Surapong rsi 2009
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This document discusses rapid sequence intubation (RSI) and the use of neuromuscular blocking agents (NMBAs) for RSI. It provides background on why NMBAs are needed for RSI, comparing succinylcholine and rocuronium. It summarizes the onset times and intubation conditions achieved with different doses of rocuronium. It also discusses tips and techniques for successful RSI, including preparation, preoxygenation, drug administration and management of complications.
Surapong rsi 2009
- 1. ผศ.นพ.สุรพงษ์ หล่อสมฤดี TIVA Center Division of Cardiothoracic and Vascular Anesthesia Division of Transplantation Anesthesia Chiang Mai University Hospital Why do we need NMBAs for RSI
- 4. Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007 Oct;21(5):636-43. Hemodynamic Effects Painful stimulus
- 5. Lorsomradee, et al: Anaesthesia. 2007 Oct;62(10):979-83. Vasoconstrictor Phenylephrine
- 6. Reversible myocardial ischemia Stunning A transient period of depressed myocardial function that follows a period of ischemia, not sufficient to result in cell death
- 7. Cardioprotection: Myocardial oxygen balance O2 supply O2 demand < ischemia supply demand Heart rate contractility afterload CBF: normal region CBF: ischemic region subendocardium
- 8. Rapid Sequence Intubation (RSI) • The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation without interposed mechanical ventilation in efforts to facilitate the procedure and minimize risks of gastric aspiration
- 9. Chiang Mai Medical Journal 2008;48(3suppl)
- 10. Rapid Sequence Intubation experience in Emergency Department Maharaj Nakorn Chiang Mai นพ.บวร วิทยชำนำญกุล Emergency Medicine Chiang Mai University Hospital
- 11. History • Awake intubation • Diazepam ??? • Midazolam
- 12. • Establish Training EM in 2548 • Workshop RSI in January 2551 • • RSI in ER October 2551 • Etomidate + Succinylcholine • Etomidate + Rocuronium • Propofol
- 13. 28 20 3 12 1 4 0 5 10 15 20 25 30 1 attempt 2 attempt 3 attempt RSI 32 non RSI 36
- 14. 2 3 2 4 1 2 2 6 0 4 0 2 0 1 2 3 4 5 6 Hypotension Desaturation Vomit prolonged intubation Oral trauma Esophageal intubation RSI non RSI
- 15. Now • More than 150 experience of RSI • Staff attending 24 hr • ER staff in morning shift and some noon – night shift
- 16. Quality Control • Resident 2 : training, coaching, direct observe • Difficult airway cart • No serious adverse event
- 17. Rapid Sequence Intubation “6 P’s” • Preparation: T-10” –Positioning • Preoxygenation: T-5” • Premedication: T-3” • Paralysis:T-0 • Placement of tube: T+45 • Post management: T+2”
- 18. Preparation • Evaluate – LEMON • Equipment Check • Positioning • Drug Selection • IV’s, monitor, oximetry • Ancillary Staff • Anticipate alternative airway maneuver
- 19. • LEMON –L-look –E-evaluate the 3-3-2 rule –M-Mallampati –O-Obstruction –N-Neck mobility
- 20. Preoxygenation • 100% O2 for 5 minutes of 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs
- 21. Troubleshoot • Hypotension after procedure • > 1 attempt –Non experience –Position
- 22. Prepare : sniff position
- 23. Prepare : sniff position
- 24. Troubleshoot • Hypotension after procedure • > 1 attempt –Non experience –Position –Not wait til onset of drugs • Myoclonus 1 time • Drug preparation time
- 25. Tip & Trick in RSI
- 31. Emergency Airway
- 38. Succinylcholine Rapid onset Profound depth of NMB Short duration of action
- 39. Succinylcholine’s weaknesses Cardiovascular effects sinus bradycardia nodal rhythm ventricular dysrhythm Increase IOcP Increase IGP Increase ICP
- 40. Succinylcholine’s weaknesses • Myalgia • Masseter spasm • Fasciculations • Anaphylaxis • Abnormal plasma cholinesterase • Hyperkalemia
- 41. Overview NMBAs Arguments against Succinycholine • Used just out of convenience • Many contraindications in particular in certain patient populations • FDA Warning box for pediatrics • Perceived advantage of fast spontaneous breathing in “can’t intubate, can’t ventillate” is not as fast in reality • Severity of its side effects may increase costs of prolonged hospital stay and treatment
- 42. Contraindications • MH • Burn • UMNL • Severe muscle trauma • Disuse atrophy
- 43. Is Suxamethonium Really Safe ? Morbidity Fasciculation C-spine
- 44. Comparative Intubating Doses and Time to Intubation of NDMRs
- 45. Effects of Rocuronium on Heart Rate Time (minutes) 100 90 80 70 60 50 40 0.0 1.0 2.0 3.0 4.0 5.0 6.0 HeartRate(beats/min) Levy et al. Anesth Analg 1994;78,318-321. 600 mcg/kg 900 mcg/kg 1200 mcg/kg
- 46. Effects of Rocuronium on Mean Arterial Pressure Time (minutes) 100 90 80 70 60 50 0.0 1.0 2.0 3.0 4.0 5.0 6.0 MeanArterialPressure(mmHg) 600 mcg/kg 900 mcg/kg 1200 mcg/kg Levy et al. Anesth Analg 1994;78,318-321.
