surapong rsi 2009
TRANSCRIPT
ผศ.นพ.สรุพงษ์ หล่อสมฤดีTIVA Center
Division of Cardiothoracic and Vascular Anesthesia
Division of Transplantation Anesthesia
Chiang Mai University Hospital
Why do we need NMBAs
for RSI
Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007
Oct;21(5):636-43.
Hemodynamic Effects
Painful stimulus
Lorsomradee, et al: Anaesthesia. 2007
Oct;62(10):979-83.
Vasoconstrictor
Phenylephrine
Reversible myocardial ischemia
Stunning
A transient period of
depressed myocardial function
that follows a period of ischemia,
not sufficient to result in cell death
Cardioprotection: Myocardial oxygen balance
O2 supply
O2 demand<
ischemia
supply demand
Heart rate
contractility
afterload
CBF: normal region
CBF: ischemic region
subendocardium
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
Chiang Mai Medical Journal 2008;48(3suppl)
Rapid Sequence
Intubation experience in
Emergency DepartmentMaharaj Nakorn Chiang Mai
นพ.บวร วิทยช ำนำญกุลEmergency Medicine
Chiang Mai University Hospital
History
• Awake intubation
• Diazepam ???
• Midazolam
• Establish Training EM in 2548
• Workshop RSI in January 2551
•
• RSI in ER October 2551
• Etomidate + Succinylcholine
• Etomidate + Rocuronium
• Propofol
28
20
3
12
14
0
5
10
15
20
25
30
1 attempt 2 attempt 3 attempt
RSI 32 non RSI 36
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
Now
• More than 150 experience of RSI
• Staff attending 24 hr
• ER staff in morning shift and
some noon – night shift
Quality Control
• Resident 2 : training, coaching, direct
observe
• Difficult airway cart
• No serious adverse event
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”
Preparation
• Evaluate
– LEMON
• Equipment Check
• Positioning
• Drug Selection
• IV’s, monitor, oximetry
• Ancillary Staff
• Anticipate alternative airway maneuver
• LEMON
–L-look
–E-evaluate the 3-3-2 rule
–M-Mallampati
–O-Obstruction
–N-Neck mobility
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
Troubleshoot• Hypotension after procedure
• > 1 attempt
– Non experience
– Position
Prepare : sniff position
Prepare : sniff position
Troubleshoot• Hypotension after procedure
• > 1 attempt
– Non experience
– Position
– Not wait til onset of drugs
• Myoclonus 1 time
• Drug preparation time
Tip & Trick in RSI
Airway Assessment
Emergency Airway
Muscle Relaxation
Succinylcholine
Rapid onset
Profound depth of NMB
Short duration of action
Succinylcholine’s weaknesses
Cardiovascular effects
sinus bradycardia
nodal rhythm
ventricular dysrhythm
Increase IOcP
Increase IGP
Increase ICP
Succinylcholine’s weaknesses• Myalgia
• Masseter spasm
• Fasciculations
• Anaphylaxis
• Abnormal plasma cholinesterase
• Hyperkalemia
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
Contraindications• MH
• Burn
• UMNL
• Severe muscle trauma
• Disuse atrophy
Is Suxamethonium Really Safe ?
Morbidity
Fasciculation
C-spine
Comparative Intubating Doses and Time to Intubation of NDMRs
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
He
art
Ra
te (
be
ats
/min
)
Levy et al. Anesth Analg 1994;78,318-321.
600 mcg/kg
900 mcg/kg
1200 mcg/kg
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
Me
an
Art
eria
l P
ressu
re (
mm
Hg
) 600 mcg/kg
900 mcg/kg
1200 mcg/kg
Levy et al. Anesth Analg 1994;78,318-321.
Effects of Rocuronium on Histamine Release
Time (minutes)
0.0 1.0 2.0 3.0 4.0 5.0
Pla
sm
a H
ista
min
e (
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
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)
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
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)
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 3http://www.thecochranelibrary.com
Rocuronium versus
Rocuronium bromide 0.6 mg/kg
spontaneous recovery
Rocuronium bromide 0.6 mg/kg
reversal of block
SugammadexOrg 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
หลับ
-50
-40
-30
-20
-10
0
10
20
Hea
rt r
ate
(%
fro
m b
ase
lin
e)
TIVA VIMA
Baseline BeforeIntubation
AfterIntubation
BeforeIncision
AfterIncision
BeforeExtubation
AfterExtubation
* *+
+
+ + +
+
+
Heart Rate
-50
-40
-30
-20
-10
0
10
20
MA
P (
% f
ro
m b
aseli
ne)
TIVA VIMA
Baseline BeforeIntubation
AfterIntubation
BeforeIncision
AfterIncision
BeforeExtubation
AfterExtubation
+
+ +
+
+ +
+
+
+
*
Blood Pressure
0
20
40
60
80
100
BIS
0
1
2
3
4
5
Ce P
ro
po
fo
l
(m
cg
/ml)
mean BIS mean Ce Propofol
Multi-compartmental pharmacokinetic models
Comp2
24 L
Comp1
4.3 L
Comp3
238 L
Multi-compartmental pharmacokinetic models
Propofol
Bolus 2 mg/kg
Propofol Bolus 2 mg/kg
3020100
Concentr
ation µ
g/m
l
10
9
8
7
6
5
4
3
2
1
0
Inf. R
ate
(ml/h
r) + D
ecr. T
ime
1000
900
800
700
600
500
400
300
200
100
0
3020100
Concentr
ation µ
g/m
l
10
9
8
7
6
5
4
3
2
1
0
Inf. R
ate
(ml/h
r) + D
ecr. T
ime
1000
900
800
700
600
500
400
300
200
100
0
3020100
Concentr
ation µ
g/m
l
10
9
8
7
6
5
4
3
2
1
0
Inf. R
ate
(ml/h
r) + D
ecr. T
ime
1000
900
800
700
600
500
400
300
200
100
0
3020100
Concentr
ation µ
g/m
l
10
9
8
7
6
5
4
3
2
1
0
Inf. R
ate
(ml/h
r) + D
ecr. T
ime
1000
900
800
700
600
500
400
300
200
100
0
IV Bolus
Personnel Controlled Infusion
• Drop counting
• Intermittent manual injection
IV line Trouble Shooting
• Occlusion
• Air in line
• Position
• Technique
Infusion Devices
Pre-load
Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007
Aug;21(5):492-6.
Leg Elevation
Response to
increased
cardiac load,
obtained by leg elevation
The End
Thank you
for your
attention