Rapid Sequence Induction

Case InsertA 38 year old female 38Peritonitis for 3 days 3Shocked with: 1. T: 38 o C 38 2. Pulse:120/minute 120/ 3. BP: 70 mmHg systolic 70mmHg 4. Poor nail bed capillary return 5. Respiratory rate 30/ 6. Confused 7. Urinary: 20mL of concentrated urine : 20mL The surgeon wants to operate immediately

Anesthesia ?regional anesthesia?

General anesthesia?

Induction Fentanyl Propofol Rocuronium RSI

Rapid Sequence Intubation INTUBATION

CasesAdult patient Child

Main complications of GA Regurgitation Vomiting Aspiration Desaturation, Laryngospasm , Airway obstruction, Bronchospasm, Cardiac arrest

GOAL of RSI Protect airway

Facilitate intubations

Rapidly induce anesthesiaACEP, 2000

HistoryCricoid cartilage pressure to prevent regurgitation- Sellick1961.First series of ED intubations Taryle, 1979First series of intubations using succinylcholine in the ED Thompson, 1982American College of Emergency Physicians (ACEP) RSI policy statement(1997):- Reaffirmed, 2000physicians performing RSI should possess training, knowledge, and experience in the techniques and pharmacologic agents used to perform RSI

Today 1.RSI resides in the domain of emergency medicine practice

2. Key in the successful management of the A of ABCsABCA

3. Increases the chance of successful intubation and minimizes the risks

COMPLICATION:: 15% aspiration, 28% airway trauma, 3% death 1999 Li et.al.

Chart1

0.28

0.78

Complication

Sheet1

MethodComplication

RSI28%

Without Paralysis78%

78%*

WITHOUT PARALYSISn=67

28%

RSI n=166

COMPLICATIONS

METHOD

Sheet1

0

0

Complication

Sheet2

Sheet3

National Emergency Airway Registry (NEAR)Series of > 6000 ED intubations26 teaching hospitals88.1% adult and 81.1% pediatric intubations

(Indication)Full stomach ().

Gastric content aspiration risk (,

Contraindications

The predicted difficult airway Inexperience Inadequate difficult airway tools and techniques

RSI: Rapid Sequence Induction (Preparation) (Preoxygenation) (Premedication) (paralysis) (Pass the tube)

Preparation for RSIS: Suction)O: OxygenA: Airway EquipmentP: PharmacologyME: Monitoring Equipment

Head positioningMaintaining a patent airway Chin lift / jaw thrust The patient is /

Preoxygenation Preoxygenated for a full three minutes

Wash all of the nitrogen out of the lungs

Create a resevoir of O2

PRESSURE GOAL: REDUCTION OF RISK OF ASPIRATION: Sellick maneuverTechniqueRisk reductionPassive regurgitationGastric insufflation Cricoid pressure

No positive pressure ventilationImportant !Risk reductionPassive regurgitation Gastric insufflation

(paralysis)Muscle relaxation in Succinylcholine occurs in just 30 seconds, with total paralysis in 45 seconds (1.5 mg/kg-2.0 mg/kg). 3045 (1.5 mg/kg-2.0 mg/kg)

Muscle relaxation in Rocuronium occurs in 60-90 seconds (0.6 mg/kg ) 6090 (0.6 mg/kg )uscle relaxation

Anaesthesia

The anaesthetist is happy that the airway is intact Administers the remainder of the anaesthetic agents - fentanyl, nitrous oxide and the volatile agent (Sevoflurane). , () A non depolarising neuromuscular blocker

fter intubation

ET tube Chest X Ray X

At the completion of surgeryThe risk of aspiration of gastric contents is as high now as at the beginning:: The anaesthetic agent is turned off 100% oxygen is administered 100% Neuromuscular blockade is reversed The airway is carefully cleaned with suction Ett remains in situ until the patient is fully awake, lying on their side,

Conclusion RSI could provide a safe airway and Minimizing any possible complications during intubation.RSI successful avoid aspiration in full-stomach patients. Dronen,S.C., 1999Whereas anaesthesiologists use RSI to intubate patients requiring anaesthesia, emergency physicians commonly use RSI to induce anaesthesia in patients requiring intubationRSI RSI.

RSIWhat are the difference between the RSI and traditional rapid induction RSI?

Differences are An organized approach to endotracheal intubationRapidly induce anesthesia facilitate intubationsNo positive pressure ventilation Cricoid pressure to protect airway Avoid aspiration in full-stomach patients

ACEP, 2000

VS point 2 could read : rapidly create the ideal intubating conditionsDronen,S.C., 1999VS point 2 could read : rapidly create the ideal intubating conditions