Complications of Rapid Sequence Induction and Moderate Sedation, and - PowerPoint Presentation

Slide1

Complications of Rapid Sequence Induction and Moderate Sedation, and the Difficult Airway

Ryan J Fink, MD

Raquel

Bartz

, MD

Duke University Medical Center

Dept. of AnesthesiologySlide2

Objectives

Goals of airway management

Recognizing the difficult airway

Complications surrounding airway management

Other Complications

Rapid Sequence Induction/Intubation

Moderate Sedation Slide3

RSI and MS and the AirwayRSI = planned intubation

MS = intubation as recue technique

Airway evaluation for all patients

Plan on

intubating

Slide4

Emergency Airway Management: Indications for Intubation

Loss of Airway Protection

Loss of gag/cough (GCS ≤ 8)

Airway obstruction (i.e. edema)

Anticipated loss of airway control (i.e. worsening

stridor

, burns) Slide5

Emergency Airway Management: Indications for Intubation

Failure of Ventilation (PaCO2 > 50 mmHg)

Neurological problems

Sedation, narcosis, brain or spinal cord injury, peripheral nerve disease (i.e.

Guillian-Barre

)

Muscular problems

Myasthenia gravis, steroid-induced

myopathy

Anatomical problems

Rib fractures,

pneumothorax

, abdominal hypertension

Gas exchange Problems

Acute lung injury, lung contusionSlide6

Emergency Airway Management: Indications for Intubation

Failure of Oxygenation (PaO2 <60mmHg)

Diffusion abnormality

Pulmonary edema, alveolar

proteinosis

, aspiration

Increased Dead Space (ventilations w/o perfusion)

Pulmonary embolus, shallow breathing

Shunt (perfusion w/o ventilation)

Airway collapse, pneumonia, acute lung injurySlide7

Loss of Airway Protection+Failure of Ventilation

+

Failure of Oxygenation

=

Respiratory Failure and Need for Intubation

Emergency Airway Management:

Indications for IntubationSlide8

Airway AssessmentGoals:

Assess for risk of difficult mask ventilation

Assess for risk of difficult intubationSlide9

Predictors of Difficult

Mask Ventilation

M

= difficult

M

ask

seal (full beard)

O

=

O

bese

or airway

O

bstruction

A

= advanced

A

ge

N

=

N

o

teeth

S

=

S

tiff lungs/history

of

S

noringSlide10

Predictors of Difficult Intubation:Mallampati ClassificationSlide11

Predictors of Difficult Intubation:Mallampati Classification

↑ MP score correlates with difficult intubation

Relative Risk of difficult intubation

Class III 7.5 times compared to class I

Sensitivity = 60-80%

Specificity = 53-80%

Positive Predictive Value = 20%

Longnecker

,

Anesthesiology,

2008

Fleischer,

Evidence Based Practice of Anesthesiology, 2009Slide12

Weight (>90kg)Head/neck movement (≤ 90⁰)Poor jaw mobilityIncisior gap (≤ 5 cm)

Difficulty with lower jaw

subluxation

Receding mandible

Protruding maxillary teeth

Short

thyromental

distance (<6cm)

Other anatomic changes (tumor, goiter, etc…)

Predictors of Difficult IntubationSlide13

Small mandibleSlide14

Large tongue, airway edemaSlide15
Slide16

Limited mouth openingSlide17

Protruding front teethSlide18

Airway Assessment: Helping to Prevent Complications

Identify patients who might be difficult to ventilate and

intubate

prior to proceeding

Call for assistance and have back-up plans

Know potential complications

Prevent potential complications

PREPARATIONSlide19

RSI 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: 508-516Schwartz DE Anesthesiology 1995; 82:367-376Jaber S Crit Care Med 2006; 34:2355 - 2361Slide20

RSI Complications

↑ complications with ↑ number of attempts

Dental injury

> 3 attempts = severe hypoxemia in all patients

> 3 attempts = 25% require surgical airway

Prevention/Management

Thorough airway assessment

If unsuccessful, make adjustments

Position, equipment, or personnel

Mort TC J

Clin

Anesth

2004; 16:508Slide21

RSI 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: 508-516Schwartz DE Anesthesiology 1995; 82:367-376Jaber S Crit Care Med 2006; 34:2355 - 2361Slide22

RSI Complications

Esophageal Intubation

Delay to ventilation

 hypoxemia

Gastric

insufflation

 aspiration

Esophageal tear

Cardiac arrest/death

Prevention/Management

Airway assessment and preparation

Avoid “blind” intubations

Ascultate

, bag compliance,

+ end tidal CO2

Avoid gastric

insufflation

, remove the ETTSlide23

RSI 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: 508-516Schwartz DE Anesthesiology 1995; 82:367-376Jaber S Crit Care Med 2006; 34:2355 - 2361Slide24

Aspiration Difficult to visualize vocal cords and intubate Pneumonia

Airway obstruction



Hypoxemia

 Death

Prevention/Management

Airway assessment and preparation

? Pharmacotherapy

Intubate

 suction trachea before ventilation

30 degrees head-down tilt

Treat hypoxemia (FiO2, PEEP)

RSI ComplicationsSlide25

RSI 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: 508-516Schwartz DE Anesthesiology 1995; 82:367-376Jaber S Crit Care Med 2006; 34:2355 - 2361Slide26

HypoxemiaPt characteristics: ↓ FRC; PE, pleural effusionProcedural: multiple attempts, poor preoxygenation

Prevention/Management

Airway assessment and preparation

Preoxygenation

Mask ventilate if needed, 100% oxygen

Tube migration, kinking, or circuit disconnect

Bronchspasm

,

pneumothorax

RSI ComplicationsSlide27

RSI Complications: ↓Blood Pressure

Jaber

S

Crit

Care Med 2006; 34:2355 - 2361Slide28

Sedation ComplicationsRegurgitation/aspiration

Hypoxemia

Hypotension

Uncooperative patient

Pain?

Anxiety?

Hypoxemia?

Dis

-inhibition?Slide29

RSI and Sedation Complications and the Difficult Airway Algorithm Slide30

Airway assessment

Basic airway management choices, determined by clinical situation

Awake intubation: invasive or non-invasiveSlide31

Initial attempt is unsuccessfulSlide32

Initial attempt is unsuccessfulSlide33

Cannot

intubate

, cannot ventilateSlide34

The Difficult Airway

Airway assessment

Ventilation possible

vs

impossible

Always plan for multiple different techniques

esp. LMA

Call for assistance early

Including surgical assistance

Have surgical airway kits available Slide35

Conclusions

Complications of RSI and sedation are similar

Thorough airway assessment is a must

Plan for intubation must be individualized

Have back-up plans available

Be sure equipment is working properly

Call for help early if needed