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ผศ.นพ.สุรพงษ์ หล่อสมฤดี TIVA Center Division of Cardiothoracic and Vascular Anesthesia Division of Transplantation Anesthesia Chiang Mai University Hospital Why do we need NMBAs for RSI

Why do we need NMBAs for RSI?

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Page 1: Why do we need NMBAs for RSI?

ผศ.นพ.สุรพงษ์ หล่อสมฤดีTIVA Center

Division of Cardiothoracic and Vascular Anesthesia

Division of Transplantation Anesthesia

Chiang Mai University Hospital

Why do we need NMBAs

for RSI

Page 2: Why do we need NMBAs for RSI?

Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007

Oct;21(5):636-43.

Hemodynamic Effects

Painful stimulus

Page 3: Why do we need NMBAs for RSI?
Page 4: Why do we need NMBAs for RSI?

-50

-40

-30

-20

-10

0

10

20

Hea

rt r

ate

(%

fro

m b

ase

lin

e)

TIVA VIMA

Baseline BeforeIntubation

AfterIntubation

BeforeIncision

AfterIncision

BeforeExtubation

AfterExtubation

* *+

+

+ + +

+

+

Heart Rate

Page 5: Why do we need NMBAs for RSI?

-50

-40

-30

-20

-10

0

10

20

MA

P (

% f

ro

m b

aseli

ne)

TIVA VIMA

Baseline BeforeIntubation

AfterIntubation

BeforeIncision

AfterIncision

BeforeExtubation

AfterExtubation

+

+ +

+

+ +

+

+

+

*

Blood Pressure

Page 6: Why do we need NMBAs for RSI?
Page 7: Why do we need NMBAs for RSI?

Multi-compartmental pharmacokinetic models

Page 8: Why do we need NMBAs for RSI?

Overview NMBAs

Succinylcholine

• Introduced in 1952

• Only depolarizing NMBA

• NMBA with the fastest onset and ultra-short duration

• Used for routine intubation in the USA (not for children)

• But in Europe mainly Rapid Sequence Induction

• Elimination by pseudocholinesterase

Page 9: Why do we need NMBAs for RSI?

Succinylcholine’s strengths

Rapid onset

Profound depth of NMB

Short duration of action

Page 10: Why do we need NMBAs for RSI?

Succinylcholine’s

weaknessesCardiovascular effects

sinus bradycardia

nodal rhythm

ventricular dysrhythm

Increase IOcP

Increase IGP

Increase ICP

Page 11: Why do we need NMBAs for RSI?

• Myalgia

• Masseter spasm

• Fasciculations

• Anaphylaxis

• Abnormal plasma cholinesterase

• Hyperkalemia

Succinylcholine’s weaknesses

Page 12: Why do we need NMBAs for RSI?

Contraindications

• MH

• Burn

• UMNL

• Severe muscle trauma

• Severe intraabdomen infection

• Disuse atrophy

Page 13: Why do we need NMBAs for RSI?

ROCURONIUM BROMIDE RAPID

SEQUENCE INTUBATION

n = 230 (six clinical trials)

Premedication: midazolam or temazepam

Induction: thiopental (3-6 mg/kg) fentanyl (2-5

mcg/kg)

or + or

propofol (1.5 - 2.5 mg/kg) alfentanil (1

mg)

Rocuronium bromide dose: 0.6 mg/kg

Succinylcholine chloride dose: 1-1.5 mg/kg

Page 14: Why do we need NMBAs for RSI?

RAPID SEQUENCE

INTUBATION

Rapid sequence intubation: excellent-to-good conditions achieved within 60 - 90 seconds of administration in most patients

Dose Percentage of patients with excellent-to-good conditions

Rocuronium bromide (n=120) 0.6 mg/kg 99% (95% confidence

interval 95%-99.9%)

Succinylcholine chloride (n=110) 1.0-1.5 mg/kg 98% (95% confidence interval 95%-99.8%)

Page 15: Why do we need NMBAs for RSI?

ONSET OF ROCURONIUM

BROMIDE

Onset: rapid to

intermediate

(dose dependent)

Page 16: Why do we need NMBAs for RSI?

TRACHEAL INTUBATION

Pre-Medication Meperidine 1 mg/kg

Atropine 0.01mg/kg

Induction Propofol to 2.5mg/kg

Alfentanil to 0.25 mg/kg

Rocuronium bromide 0.6 mg/kg OR

Succinylcholine chloride 1 mg/kg

Intubation 60 sec. later

Page 17: Why do we need NMBAs for RSI?

