Ryan J Fink MD Raquel Bartz MD Duke University Medical Center Dept of Anesthesiology Learning Objectives Components of Rapid Sequence Intubation RSI Basic Equipment Preparation Reasons for RSI ID: 695714
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Slide1
Components of Rapid Sequence Intubation
Ryan J Fink, MD
Raquel Bartz, MD
Duke University Medical Center
Dept. of AnesthesiologySlide2
Learning Objectives
Components of Rapid Sequence Intubation (RSI)
Basic Equipment
Preparation
Reasons for RSISlide3
Good Clinical Judgment Required
Clinical judgment is required who, when, and how to support ventilation in a patient
Choices, Choices, and more Choices
Mechanical ventilation via
endotracheal
tube or
Bilevel
positive airway pressure (BIPAP)
Which tools to use
How to intubate: awake versus unconscious and/or paralyzed
Which induction agent or paralyticSlide4
Intubation Goal
Provide means for improved oxygenation, improved ventilation, securing the airway
Minimize risk of complication and/or death associated with the procedure of intubationSlide5
Reported Complications
Mort
Study;
N = 102
Jaber
Study;
N = 251
Schwartz Study; N = 238
Hypoxemia : 17%Hypoxemia: 26%Aspiration: 1.7%Aspiration: 4%Aspiration: 4%Regurgitation: 4.4%Dental Injury: 1%Surgical Airway: 0.4%Pneumothorax: 1%Esophageal Intubation: 10%Esophageal Intubation: 4%Esophageal Intubation: 8%Bradycardia: 3.5%Severe Hemodynamic Collapse: 25%Cardiac Arrest: 2%Cardiac Arrest: 1%Cardiac Arrest/ Death 3%> 3 Attempts: 10%> 3 Attempts: 11%
Mort TC J
Clin
Anesth
2004; 16: 508-516
Schwartz DE Anesthesiology 1995; 82:367-376
Jaber
S
Crit
Care Med 2006; 34:2355 - 2361Slide6
Rapid Sequence Induction/Intubation
Purpose:
To decrease the risk of pulmonary aspiration
Improve likelihood of quick intubation with minimal physiologic compromise
Indications:
Patients considered to have a “full stomach”
NPO < 8 hours
Pregnancy
Significant GERD, delayed gastric emptying, hiatial herniaIleus, SBO, acute abdomen, or traumaMany times this is unknown in the Emergency Room or Intensive Care UnitContraindication to RSI:Predicted difficult mask ventilation or intubationConsider awake fiberoptic intubationEven the most experienced practitioners ask for helpSlide7
What is Rapid Sequence Induction/Intubation
Preparation (equipment and patient)
Induction agent
To cause hypnosis/unconsciousness
To prevent memory of intubation
Maintain
hemodynamics
Paralytic
To increase success of
endotracheal tube placementTo prevent aspirationCricoid PressureTo reduce risk of aspirationNo mask ventilationIntubationSlide8
Basic Equipment (MS-MAIDS)
M
–
machine (
ambubag
, ventilator)
S
–
suction is available and turned onM – monitors, O2 saturation tone is audible A – airway to include endotracheal tube with stylet, LMA, blades or other intubating deviceI – IV free, functioning, and flowingD – drugs available – Induction agent, Paralytic agent, drugs to increase blood pressure, drug to increase heart rate S – suction again/Special stuff Slide9
Preparation For RSI: Pt Positioning
Position your patient for success
Patient at the head of the bed
Bed is locked and fully inflated
Bed is at proper height
“Sniffing position”
Contraindicated:
Cervical spine injury
Goal is to align airway axesSlide10
Preparation For RSI: Pt PositioningSlide11
Preparation For RSI: Pt Positioning
Sniffing PositionSlide12
Preparation For RSI
Pre-oxygenation:
5 minutes while preparing for intubation
BiPAP
works well, with F
I
O
2
at 100%
Assist with bag-mask ventilation if decreased level of consciousnessSupply 100% oxygen into bag-valve maskHave more than one practitioner available to help with intubationSlide13
Why
Preoxygenate
?Slide14
Time of Apnea
90%
100%
8 min
Why
Preoxygenate
?Slide15
Preparation For RSI
Suction should be audible
Monitors in place:
Non-invasive BP at least every 1-3 minutes
ECG
O
2
saturation monitor with audible tone
Airway devices should be readily available:
Endotracheal tube – multiple sizes (7.0 for women, 8.0 for men)Stylet if needed, endotracheal tube cuff checkedLaryngeal Mask Airway (LMA)Blades (Multiple types – Miller, MacIntosh, Phillips, etc.Oral/nasal airways IV should be checked and free-flowingSlide16
Preparation For RSI: Drugs
Induction agent (next module)
Etomidate
/
Propofol
/Midazolam/
Ketamine
Paralytic (next module)
Succinylcholine/RocuroniumVasopressor – to treat hypotension if it developsAnticholinergic – to treat bradycardia Atropine 0.2 – 1 mgGlycopyrrolate 0.2 – 0.6 mgPost-intubation sedation/anesthesiaSlide17
Preparation For RSI:
Cricoid
Pressure
Pressure on
cricoid
cartilage
Backwards against cervical vertebra
Purpose: to occlude esophagus
(Possibly) prevents aspirationSlide18
Preparation For RSI:
Cricoid
Pressure – Warn your patientSlide19
Preparation For RSI: Cricoid
Pressure
Controversy still exists
Amount of pressure: 10 - 40
Newtons
May cause retching/vomiting in awake patients
Decreases lower esophageal sphincter tone
Aspiration can still occur
May limit laryngeal visualization
Pushes esophagus to the side, not always compressedStill a standard of careSlide20
RSI: Completion
No mask ventilation
Confirm
endotracheal
tube placement
End-tidal carbon dioxide monitoring
May be inaccurate in cases of cardiac arrest (no CO = no EtCO2)
Condensation in the tube
Chest rise
Bilateral breath sounds Bronchoscopy Esophageal detection deviceDo not release cricoid pressure until confirmedBegin post-intubation sedationSlide21
Prepare equipment and patientPreoxygenate for 5 min with 100% O2
Assistant holds
cricoid
pressure
Lightly when patients is still awake
Assistant pushes induction agent and then paralytic
Intubate
after approximately 45 seconds
Confirm
endotracheal tube placementBegin sedation/anesthesiaRapid Sequence Intubation (RSI)Slide22
Rapid Sequence Intubation (RSI): Conclusions
Preparation is key!
MSMAIDS mnemonic
Free flowing IV
Assistance available for drugs and
cricoid
pressure
Multiple airway devices
Have a back-up plan if intubation is difficult