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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
� Lidocaine � Opioid � Atropine � Defascicula'ng agent
� 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)
� 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)
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 (1/10th 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
Non-‐Depolarizing NMBAs
� 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
Non-‐Depolarizing NMBAs
� 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
Non-‐Depolarizing NMBAs
� 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.