Cristagali

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Question for the experts....I'm a future FM doc. In the FM Handbook on RSI, it list etomidate as the drug of protocol. But what about propofol? And is there a big difference in "procedure sedation" vs. RSI? Can you substitute propofol for versed? Just curious. Don't worry, I'll follow whatever protocol the hospital sets down. Just curious. :)
 

jwk

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Cristagali said:
Question for the experts....I'm a future FM doc. In the FM Handbook on RSI, it list etomidate as the drug of protocol. But what about propofol? And is there a big difference in "procedure sedation" vs. RSI? Can you substitute propofol for versed? Just curious. Don't worry, I'll follow whatever protocol the hospital sets down. Just curious. :)
You're not going to get the drops in BP with etomidate that you will get with propofol. Procedure sedation and RSI are two entirely different things. An RSI implies a general anesthetic - it goes beyond simple sedation. When the patient loses their protective airway reflexes, it's no longer sedation.
 

Platysma

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Cristagali said:
Question for the experts....I'm a future FM doc. In the FM Handbook on RSI, it list etomidate as the drug of protocol. But what about propofol? And is there a big difference in "procedure sedation" vs. RSI? Can you substitute propofol for versed? Just curious. Don't worry, I'll follow whatever protocol the hospital sets down. Just curious. :)
The term Rapid Sequence Induction is a little misleading, it isn't necessarily tied to speed or the immediate need for intubation. Rather, it's based on the assumption that you have a full stomach. Normally, in a regular intubation, you knock them out with some propofol, you bag-ventilate for a bit, push a non-depolarizing paralyzer like Vecuronium, then you intubate.

Now, if you have a full stomach, you don't want to bag ventilate very aggresively because you don't want to push air into the stomach and increase the chance of aspiration. You let them breathe 100% O2 for a few minutes prior to the intubation. However, because you are not bag ventilating the patient beforehand, you don't know that when the time comes you can do it. Some patients are just impossible to ventilate by mask, and if a patient is paralyzed and you can't intubate them and you can't ventilate them by mask, you are screwed.

That's why Succinylcholine is used-- it has the fastest on and off time, so hopefully if you find you can't ventilate the patient with the Sux, then at least the paralysis will wear off by itself before the patient starts to drop their O2 saturations. A non-depolarizing relaxant is a big risk-- even though it can be reversed, typically the relaxant has to start coming off by itself a little before you can reverse it. So, if you give a non-depolarizing relaxant, you can't just get out of trouble by reversing it. Finally, because of the risk of aspiration, you place cricoid pressure during the whole procedure.

Etomidate is recommended because of its lack of effects hemodynamically, but you could get away with Propofol, as long as the patient doesn't have anything that would lead them to tolerate the hypotension poorly. Likewise, even during a code, if you know the stomach is empty, then you don't need to do a true RSI--- no need for Cricoid pressure, no need for Sux provided you can bag your patient well.

Hope this helps,

Platysma
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PGY-1: Transitional Internship, Inova Fairfax Hospital
PGY-2: Columbia Anesthesiology

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