The occasional intubator By Dr Minh Le Cong RFDS Cairns, April 2011

Objectives Definition Key Challenges RSI = really stupid idea and why you should avoid it Helpful strategies Illustrative cases

Acknowledgements Dr Scott Weingart lecture “Preoxygenation and reoxygenation”, www.emcrit.blog Dr Richard Levitan ‘s Emergency Airway handbook Dr Richard Levitan’s article “No Desat” www.epmonthly.com

Case 1 55yo man Chest pain for 16hrs Dyspnoeic Coughing pink frothy sputum O/E: GCS 12, BP 70/50, HR 110, SaO2 88% on 15l/Min, creps to apices bilaterally

His ECG

He rips off oxygen mask,agitated He does not tolerate CPAP mask What do you do next? Do you do classic RSI? How would you modify RSI in this case?

Who is an occasional intubator?

Definitions in the literature <57 intubations = “novice” <10 months of regular anaesthesia using laryngoscope <1 intubation per month

The occasional intubator

This is probably one of the highest risk procedures we do to a patient

Why?

RSI or Rapid Sequence Intubation At least 7 steps to make critical mistakes along the way..... Pre-oxygenation Short acting induction agent Short acting neuromuscular blocking agent Cricoid pressure Apnoeic period Tube placement Tube position confirmation

RSI or Really Stupid Idea Forgetting the basics : positioning, equipment checks, role allocations, failed airway drill Focussing on getting a perfect view Obsession with passing the tube Failure to confirm position early and reliably Failure to oxygenate Failure to give up early and proceed to alternative techniques

Rapid Sequence Induction and Intubation: Current Controversy Mohammad El-Orbany, MD and Lois A. Connolly, MD Anesthesia & Analgesia,2010, 110(5):1318-1325 “The changing opinion regarding some of the traditional components of rapid sequence induction and intubation (RSII) creates wide practice variations that impede attempts to establish a standard RSII protocol.”

RSI protocol

In this Australian study, paramedics Gave RSI drugs to patients with unrecordable BPs to facilitate intubation in 6 cases ALL suffered cardiac arrest during transport BUT survival was no different

Lesson learnt Cookbook recipe RSI in the prehospital setting is hazardous to your patient’s health Do not adhere to protocol rigidly Beware the hypotensive patient and RSI

Recommended bed time reading

The occasional intubator should not do classic RSI with a laryngoscope!

What’s wrong with this image?

And this one?

Don’t be a gambler

What do we really want for patient safety during intubation? Maintain oxygenation Minimise airway trauma Prevent aspiration Minimise awareness and pain

But classic RSI preoxygenation achieves the first goal of safety But classic RSI preoxygenation achieves the first goal of safety...?? Oh really..

So how do you optimise preoxygenation? If possible sit up Nasal cannula + NRBM Consider CPAP or BiPAP ( DSI =delayed sequence intubation) Judicious sedation with ketamine in the agitated hypoxic patient LMA Supreme strategy

How do you maintain oxygenation in the critically ill or high risk airway patient? Jaw thrust Apnoeic oxygenation with NRBM Nasal cannula at 5L/min during laryngoscopy Frova bougie technique gentle BVM during apnoeic period BVM MUST BE DONE WITH TWO PERSON TECHNIQUE. DON’T TRY TO PLAY THE HERO

Nasal cannula oxygenation during laryngoscopy

Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. Ramachandran et al. Journal of Clinical Anesthesia (2010) 22, 164–168 Main Results: Nasal O2 administration was associated with significant prolongation of SpO2 ≥95% time (5.29 ± 1.02 vs. 3.49 ± 1.33 min, mean ± SD), a significant increase in patients with SpO2 ≥95% apnea at 6 minutes (8 vs. one pt), and significantly higher minimum SpO2 (94.3 ± 4.4% vs. 87.7 ±9.3%). Resaturation times were no different between the groups.

