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This post is partially prompted by several recent posts:
http://forums.gasforums.net/showpost.php?p=4118240&postcount=6
http://forums.gasforums.net/showpost.php?p=4111352&postcount=49
There are likely many more that I just don't remember off the top of my head. My examples shouldn't be an indictment of the posters but rather serve to illustrate the issue.
I'd like to get some input from people here about RSI in the ICU by non-anesthesiologists. After all, we're headed for a nationwide shortage of intensivists and in most places, during off hours or even during the day on the weekends the anesthesiologist will be at home.
http://www.chestjournal.org/cgi/content/full/127/4/1397
RSI is the nearly simultaneous administration of a potent induction agent with a paralyzing dose of a neuromuscular blocking agent (NMBA). When applied by skilled operators for appropriately selected patients, RSI increases the success rate of intubation to 98% while reducing complications.
The National Emergency Airway Registry II,6 a data bank of 7,712 intubations, has demonstrated that RSI is the most common technique of intubation with a success rate > 98.5%. These results contrast with the 18% incidence of failed intubation in the absence of RSI reported by Li and coworkers.7 This prospective study compared complications arising from intubation utilizing paralytic agents within an RSI protocol to intubations those arising from intubations without the use of NMBAs. Esophageal intubations and airway trauma occurred with greater frequency in the group that did not receive RSI (18% vs 3%, respectively, and 28% vs 0%, respectively).
Although limited outcomes data exist for the use of these techniques in the ICU, similarities of patients and conditions with the emergency setting warrant the adoption of algorithmic approaches and RSI as the standard mode of intubation for critically ill patients. RSI requires a thorough understanding of the physiology of intubation, and of the various drugs used for induction and paralysis in addition to careful patient selection. The standardization of intubation efforts with well-conceived algorithms requires a regimented approach that is similar to that employed for cardiopulmonary resuscitation. The training of critical care physicians requires greater attention to teaching these advanced airway management skills, more collaboration between anesthesiologists and critical care physicians to promote these skills,4 and careful monitoring for adverse events and outcomes to improve patient selection for the various intubation approaches that are available.
(I'm reproducing large chunks of this article because although copyrighted they are available for free at chestjournal.org.)
I'll highlight with two personal examples. I've done somewhere between 50-100 intubations but I don't do them enough that I consider them "routine" plus based on my practice patterns I doubt I'll ever consider them routine.
Person #1: Airway backup is at home. I have all the drugs of my choosing available. Woman with advanced liver disease in the ICU who is clearly going nowhere fast. I can see her slowly spiraling and I know she's going to get intubated sometime during my shift. Now the question is, will this happen at a time of my choosing (i.e. controlled, elective intubation) or her choosing (i.e. crash intubation, probably when it's not convenient). She has a normal habitus, full neck/mouth ROM and no teeth of her own. She "looks" reasonable. I elect to use propofol and succinylcholine and get a superb grade I view and pass a tube on the first attempt.
Person #2: Airway backup is at home. I have succ, versed and morphine available only (yes there ARE hospitals like this out there). Elderly demented man who needed intubation for airway control as he was fading in and out of consciousness and lacking the ability to protect his airway. Something about him doesn't strike me as quite right. Normal habitus but unable to really assess neck or mouth movement because he's quite uncooperative when he is awake. I elect to only give versed and probably not in high enough of a dose.
First look with a Mac 3 yields a very, very anterior airway and probably an esophageal intubation. No problem as I'd been giving him 100% O2 via a NRB for at least 10 minutes while we got all of our stuff together. Tube comes out while he's still in the mid 90s and we bag him while he's still spontaneously breathing. Second attempt with a Mac 3 and cricoid pressure yields a better look at the chords and in retrospect I was probably in but it's unclear whether there's color change on the ETCO2 and due to his paradoxical abdominal movement it was hard to tell whether we were inflating his stomach. His O2 sat dropped a bit to the mid 90s so I elect to pull the tube, perhaps too early. Most of the air was likely due to excessively vigorous bag-mask ventilation between attempts.
At this point I call for help (my rule is 2 attempts before I collect additional resources). Backup arrives in the form of the CT surgery fellow as the anesthesiologist is coming in from home. We switch to a Mac 4 which yields a better view. He's also a bit put off by the very anterior airway but we put the tube in and this time we leave it in, drop an NG to decompress the stomach and eventually confirm placement by bronchoscope.
Of course after that the difficult airway cart finally arrives from the OR. A gum elastic bougie would have been great after attempt #1, or even during attempt #1.
Due to the lack of a paralytic I had a spontaneously breathing individual at all times. However due to the limited induction agent choices we also had a somewhat poorly relaxed patient. Perhaps the paralytic would have yielded a better view but in retrospect I think I preferred spontaneous respiration. Perhaps a better induction agent would also have been useful.
