MEDICATIONS and COMPLICATIONS of INTUBATION SHIKHA GUPTA / MILEN PETKOV

Transcription

1 MEDICATIONS and COMPLICATIONS of INTUBATION SHIKHA GUPTA / MILEN PETKOV

2 Medica'ons Pretreatment agents Induc'on agents Neuromuscular blockers

3 Pretreatment agents A8enuate adverse pathophysiologic responses to laryngoscopy and intuba'on Reflex sympathe'c response o Increase in heart rate and blood pressure o Increase in intracranial pressures Laryngeal s'mula'on o Laryngospasm, cough, and bronchospasm To be effec've, pretreatment agents should be given 3-5min prior to RSI Not prac'cal at most 'mes and not rou'nely used

4 Pretreatment Lidocaine Opioid Atropine Defascicula'ng agent Dose: 1.5 mg/kg IV To prevent rise in ICP by Preven'ng cough Blun'ng pressor response May reduce reac've bronchospasm in asthma when added to albuterol Helpful in awake intuba/on

5 Pretreatment Lidocaine Opioid Atropine Defascicula'ng agent Fentanyl

6 Opioids Fentanyl µg/kg IV Onset of ac'on: 30 sec, Dura'on: mins Short- ac'ng, potent Seda'on is rate- AND dose- dependent Combined with other induc'on agents for analgesia Adverse effects o hypotension and bradycardia o muscle rigidity, can make it difficult to bag o grand mal seizures (rare)

7 Pretreatment Lidocaine Opioid Atropine Defascicula'ng agent Dose: 0.02 mg/kg To prevent bradycardia caused by airway manipula'on and succinylcholine Used in pediatrics. Not usually used in adults Can cause arrythmias May be more beneficial with repeated doses of succinylcholine (i.e. OR se^ng)

8 Pretreatment Lidocaine Opioid Atropine Defascicula'ng agent Fascicula'ons occur in >90% of pa'ents given succinylcholine Muscle pain Increase intragastric pressure à emesis Increase ICP (?) Higher doses of succinylcholine (1.5 mg/ kg vs 1 mg/kg) Non- depolarizing NMB (1/10 th of paraly'c dose)

9 Step 1: Pretreatment : blunts sympatheac drive Drug Dosage Onset Dura/on Cau/ons Fentanyl µg/kg 30 s 30-60m Hypotension, bradycardia

10 Induc'on Agents Given as rapid IV push immediately before paralyzing agent Ideally provides: Rapid loss of consciousness Analgesia Amnesia Stable hemodynamics Most commonly used Etomidate Propofol

11 Etomidate Non- barbiturate hypno'c 0.3 mg/kg Onset: sec, Dura'on: 3-5 mins Hemodynamic stability: least depression of cardiac output Decrease intracranial pressure with minimal effects on cerebral perfusion NO analgesia Adverse effects: o Myoclonic jerks, not seizure with induc'on dose o Decrease cor'sol produc'on: inhibits 11- β- hydroxylase for 4-8 hours with induc'on dose. Con'nuous infusion increase mortality o Cough and hiccups: not ideal with LMA

12 Propofol mg/kg Onset: 30 sec, Dura'on: 3 10 mins Systemic vasodila'on and profound hypotension Respiratory depression Adverse effects o Hypotension o Bradycardia o Movements with induc'on (not seizure) o Propofol infusion syndrome

13 Ketamine NMDA- antagonist and blocks glutamate à dissocia've anesthesia o Analgesic, amnes'c, catalepsy mg/kg IV Onset: 30 sec, Dura'on: 5-15 mins Sympathomime'c effects (é HR, BP, CO, ICP) o Helpful in hemodynamic unstable pa'ents o Maintains respira'on and airway reflexes o Bronchial smooth muscle relaxant helpful in obstruc've lung disease Adverse effects/contraindica'ons o Elevates intracranial pressures, contraindicated in head injuries o Coronary artery disease o Emergence delirium, hallucina'ons Premed: midazolam 0.07 mg/kg o Emesis, mostly in adolescents o Schizophrenia/schizoaffec've disorder, especially within last 3 months o Increase saliva'on: reduced if premedicated with glycopyrrolate

14 Dexmedetomidine Used for awake, fiberop'c intuba'on Adverse effects Bradycardia Hypotension

15 Benzodiazepines Midazolam mg/kg IV Onset: 3-5 mins, Dura'on: 2-6 hours Seda've, amnes'c, muscle relaxant o NOT analgesic Less cardiorespiratory depression vs. other benzos Adverse effects o Hypotension, tachycardia o Use lower dose in hypovolemic, elderly, or trauma'c brain injury pa'ents (0.05 mg/kg) Generally never used alone

16 Step 2: InducAon: causes unconsciousness Drug Dosage Onset Dura/on Cau/ons Etomidate 0.3 mg/kg s 3-5m decrease seizure threshold, low cor'sol Propofol mg/kg 30 s 3-10m Hypotension Ketamine mg/kg 30 s 5-15m CAD, HTN, hallucina'on, seizure, ICP Midazolam 0.2 mg/kg 3-5 m 2-6h Hypotension

17 Neuromuscular Blocking Agents (NMBAs) Contraindicated if difficult to ven/late or an'cipa'ng difficult airway Advantages Allow complete airway control o Higher success (100% vs 82%) o Less aspira'on and airway trauma Enable lower doses of seda've o Be8er hemodynamic stability Depolarizing Non- depolarizing

18 Depolarizing agents Succinylcholine Non- depolarizing Agents Pancuronium Vecuronium Atracurium Rocuronium Cis- atracurium Mivacurium

