A review of the Literature

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Presentation transcript:

A review of the Literature Airway Notes A review of the Literature Weingart, Levitan Annals of EM Mar 2012 Weingart et al Annals of EM Apr 2015 April 11, 2018

Goals of Preoxygenation SpO2 of 100% Denitrogenate lungs and blood Delay desaturation as long as possible Note: Does nothing for hypercapnea though April 11, 2018

Preoxygenation Steep portion of deoxygenation curve happens at SpO2 of 88 – 90% Desaturation occurs at 45 – 60 secs, for pt on RA after RSI. Standard “non breather” at 15 L/min only gives FiO2 60 – 70% With BVM get best seal with 2 hands April 11, 2018

Preoxygenation Maximal tidal volume (8 full inhale/exhale) or 3 mins with normally breathing cooperative pt NIPPV can delay deoxygenation in critical patients who are shunting. April 11, 2018

Preoxygenation Consider PEEP valve on BVM or CPAP/BiPAP if SpO2<93-95% during preoxygenation Elevate HOB 25 -30˚ or reverse trendelenburg and look at “ear to sternal notch” alignment April 11, 2018

Preoxygenation Critically ill/injured pt’s will desaturate more quickly – due to R to L shunting Shunt = oxygen poor blood returning from lung to heart NODESAT=Nasal Oxygen During Efforts at Securing a Tube Apneic Oxygenation 15L/min – adult 10L/min – child 5L/min – infant April 11, 2018

Preoxygenation Positive press ventilation: if SpO2<91-95% with preoxygenation Caution: use low volume, low rate &PEEP valve recommended Benefits/Risks: full stomach - ? Vomit or aspirate April 11, 2018

Choice of Paralytic Rocuronium associated with delayed time to desaturation vs. Succinylcholine Hypothesis – increased oxygen usage due to fasciculation April 11, 2018

Bottom Line Preoxygenation is key to prevent hypoxic complications during RSI Consider techniques and recommendations discussed April 11, 2018

Delayed Sequence Intubation DSI Prospective study of pt’s who had altered mental status and/or could not be preoxygenated Poor O2 reserves leads to faster desaturation Need to preoxygenate with respiratory effort preserved April 11, 2018

Delayed Sequence Intubation DSI Ketamine – 1mg/kg followed by 0.5mg/kg if needed (Give Ketamine over 30 to 45 secs) Preoxygenate with HOB at 30˚ NRB mask or CPAP if needed Then high flow nasal cannula for apneic oxygenation April 11, 2018

Delayed Sequence Intubation DSI Multiple conditions for intubation Pt’s with SpO2<93% were able to increase their SpO2 to >93% with DSI All but one required NIPPV April 11, 2018

Delayed Sequence Intubation DSI Possible complications Apnea pre paralysis Vomiting Cardiac arrest/death None of these occurred in this study April 11, 2018

Delayed Sequence Intubation DSI Discussion Authors feel safe to use Ketamine and NIPPV to aid in preoxygenation, as it is a bridge/temporary to intubation No other sedatives considered due to apnea concerns April 11, 2018

Delayed Sequence Intubation DSI Conclusion DSI seems safe and effective as long as provider/team are experienced in sedation and airway. April 11, 2018