ROCURONIUM BROMIDE:

TRACHEAL INTUBATION

• Median time to 80% block with

0.6 mg/kg is 60 seconds (0.4-

6.0 minutes)

• Median onset time with 0.6

mg/kg is 1.8 minutes (0.6-13

minutes)

Page 18: Why do we need NMBAs for RSI?

HISTAMINE RELEASING

POTENTIAL

Significant Insignificant

Tubocurarine + + + Rocuronium bromide±

Metocurine ++ Vecuronium bromide±

Atracurium besylate + Pancuronium bromide±

Mivacurium chloride + Pipecuronium bromid ±

Succinylcholine chloride + Doxacurium chloride±

Page 19: Why do we need NMBAs for RSI?

Effects of Rocuronium on Heart Rate

Time (minutes)

100

90

80

70

60

50

40

0.0 1.0 2.0 3.0 4.0 5.0 6.0

Heart

Rate

(beats

/min

)

Levy et al. Anesth Analg 1994;78,318-321.

600 mcg/kg

900 mcg/kg

1200 mcg/kg

Page 20: Why do we need NMBAs for RSI?

Effects of Rocuronium on Mean Arterial Pressure

Time (minutes)

100

90

80

70

60

50

0.0 1.0 2.0 3.0 4.0 5.0 6.0

Mean A

rterial P

ressure

(m

mH

g) 600 mcg/kg

900 mcg/kg

1200 mcg/kg

Levy et al. Anesth Analg 1994;78,318-321.

Page 21: Why do we need NMBAs for RSI?

Effects of Rocuronium on Histamine Release

Time (minutes)

0.0 1.0 2.0 3.0 4.0 5.0

Pla

sm

a H

ista

min

e (

ng/m

l)

Levy et al. Anesth Analg 1994;78,318-321.

600 mcg/kg

900 mcg/kg

1200 mcg/kg

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Page 22: Why do we need NMBAs for RSI?

ROCURONIUM BROMIDE:

CARDIOVASCULAR PROFILE

• Favorable cardiovascular profile

• Histamine release unlikely

• Mild vagolytic activity

Page 23: Why do we need NMBAs for RSI?

• Cardiovascular stability

• Nondepolarizing vs depolarizing

• Organ-independent elimination

• Clinically significant active or toxic metabolites

• Predictability of duration

• Cumulative effects

• Reversibility

• Time to onset

• Stability of solution

• Cost

Rationale for Selection of NMBs:

Page 24: Why do we need NMBAs for RSI?

Rapid Sequence

Intubation experience in

Emergency Department Maharaj Nakorn Chiang Mai

นพ.บวร วิทยช ำนำญกุลEmergency Medicine

Chiang Mai University Hospital

Page 25: Why do we need NMBAs for RSI?

History

• Awake intubation

• Diazepam ???

• Midazolam

Page 26: Why do we need NMBAs for RSI?

• Establish Training EM in 2548

• Workshop RSI in January 2551

• RSI in ER October 2551

• Etomidate + Succinylcholine

• Etomidate + Rocuronium

• Propofol

Page 27: Why do we need NMBAs for RSI?

28

20

3

12

14

0

5

10

15

20

25

30

1 attempt 2 attempt 3 attempt

RSI 32 non RSI 36

Page 28: Why do we need NMBAs for RSI?

2

3

2

4

1

2 2

6

0

4

0

2

0

1

2

3

4

5

6

Hypotension Desaturation Vomit prolonged

intubation

Oral trauma Esophageal

intubation

RSI non RSI

Page 29: Why do we need NMBAs for RSI?

Now

• More than 150 experience of RSI

• Staff attending 24 hr

• ER staff in morning shift and some noon –

night shift

Page 30: Why do we need NMBAs for RSI?

Quality Control

• Resident 2 : training, coaching, direct

observe

• Difficult airway cart

• No serious adverse event

Page 31: Why do we need NMBAs for RSI?

Troubleshoot

• Hypotension after procedure

• > 1 attempt

– Non experience

– Position

Page 32: Why do we need NMBAs for RSI?

Prepare : sniff position

Page 33: Why do we need NMBAs for RSI?

Prepare : sniff position

Page 34: Why do we need NMBAs for RSI?

Troubleshoot

• Hypotension after procedure

• > 1 attempt

– Non experience

– Position

– Not wait til onset of drugs

• Myoclonus 1 time

• Drug preparation time

Page 35: Why do we need NMBAs for RSI?
Page 36: Why do we need NMBAs for RSI?

The End

Thank you

for your

attention