What’s New With RSI Drugs? State-Of-The-Art Revie · What’s New With RSI Drugs?...
Transcript of What’s New With RSI Drugs? State-Of-The-Art Revie · What’s New With RSI Drugs?...
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What’s New With RSI Drugs?State-Of-The-Art Review
Michael Gibbs, MD, FACEP
Department of Emergency MedicineMaine Medical Center
Portland, Maine U.S.A.
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Rapid Sequence Intubation
Rapid sequence intubation (RSI) involves the rapid and simultaneousadministration of a short-acting sedative and a paralytic agent to facilitate intubation and decrease the risk of aspiration.
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The 7 P’s Of RSI
� Preparation
� Preoxygenation
� Pretreatment
� Paralysis WITH sedation
� Protection + Positioning
� Placement with Proof
� Post-intubation management
National Emergency Airway Course©
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The 7 P’s Of RSI
� Pretreatment� Paralysis WITH sedation
National Emergency Airway Course©
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Pretreatment
The delivery of drugs to reduce the “RSRL”
[Reflex sympathetic response to laryngoscopy]
National Emergency Airway Course©
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RSRL
� The RSRL results from physical manipulation of the airway
� Not eliminated by paralysis� Consequences:
� Catecholamine release� Hypertension, tachycardia� Increased ICP in patients with impaired
cerebral autoregulation
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RSRL
Who is at risk?� Medical intracranial hypertension� Traumatic brain injury� Vascular emergencies� Cardiac ischemia
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Pretreatment – “LOAD”
Lidocaine 1.0 mg/kg
Opiates 3-5 µg/kg
Atropine 0.02 mg/kg
Defasculation [eg: vecuronium] 0.01 mg/kg
National Emergency Airway Course©
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Do hemodynamic alterations during RSI have the potential to increase ICP?
YES
Does lidocaine blunt this response? YES
Is there evidence that lidocaine improves outcome in at-risk patients?
NO
Robinson N. Emerg Med J 2001; 18:453.
Lidocaine: What Do We Know?
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Do hemodynamic alterations during RSI have the potential to increase ICP?
YES
Does fentanyl blunt this response? YES
Is there evidence that fentanyl improves outcome in at-risk patients?
NO
Can fentanyl precipitate hypotension? YES
Fentanyl: What Do We Know?
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Clancy M. Emerg Med J 2001; 18:373.
Defasciculation: What Do We Know?
Do SCH-associated fasciculations increase ICP?
YES
Does pretreatment with a non-depolarizer reduce this phenomena?
YES
Is there evidence that SCH worsens outcome in at-risk patients?
NO
Is there evidence that defasciculation improves outcome in at-risk patients?
NO
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Pretreatment
Aneurysmal Subarachnoid Hemorrhage
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Pretreatment
Traumatic Brain Injury
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Secondary Injury In TBI
� Prospective study of 717 patients with severe TBI at 4 centers.
� A single episode of hypotension (BP <90)or hypoxia (PaO2 <60) during the initial resuscitation was associated with a 150% increase in mortality.
Chestnut RM. J Trauma 1993; 34:216.
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Pretreatment
Acute Aortic Dissection
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Pretreatment
Acute Myocardial Ischemia
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Paralysis WITH Sedation
Goal: optimal intubating conditions
� Administered simultaneously� Agent synergy important� Don’t be temped to omit sedation in
the “comatose” patient!
National Emergency Airway Course©
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RSI Induction Agents
Important side effects:� Apnea� Myocardial depression� Hypotension� Others, drug-specific
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RSI Induction Agents
� Midazolam� Thiopental� Propofol� Ketamine� Etomidate
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RSI Induction Agents
Midazolam:� Commonly used if etomidate n/a
� Little effect on RSRL or ICP� Dose-dependent respiratory depression
& hypotension� Often under-dosed [NEAR mean = 4 mg ]
0.1-0.3 mg/kg
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RSI Induction Agents
Thiopental:� Significant benefit in acute CNS pathology
� Decreases ICP at the expense of CPP� Hypotension the major downside
3-5 mg/kg adult5-6 mg/kg pediatric
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RSI Induction Agents
Propofol:� Pharmacologically similar to thiopental
� Decreases ICP at the expense of CPP� Hypotension a significant risk
0.5-1.2 mg/kg
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RSI Induction Agents
Ketamine:� Catecholamine release
� Typically augments blood pressure � Direct bronchodilator
� Increased ICP in the setting of TBI?