This example in the context of the paper makes me wonder which of the factors could have been most readily modified to achieve success on the first attempt.
http://forums.gasforums.net/showpost.php?p=4118240&postcount=6
http://forums.gasforums.net/showpost.php?p=4111352&postcount=49
There are likely many more that I just don't remember off the top of my head. My examples shouldn't be an indictment of the posters but rather serve to illustrate the issue.
I'd like to get some input from people here about RSI in the ICU by non-anesthesiologists. After all, we're headed for a nationwide shortage of intensivists and in most places, during off hours or even during the day on the weekends the anesthesiologist will be at home.
http://www.chestjournal.org/cgi/content/full/127/4/1397
RSI is the nearly simultaneous administration of a potent induction agent with a paralyzing dose of a neuromuscular blocking agent (NMBA). When applied by skilled operators for appropriately selected patients, RSI increases the success rate of intubation to 98% while reducing complications.
The National Emergency Airway Registry II,6 a data bank of 7,712 intubations, has demonstrated that RSI is the most common technique of intubation with a success rate > 98.5%. These results contrast with the 18% incidence of failed intubation in the absence of RSI reported by Li and coworkers.7 This prospective study compared complications arising from intubation utilizing paralytic agents within an RSI protocol to intubations those arising from intubations without the use of NMBAs. Esophageal intubations and airway trauma occurred with greater frequency in the group that did not receive RSI (18% vs 3%, respectively, and 28% vs 0%, respectively).
Although limited outcomes data exist for the use of these techniques in the ICU, similarities of patients and conditions with the emergency setting warrant the adoption of algorithmic approaches and RSI as the standard mode of intubation for critically ill patients. RSI requires a thorough understanding of the physiology of intubation, and of the various drugs used for induction and paralysis in addition to careful patient selection. The standardization of intubation efforts with well-conceived algorithms requires a regimented approach that is similar to that employed for cardiopulmonary resuscitation. The training of critical care physicians requires greater attention to teaching these advanced airway management skills, more collaboration between anesthesiologists and critical care physicians to promote these skills,4 and careful monitoring for adverse events and outcomes to improve patient selection for the various intubation approaches that are available.
(I'm reproducing large chunks of this article because although copyrighted they are available for free at chestjournal.org.)
I'll highlight with two personal examples. I've done somewhere between 50-100 intubations but I don't do them enough that I consider them "routine" plus based on my practice patterns I doubt I'll ever consider them routine.
Person #1: Airway backup is at home. I have all the drugs of my choosing available. Woman with advanced liver disease in the ICU who is clearly going nowhere fast. I can see her slowly spiraling and I know she's going to get intubated sometime during my shift. Now the question is, will this happen at a time of my choosing (i.e. controlled, elective intubation) or her choosing (i.e. crash intubation, probably when it's not convenient). She has a normal habitus, full neck/mouth ROM and no teeth of her own. She "looks" reasonable. I elect to use propofol and succinylcholine and get a superb grade I view and pass a tube on the first attempt.
Person #2: Airway backup is at home. I have succ, versed and morphine available only (yes there ARE hospitals like this out there). Elderly demented man who needed intubation for airway control as he was fading in and out of consciousness and lacking the ability to protect his airway. Something about him doesn't strike me as quite right. Normal habitus but unable to really assess neck or mouth movement because he's quite uncooperative when he is awake. I elect to only give versed and probably not in high enough of a dose.
First look with a Mac 3 yields a very, very anterior airway and probably an esophageal intubation. No problem as I'd been giving him 100% O2 via a NRB for at least 10 minutes while we got all of our stuff together. Tube comes out while he's still in the mid 90s and we bag him while he's still spontaneously breathing. Second attempt with a Mac 3 and cricoid pressure yields a better look at the chords and in retrospect I was probably in but it's unclear whether there's color change on the ETCO2 and due to his paradoxical abdominal movement it was hard to tell whether we were inflating his stomach. His O2 sat dropped a bit to the mid 90s so I elect to pull the tube, perhaps too early. Most of the air was likely due to excessively vigorous bag-mask ventilation between attempts.
At this point I call for help (my rule is 2 attempts before I collect additional resources). Backup arrives in the form of the CT surgery fellow as the anesthesiologist is coming in from home. We switch to a Mac 4 which yields a better view. He's also a bit put off by the very anterior airway but we put the tube in and this time we leave it in, drop an NG to decompress the stomach and eventually confirm placement by bronchoscope.
Of course after that the difficult airway cart finally arrives from the OR. A gum elastic bougie would have been great after attempt #1, or even during attempt #1.
Due to the lack of a paralytic I had a spontaneously breathing individual at all times. However due to the limited induction agent choices we also had a somewhat poorly relaxed patient. Perhaps the paralytic would have yielded a better view but in retrospect I think I preferred spontaneous respiration. Perhaps a better induction agent would also have been useful.
This example in the context of the paper makes me wonder which of the factors could have been most readily modified to achieve success on the first attempt.