Induction agents Classically something rapid onset and short acting = Thiopentone (AUS), Etomidate (rest of the world) I would argue ketamine in most situations is better I would suggest titration till loss of response/reflex rather than crash bolus method Koerber et al survey = 10% anaesthetists used crash bolus method Makes more sense and no evidence to prove any way is superior to another

Thiopental-rocuronium versus ketamine-rocuronium for rapid-sequence intubation in parturients undergoing cesarean section Baraka et al, Anesthesia &Analgesia, 1997,84(5):1104-1107 “Tracheal intubation at 50% NMB was easily performed in all patients in the ketamine-rocuronium group but was difficult in 75% of the thiopental-rocuronium group. We concluded that ketamine 1.5 mg/kg followed by rocuronium 0.6 mg/kg may be suitable for rapid-sequence induction of anesthesia in parturients undergoing cesarean section. “

“We have demonstrated that non-physicians may administer ketamine safely and effectively to facilitate endotracheal intubation. We believe that ketamine is a suitable choice for the intubation of critically ill patients in the HEMS and potentially other EMS settings”

Suxamethonium THE RSI agent Give a decent dose at least 1.5mg/kg..I would suggest 2mg/kg for occasional intubators Evidence indicates shorter onset and better intubating conditions more likely Caveat = longer time to recovery (7.7 min for 2mg/kg dose)

Conclusions of authors = 1.5mg/kg dose is just right The Dose of Succinylcholine Required for Excellent Endotracheal Intubating Conditions Naguib et al, Anesthesia & Analgesia, 2006,102(1):151-155. “The incidence of excellent intubating conditions was significantly more frequent (P 0.001) in patients receiving succinylcholine than in the controls and in patients who received 2.0 mg/kg succinylcholine (P 0.05) than in those who received 0.3 mg/kg succinylcholine” Conclusions of authors = 1.5mg/kg dose is just right

ACADEMIC EMERGENCY MEDICINE 2011; 18:11–14 Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department Asad E. Patanwala, PharmD, Sara A. Stahle, PharmD, John C. Sakles, MD, and Brian L. Erstad, PharmD Abstract Conclusions: Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study. ACADEMIC EMERGENCY MEDICINE 2011; 18:11–14

For the occasional intubator Sux is still king! Who hasn’t been spared a coroner’s inquest due to Sux wearing off during a difficult intubation? But Sux’s days are numbered Evidence for more rapid reversal with sugammadex/rocuronium

Avoid cricoid pressure if airway looks difficult Avoid cricoid pressure if airway looks difficult..perhaps even if it doesn’t

When to use cricoid pressure High risk aspiration ( consider NGT drainage) Pregnancy Bowel obstruction/ileus Substance abuse Upper GIT bleeding

Cricoid pressure in emergency rapid sequence induction, Butler, Best BETS EMJ 2005

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation. Ellis et al, Resuscitation,2010,81(7):810-816 Results 402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations.

Consider using an Intubating LMA first if airway looks tricky Allows oxygenation and intubation to be done by one device Low skill required to maintain competency Almost 100% successful ventilation by novices >85% successful intubation Evidence indicates least c spine movement with quickest time to intubation Caveat = risk of losing laryngoscopy skills

Bougie tips Practice before trying Suggest using this first line for C Spine immobilisation intubations ( FDEAR data) Leave laryngoscope in once bougie inserted trachea Oxygenation tips with bougie

Bougie in but can’t pass tube..Sats dropping!! Don’t take it out! Rotate bougie laterally to corner of mouth BVM to reoxygenate whilst bougie in situ Frova bougie = use adapter to attach BVM and deliver oxygen directly into trachea

Tube placement and confirmation FDEAR results = almost 20% intubations not confirmed with ETCO2 waveform UNACCEPTABLE IF YOU HAVE THE EQUIPMENT AND IT IS FUNCTIONING This is what happens when you don’t use it routinely...

Case 1 55yo man Chest pain for 16hrs Dyspnoeic Coughing pink frothy sputum O/E: GCS 12, BP 70/50, HR 110, SaO2 88% on 15l/Min, creps to apices bilaterally

His ECG

He rips off oxygen mask,agitated He does not tolerate CPAP mask What do you do next? Do you do classic RSI? How would you modify RSI in this case?

Case 2 24yo man, fall from 12 m into river Obvious C spine injury with quadriplegia Respiratory failure with episodic apnoea O/E GCS 10, BP 60/40, HR 70, SaO2 90% on 15L/min, RR 12 weak Is classic RSI appropriate? How would you modify RSI in this case?

Take home messages Occasional intubators should not stick to cookbook RSI recipes Maximise and maintain oxygenation = patient safety Drugs are least important thing in RSI apart from the most important drug OXYGEN