesAccumulates
Renal dosing required
NOT recommended for RSI
Non-Depolarizing NMBAsVecuronium
Slower onset than rocuroniumNon-vagolytic; no histamine releaseActive metabolitesOften requires “priming” dose
0.01 mg/kg during pre-oxygenation phase, then1.5 mg/kg given 3 min later for paralysis
Non-Depolarizing NMBAsRocuronium
Onset similar to succinylcholineNon-vagolytic; no histamine releaseNo active metabolites
Preferred alternative to succinylcholine in RSI
Post-intubation CareAfter endotracheal tube is placed:
Provide continued sedation/analgesiaPropofol drip (No analgesia)
≤ 120 kg begin infusion at 20 mcg/kg/min 121-150 kg begin infusion at 15 mcg/kg/min >151 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
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.