MEDICATIONS and COMPLICATIONS of INTUBATION management - Induction agents and...Pretreatmentagents+! A8enuate+adverse+pathophysiologic+responses+to+ laryngoscopy+and+intubaon+! Reﬂex+sympathe’c+response+

SHIKHA GUPTA / MILEN PETKOV

MEDICATIONS and COMPLICATIONS of

INTUBATION

Medica'ons

�  Pretreatment agents �  Induc'on agents �  Neuromuscular blockers

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

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


�  Fentanyl

Pretreatment

Opioids

�  Fentanyl §  0.2-‐0.3 µg/kg IV §  Onset of ac'on: 30 sec, Dura'on: 30-‐60 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)


�  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)

Pretreatment


�  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 (1/10th of paraly'c dose)

Pretreatment

Step 1: Pretreatment : blunts sympatheAc drive Drug Dosage Onset Dura/on Cau/ons Fentanyl 0.2-‐0.3 µg/kg 30 s 30-‐60m Hypotension,

bradycardia

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

Etomidate

§  Non-‐barbiturate hypno'c §  0.3 mg/kg §  Onset: 30 – 60 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

Propofol

§  0.5 – 2 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

Ketamine

§  NMDA-‐antagonist and blocks glutamate à dissocia've anesthesia o  Analgesic, amnes'c, catalepsy

§  1.5 -‐ 2 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

Dexmedetomidine

�  Used for awake, fiberop'c intuba'on

�  Adverse effects §  Bradycardia §  Hypotension

Benzodiazepines

�  Midazolam §  0.1 – 0.4 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

Step 2: InducAon: causes unconsciousness Drug Dosage Onset Dura/on Cau/ons Etomidate 0.3 mg/kg 30-‐60 s 3-‐5m decrease seizure

threshold, low cor'sol

Propofol 0.5-‐2 mg/kg 30 s 3-‐10m Hypotension Ketamine 1.5-‐2 mg/kg 30 s 5-‐15m CAD, HTN,

hallucina'on, seizure, ICP

Midazolam 0.2 mg/kg 3-‐5 m 2-‐6h Hypotension

�  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

Neuromuscular Blocking Agents (NMBAs)

�  Depolarizing agents §  Succinylcholine

�  Non-‐depolarizing Agents §  Pancuronium §  Vecuronium §  Atracurium §  Rocuronium §  Cis-‐atracurium §  Mivacurium

Succinylcholine

�  Gold standard for use in RSI �  1.5 mg/kg IV �  Onset in 30 -‐ 60 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

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

Non-‐Depolarizing NMBAs

�  Rocuronium §  Dose: 0.6 -‐ 1.2 mg/kg §  Onset: 1-‐2 min, Dura'on: 45-‐70 min §  Non-‐vagoly'c; no histamine release §  No ac've metabolites §  Preferred alterna/ve to succinylcholine in rapid sequence intuba/on


�  Cisatracurium §  Dose: 0.15 – 0.2 mg/kg IV §  Onset: 1.5 – 2 mins, Dura'on: 55-‐60 mins §  More commonly causes bradycardia than other NMBAs §  Excreted by Hoffman excre'on

o  No accumula'on in renal or hepa'c failure


�  Pancuronium §  Dose: 0.10-‐0.15 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


�  Vecuronium §  Slower onset 1-‐4 min, dura'on 30-‐60 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

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 30-‐60 s 5-‐15m Malignant hyperthermia,

hyperK burn, trauma, demyelina'ng dz

Rocuronium 0.6-‐1 mg/kg 1-‐2 m 45-‐70m Allergy to aminosteroid, consider dose reduc'on in hepa'c dz

COMPLICATIONS OF ENDOTRACHEAL

INTUBATION

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

Pa'ent factors

�  Infant, children and women §  Small larynx and trachea

�  Difficult airway �  Congenital and chronic acquired diseases �  Emergent intuba'on

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.

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.

PART 1

Complications requiring immediate

recognition and management

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

�  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

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

PART 2

Complications of lesser significance and Complications after extubation

�  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

Thank you

� 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

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.

Documents

MEDICATIONS and COMPLICATIONS of INTUBATION management - Induction agents and...Pretreatmentagents+! A8enuate+adverse+pathophysiologic+responses+to+ laryngoscopy+and+intubaon+! Reﬂex+sympathe’c+response+