19 Succinylcholine Gold standard for use in RSI 1.5 mg/kg IV Onset in sec. Dura'on ~ 5 min Prolonged in pseudocholinesterase deficiency (gene'c, hepa'c/ renal failure, pregnancy, cocaine) Repeat doses prolong paralysis o May increase bradycardia/hypotension

20 Succinylcholine Adverse effects Muscle fascicula'on Hyperkalemia o Avoid in renal failure, burns, crush injuries, neuromuscular disorders, CVAs Bradycardia/hypotension Mild increase in ICP Malignant hyperthermia o Treatment: cooling, volume reple'on, and Dantrolene sodium (1-2 mg/ kg IV) Trismus

21 Non- Depolarizing NMBAs Rocuronium Dose: mg/kg Onset: 1-2 min, Dura'on: min Non- vagoly'c; no histamine release No ac've metabolites Preferred alterna/ve to succinylcholine in rapid sequence intuba/on

22 Non- Depolarizing NMBAs Cisatracurium Dose: mg/kg IV Onset: mins, Dura'on: mins More commonly causes bradycardia than other NMBAs Excreted by Hoffman excre'on o No accumula'on in renal or hepa'c failure

23 Non- Depolarizing NMBAs Pancuronium Dose: mg/kg IV Long 'me to onset (1-5 min) and dura'on (45-90 min) Vagoly'c effect: tachycardia and hypertension Histamine release à bronchospasm/anaphylaxis Ac've metabolites Accumulates in renal failure o Renal dosing required NOT recommended for rapid sequence intuba'on

24 Non- Depolarizing NMBAs Vecuronium Slower onset 1-4 min, dura'on min Non- vagoly'c; no histamine release Can cause hypotension Ac've metabolites Biliary excre'on Open requires priming dose o 0.01 mg/kg during pre- oxygena'on phase, then o 1.5 mg/kg given 3 min later for paralysis NOT recommended for rapid sequence intuba'on

25 Step 3: ParalyAcs: ensure able to bag paaents before giving, Only use if needed Drug Dosage Onset Dura/on Cau/ons Succinylcholine 1.5 mg/kg s 5-15m Malignant hyperthermia, hyperk burn, trauma, demyelina'ng dz Rocuronium mg/kg 1-2 m 45-70m Allergy to aminosteroid, consider dose reduc'on in hepa'c dz

26 COMPLICATIONS OF ENDOTRACHEAL INTUBATION

27 Complica'ons of Intuba'on Difficult intuba'on ~ 10% Airway related complica'ons 4% Risk factors: Mul'ple a8empts, 3 or more In emergency room on on general floors Difficult intuba'on: high Mallampa' score

28 Pa'ent factors Infant, children and women Small larynx and trachea Difficult airway Congenital and chronic acquired diseases Emergent intuba'on

29 Operator Related Factors Anesthesiologist CRNA ER Doc/CCM Hospitalist Resident 1. Knowledge, technical skills 2. Crisis management capabili'es 3. A HURRIED intuba'on, without adequate evalua/on of the airway or prepara/on of the pa'ent & equipment - more likely to cause damage.

30 Equipment The shape of the endotracheal tube (ETT) - maximal pressure on the posterior aspect of the larynx. Size of the tube & dura'on of intuba'on. Stylets and bougies predispose to trauma. Addi'ves to plas'c - 'ssue irrita'on. Cuff related injuries with high pressure.

31 PART 1 Complications requiring immediate recognition and management

32 Complica'ons requiring immediate recogni'on and management Failed intuba'on Hemodynamic instability/ cardiac arrest Esophageal intuba'on Bronchial intuba'on Spinal cord and vertebral column injury Noxious autonomic reflexes Hypertension, tachycardia, arrhythmias Intracranial and intraocular hypertension Bronchospasm Laryngospasm

33 Acute traumaac complica'ons lips, teeth, tongue, nose, pharynx, larynx, trachea, bronchi Tension pneumothorax Disconnec'on and dislodgement Failure to achieve sa'sfactory seal Aspira'on of gastric contents

34 ObstrucAon of the tube Bi'ng of the ETT. Kinking of the ETT. Material in the lumen of the tube. Secre/ons, blood clots, nasal turbinates, adenoids Defec've spiral embedded tubes. Impac'on of the 'p against the tracheal wall Murphy s eye Hernia'on of the cuff over the lumen of the tube

35 PART 2 Complications of lesser significance and Complications after extubation

36 Temporomandibular joint injury Nasal injury Dental injury Sop palate injury Tongue injury Pharyngeal trauma Laryngeal trauma: ulcera/ons, erosions Arytenoid injury Vocal cord: paralysis, granuloma Delayed tracheal injury: stenosis and tracheomalacia Fistula Tracheo- esophagea Tracheo- innominate

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40 Thank you

41 Meet at 1 pm at wiser center 20 mins at each sta'on Group 1: Bag mask ven'la'on Group 2: Laryngoscopes: mac and miller blades Group 3: Glidescope Group 4: Difficult airway Post test

42 Hands- on experience 1 week of OR rota'on with anesthesia 5 intuba'ons using laryngoscope 15 intuba'ons using video- laryngoscope 10 laryngeal mask airway placement o The residents will be responsible for ge^ng the procedures signed in the log book. All the intuba/ons have to be supervised by either cri/cal care or emergency medicine physicians, even aher successfully comple/ng the course. All the intuba/ons performed by residents outside of OR, have to be performed with video- laryngoscope.