Delayed sequence intubation

Delayed sequence intubation

1. Delayed S equence Intubation Rosie Stroud

2. A bit of a discussion… You see a 50 year old male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick ! Sats are 70 % on nasal cannula; when you try to place the patient on a non- rebreather mask he just swats your hand away and rips off the mask. What are you going to do……..? RSI??

3. RSI is a bad idea Your first impulse may be to perform RSI, maybe with some bagging during the paralysis period. This is essentially a gamble. If you have first pass success, you (and your patient) may just luck out, allowing you to get the tube in and start ventilation before critical desaturation and the resultant hemodynamic instability. However , the odds are against you : bagging during RSI predisposes to aspiration conventional BVM without a PEEP valve is unlikely to raise the saturation I f there is any difficulty in first-pass tube placement your patient will be in a very bad place.

4. RSI vs. Delayed Sequence Intubation Standard RSI = simultaneous administration of a sedative and a paralytic agent + no ventilations until after endotracheal intubation This sequence can be broken to allow for adequate pre-oxygenation without risking gastric distention or aspiration

5. RSI vs. Delayed Sequence Intubation Delayed sequence intubation = specific sedative agents, which do not blunt spontaneous ventilations or airway reflexes + a period of pre-oxygenation before the a paralytic agent It’s a bit like a procedural sedation, the procedure in this case being effective pre-oxygenation. After the completion of this procedure, the patient can be paralyzed and intubated. Just like in a procedural sedation, we want our patients to be calm, but still spontaneously breathing and protecting their airway.

6. What is the evidence for pre-oxygenation? The lungs absorb approx 250ml 02 / minute In room air we have 450ml 02 in our lungs: a 1-1.5L total body resevoir With good pre-oxygenation we get 3000ml 02 in the lungs; a total of 3.5-4L total reservoir This means more time until destauration

7. Weingart study - 2014 D oes the use of ‘delayed sequence intubation’ improve pre-intubation oxygen saturations ? Prospective observational case series, non - randomised and non -blinded 3 hospitals in USA/ Denmark, Level 1 trauma centre or quarternary referral centre , Study period: May 2011 to December 2013 Outcomes Difference in SpO2 after pre-oxygenation with: a) standard attempts b) ketamine (just prior to administration of muscle relaxation) significant increase post ketamine 88.9% vs 98.8% (increase of 8.9%, 95% C.I. 6.4-10.9) Secondary outcomes: Subgroup analysis SpO2 after pre-oxygenation with ketamine in patients with initial SpO2 ≤93% after pre-oxygenation with standard attempts  all increased SpO2 to >93%

8. Nasal prongs 2L/min = 24% 4L/min = 27% 15L/min = 44% Put on at the beginning Consider use during pre-oxygenation (4-15L) Give 15l/min when drugs have been given

9. Normal lungs, ventilating OK, airway OK Correct position Nasal prongs on at 4-15L/min NRBM at 15L/min 3 minutes of pre oxygenation On induction increase nasal prongs to 15L /min

10. Normal lungs, ventilating OK, reduced GCS - obstructing Correct position Nasopharyngeal / oropharyngeal Chin lift/jaw thrust Nasal prongs at 15L/min NRBM at 15L/min 3 minutes

11. Abnormal lungs, hypoxia, airway OK Need to use CPAP/PEEP Trying to recruit alveoli Shunt situation Therefore need maximal positive pressure Use CPAP at 5-15 cm H2O with nasal prongs in place 3 minutes, induce and increase NP to 15L/min Leave CPAP in place until ready to intubate

12. CONTRA-INDICATIONS? Cardiac and respiratory arrest Spinal trauma Severe facial trauma Severe head injury

13. You see a 50 year old male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick! Sats are 70% on nasal cannula; when you try to place the patient on a non- rebreather mask he just swats your hand away and rips off the mask. What are you going to do……..?