1-2 mg/kg IV, 2-4 mg/kg IM
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Ketamine In TBI?
Effects of IV ketamine on ICP/CPP/MAP in 8 ventilated TBI patients with ICP monitors in place:
� ICP reduced� No alteration in CPP or MAP
Albanese J. Anesthesiology 1997; 87:1328.
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Ketamine In TBI?
� Several authors have recently questioned the historical dogma.
� Ketamine potentially advantageous in the hypotensive head injury patient.
� No data in the ED RSI population.
Sehdev RS. Emerg Med Austral 2006; 18:37.
Himmelseher S. Anesth Analog 2005;101:524.
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RSI Induction Agents
Etomidate:� Minimal effect of hemodynamics
� Reduces ICP while maintaining CPP� Side effects:
� Transient adrenal suppression� Myoclonus – avoided by paralysis
0.15-0.3 mg/kg
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Etomidate In The ED
� Prospective study of 522 ED RSI cases using etomidate.
� Outcome measures:� Ease of intubation� Hemodynamics [BPS, BPD, HR] at the
time of intubation, 5 minutes, 15 minutes
Zed PJ. Acad Emerg Med 2006; 13:378-383.
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Etomidate In The ED
Results:� Intubation “excellent/good” in 96.9%� BP & HR increased at 0, 5, 15 minute� Similar findings in a subgroup of 80
patients with an initial BPs <100 mmHg
Zed PJ. Acad Emerg Med 2006; 13:378-383.
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“Should We Use Etomidate as an Induction Agent forEdotracheal Intubation in Patients With Septic Shock?:
A Critical Appraisal”
Chest 2005; 127:1031-1038
Rationale :�Single dose etomidate causes transient cortisol suppression�Adrenal insufficiency is highly prevalent in sepsis�Mortality is increased when adrenal insufficiency is present�Outcome trails in the index population are lacking
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Adrenal Suppression?
� Prospective evaluation of adrenal function in 31 ED patients receiving etomidate or midazolam for RSI
� Assessed at 4/12/24 hours:� Cosyntropin stimulation test [CST]
� Serum cortisol levels
Schernarts C. Academ Emerg Med 2001; 8:1.
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Adrenal Suppression?
Results:� 4-hr CST abnormal in 70% of patients
receiving etomidate� 12 /24-hr CST normal and did not differ� Serum cortisol levels in the normal
range at every interval in both groups
Schernarts C. Academ Emerg Med 2001; 8:1.
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Upside:� “Ideal” hemodynamic profile� Predictable onset, effect, elimination
Downside:� Risk probably not zero. Options:
� Change nothing
� Monitor adrenal function� Administer steroids empirically
Etomidate In Sepsis?
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Succinylcholine
� Remains the drug of choice for the ED� Intubation level paralysis in 45 sec� Clinical duration 6-8 min� The dark side:
� Fatal hyperkalemic risk
� Bradycardia [children, 2nd dose]� Malignant hyperthermia
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Risk In Renal Failure?
Studies in adults & children with knownrenal failure and K+ above 5.5 mg/kg:
� Mean increase in K+ <0.5 mEq/L� No dysrhythmia or other adverse effect� So… not recommended but generally
safe if renal failure is unrecognized
Thapa S. Anesth Analog 2000; 91:237.
Schow AJ. Anesth Analog 2002; 95:119.
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Fatal Hyperkalemic Risk
Receptor Upregulation
� Burns, crush� Prolonged ICU stay� UMN [eg: stroke]� LMN [eg: SC
injury]
Myopathic Process� Muscular dystrophy� Rare idiopathic
Mortality 11% Mortality 30%
Gronert GA. Anesthesiology 2001; 94:523.
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Rocuronium
At a dose of 1.0 mg/kg:� 95% of patients ready in 60 seconds� Success rate comparable to SCH� Average duration of action 45 minutes
Kirkegaard-Nielsen H. Anesthesiology 1999; 91:131.
Perry JJ . Acad Emerg Med 2002; 9:813.
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RSI Paralytic Agents
Fundamental Question…
Is The Patient At Risk For An Important Succinylcholine-Related Complication?
Succinylcholine 1.5 mg/kg Rocuronium 1.0 mg/kg
NO YES
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Take Home Essentials
#1: First do no harm#2: 5 drugs more complicated than 3#3: Very limited ED outcome data#4: Careful pretreatment if indicated#5: Induction agent selection crucial#6: State-of-the art care saves lives