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

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

3. Acknowledgements
Dr Scott Weingart lecture “Preoxygenation and reoxygenation”,
Dr Richard Levitan ‘s Emergency Airway handbook
Dr Richard Levitan’s article “No Desat”

4. 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

5. His ECG

6. 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?

7. Who is an occasional intubator?

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

9. The occasional intubator

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

11. Why?

12. 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

13. 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

14. Rapid Sequence Induction and Intubation: Current Controversy Mohammad El-Orbany, MD and Lois A. Connolly, MD Anesthesia & Analgesia,2010, 110(5):
“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.”

16. RSI protocol

17. 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

18. 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

19. Recommended bed time reading

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

23. What’s wrong with this image?

24. And this one?

25. Don’t be a gambler

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

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

28. 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

29. 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

30. Nasal cannula oxygenation during laryngoscopy

31. 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 ± 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 ±9.3%). Resaturation times were no different between the groups.

32. 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

33. Thiopental-rocuronium versus ketamine-rocuronium for rapid-sequence intubation in parturients undergoing cesarean section Baraka et al, Anesthesia &Analgesia, 1997,84(5):
“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. “

34. “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”

35. 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)

36. 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):
“The incidence of excellent intubating conditions was significantly more frequent (P ) 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

37. 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

38. 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

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

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

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

42. 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):
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.

43. 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

45. 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

46. 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

47. 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...

51. 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

52. His ECG

53. 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?

54. 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?

55. 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