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Pharmacologic Management of Rapid Sequence Intubation (RSI) James Gibson, PharmD PGY1 Pharmacy Practice Resident.

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Presentation on theme: "Pharmacologic Management of Rapid Sequence Intubation (RSI) James Gibson, PharmD PGY1 Pharmacy Practice Resident."— Presentation transcript:

1 Pharmacologic Management of Rapid Sequence Intubation (RSI) James Gibson, PharmD PGY1 Pharmacy Practice Resident

2 Learning Objectives List 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.

3 Rapid Sequence Intubation (RSI) Induction of a patient using simultaneous Sedatives Rapid-acting paralytic agent Goal: to avoid assisted ventilation due to elevated risk of aspiration Un-fasted patient Pharyngeal/laryngeal manipulation

4 The Six P’s of RSI Preparation Pre-oxygenation Pretreatment and induction Paralysis Placement of the tube Post-intubation management

5 Preparation Assess patient—difficult airway? IV access Monitor (tele, pulse ox) Gather: Equipment for intubation Post-intubation medication(s) Pertinent patient history Supplies for surgical airway (just in case!!)

6 Pre-Oxygenation Goals: Establish O 2 reservoir Maximize time for intubation Prevent need for bag-mask ventilation Methods: 3-5 minutes of 100% O 2 via face mask 4 (or 8) vital capacity breaths on 100% O 2

7 Pre-Oxygenation

8 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

9 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

10 Pretreatment Lidocaine Opioid Atropine Defasciculating agent Fentanyl 3 mcg/kg IV Provides analgesia Lessens pressor response Limits ICP increase More effective than lidocaine

11 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)

12 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 (1/10 th of paralytic dose)

13 Induction Agent(s) Given as rapid IV push immediately before paralyzing agent Ideally provides: Rapid loss of consciousness Analgesia Amnesia Stable hemodynamics

14 Induction Agents DrugDose Thiopental3-5 mg/kg IV Methohexital1-3 mg/kg IV Fentanyl5-15 mcg/kg IV Midazolam0.1 mg/kg IV Ketamine1-2 mg/kg IV Etomidate0.3 mg/kg IV Propofol2 mg/kg IV

15 Induction Agents Etomidate Ultrashort-acting non-barbiturate hypnotic Rapid onset—30 to 60 secs Hemodynamic stability Hydrolyzed in liver and plasma  ICP with minimal effects on cerebral perfusion NO analgesia ADE: Myoclonic jerks,  cortisol production

16 Induction Agents Fentanyl Short-acting, potent Minimal histamine release Hemodynamically stable Sedation is rate- AND dose-dependent Combined with other induction agents for analgesia ADE: muscle rigidity, grand mal seizures (rare)

17 Induction Agents Midazolam Sedative, amnestic, muscle relaxant NOT analgesic Less cardiorespiratory depression vs. other benzos  BP;  HR Use lower dose in hypovolemic, elderly, or traumatic brain injury patients (0.05 mg/kg) Does NOT contain propylene glycol

18 Induction Agents Ketamine NMDA-antagonist  dissociative anesthesia Analgesic, amnestic, anesthetic Dissociation occurs at threshold of mg/kg IV 4-5 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 (2011):

19 Neuromuscular Blocking Agents (NMBAs) Quaternary ammonium compounds that mimic structure of ACh Depolarizing vs non-depolarizing Allow complete airway control Higher success (100% vs 82%) Less aspiration and airway trauma Enable lower doses of sedative Better hemodynamic stability Roberts: Clinical Procedures in Emergency Medicine. 5 th. Philadelphia, PA: Elsevier, Acetylcholine Succinylcholine

20 Depolarizing NMBA Non-competitively binds ACh receptors  initial membrane depolarization Longer degradation time than ACh Paralysis in ~60 sec. DOA: 3-5 min Prolonged in pseudocholinesterase deficiency (genetic, hepatic/renal failure, pregnancy, cocaine) Repeat doses prolong paralysis May increase bradycardia/hypotension DOC for RSI

21 Succinylcholine Dose: 1.5 mg/kg IV (infants: 2 mg/kg IV) Use ACTUAL body weight Rapid bolus; follow w/ mL saline flush ADEs: Muscle fasciculation  myalgias Hyperkalemia,  CPK Bradycardia/hypotension Mild increase in ICP Malignant hyperthermia

22 Succinylcholine Hyperkalemia Typical K + increase < 0.5 mEq/L Up 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

23 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 AgentDose (mg/kg)Onset (min)Duration (min) Succinylcholine Rocuronium Vecuronium Pancuronium0.12-5(60-100) Roberts: Clinical Procedures in Emergency Medicine. 5 th. Philadelphia, PA: Elsevier,

24 Non-Depolarizing NMBAs Pancuronium Long time to onset  HR and BP (vagolytic effect) Histamine release  bronchospasm/anaphylaxis Active metabolites Accumulates Renal dosing required NOT recommended for RSI

25 Non-Depolarizing NMBAs Vecuronium Slower onset than rocuronium Non-vagolytic; no histamine release Active metabolites Often requires “priming” dose 0.01 mg/kg during pre-oxygenation phase, then 1.5 mg/kg given 3 min later for paralysis

26 Non-Depolarizing NMBAs Rocuronium Onset similar to succinylcholine Non-vagolytic; no histamine release No active metabolites Preferred alternative to succinylcholine in RSI

27 Post-intubation Care After endotracheal tube is placed: Provide continued sedation/analgesia Propofol drip (No analgesia) ≤ 120 kg begin infusion at 20 mcg/kg/min kgbegin infusion at 15 mcg/kg/min >151 kgbegin infusion at 10 mcg/kg/min Bolus fentanyl and midazolam Fentanyl (analgesia): LD: mcg IV q15 min PRN (max 300 mcg in first hr) MD: 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

28 References Claudius, C, LH Garvey, J Viby-Mogensen, et al. "The Undesirable Effects of Neuromuscular Blocking Drugs." Anaesthesia (2009): 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): Print. Green, Steven, Mark Roback, et al. "Clinical Practice Guidelines for Emergency Department Ketamine Dissociative Sedation: 2011 Update." Annals of Emergency Medicine (2011): Print. Hopson, Laura, and Richard Schwartz. Roberts: Clinical Procedures in Emergency Medicine. 5th. Philadelphia, PA: Elsevier, Print. Martyn, Jeevendra, and Martina Richtsfeld. "Succinylcholine-induced Hyperkalemia in Acquired Pathologic States." Anesthesiology (2006): Web. 8 Mar Walls, Ron. Marx: Rosen's Emergency Medicine. 7th ed. Philadelphia, PA: Elsevier, Print.


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