- 47. Effects of Rocuronium on Histamine Release Time (minutes) 0.0 1.0 2.0 3.0 4.0 5.0 PlasmaHistamine(ng/ml) Levy et al. Anesth Analg 1994;78,318-321. 600 mcg/kg 900 mcg/kg 1200 mcg/kg 3.0 2.5 2.0 1.5 1.0 0.5 0.0
- 48. ROCURONIUM: TRACHEAL INTUBATION • Median time to 80% block with 0.6 mg/kg is 60 seconds (0.4- 6.0 minutes) • Median onset time with 0.6 mg/kg is 1.8 minutes (0.6-13 minutes)
- 49. LOW DOSE PHARMACODYNAMICS: CLINICAL PARAMETERS Rocuronium br Dose: 0.45 mg/kg (n = 14) Mean maximum blockade 96 ± 5% Mean time to 80% blockade 117 ± 24 seconds Mean time to maximum blockade 214 ± 25 seconds Mean time to completion of intubation 159 ± 25 seconds
- 50. ROCURONIUM BROMIDE: TRACHEAL INTUBATION • Median time to 80% blockade with 0.9 mg/kg is 66 seconds (0.3-3.8 minutes) • Median onset time with 0.9 mg/kg is 84 seconds (0.8-6.2 minutes) • Median time to 80% blockade with 1.2 mg/kg is 42 seconds (0.4-1.7 minutes) • Median onset time with 1.2 mg/kg is 60 seconds (0.6-4.7 minutes)
- 51. Rocuronium versus succinylcholine for rapid sequence induction intubation (Review) Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent and clinically acceptable intubating conditions. This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2008, Issue 3 http://www.thecochranelibrary.com
- 52. Rocuronium bromide 0.6 mg/kg spontaneous recovery
- 53. Rocuronium bromide 0.6 mg/kg reversal of block
- 54. Sugammadex Org 25969-Rocuronium complex formation Gamma cyclodextrin Org 25969 dose 8 mg/kg Outside ring :hydrophilic with negative charge Inside ring :hydrophobic ***Inside cavity specific only to Rocuronium
- 55. หลับ
- 56. -50 -40 -30 -20 -10 0 10 20 Heartrate(%frombaseline) TIVA VIMA Baseline Before Intubation After Intubation Before Incision After Incision Before Extubation After Extubation * * + + + + + + + Heart Rate
- 57. -50 -40 -30 -20 -10 0 10 20 MAP(%frombaseline) TIVA VIMA Baseline Before Intubation After Intubation Before Incision After Incision Before Extubation After Extubation + + + + + + + + + * Blood Pressure
- 61. Comp2 24 L Comp1 4.3 L Comp3 238 L Multi-compartmental pharmacokinetic models
- 63. Propofol Bolus 2 mg/kg 3020100 10 9 8 7 6 5 4 3 2 1 0 1000 900800700600500400300200100 0 3020100 10 9 8 7 6 5 4 3 2 1 0 1000 900800700600500400300200100 0 3020100 10 9 8 7 6 5 4 3 2 1 0 1000 900800700600500400300200100 0 3020100 10 9 8 7 6 5 4 3 2 1 0 1000 900800700600500400300200100 0
- 64. IV Bolus Personnel Controlled Infusion • Drop counting • Intermittent manual injection
- 65. IV line Trouble Shooting • Occlusion • Air in line • Position • Technique
- 66. Infusion Devices
- 69. Pre-load
- 70. Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007 Aug;21(5):492-6. Leg Elevation
- 71. Response to increased cardiac load, obtained by leg elevation
- 72. The End Thank you for your attention