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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
Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007
Oct;21(5):636-43.
Hemodynamic Effects
Painful stimulus
-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
-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
Multi-compartmental pharmacokinetic models
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
Succinylcholine’s strengths
Rapid onset
Profound depth of NMB
Short duration of action
Succinylcholine’s
weaknessesCardiovascular effects
sinus bradycardia
nodal rhythm
ventricular dysrhythm
Increase IOcP
Increase IGP
Increase ICP
• Myalgia
• Masseter spasm
• Fasciculations
• Anaphylaxis
• Abnormal plasma cholinesterase
• Hyperkalemia
Succinylcholine’s weaknesses
Contraindications
• MH
• Burn
• UMNL
• Severe muscle trauma
• Severe intraabdomen infection
• Disuse atrophy
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
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%)
ONSET OF ROCURONIUM
BROMIDE
Onset: rapid to
intermediate
(dose dependent)
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
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)
HISTAMINE RELEASING
POTENTIAL
Significant Insignificant
Tubocurarine + + + Rocuronium bromide±
Metocurine ++ Vecuronium bromide±
Atracurium besylate + Pancuronium bromide±
Mivacurium chloride + Pipecuronium bromid ±
Succinylcholine chloride + Doxacurium chloride±
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
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.
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
ROCURONIUM BROMIDE:
CARDIOVASCULAR PROFILE
• Favorable cardiovascular profile
• Histamine release unlikely
• Mild vagolytic activity
• 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:
Rapid Sequence
Intubation experience in
Emergency Department Maharaj Nakorn Chiang Mai
นพ.บวร วิทยช ำนำญกุลEmergency Medicine
Chiang Mai University Hospital
History
• Awake intubation
• Diazepam ???
• Midazolam
• Establish Training EM in 2548
• Workshop RSI in January 2551
• RSI in ER October 2551
• Etomidate + Succinylcholine
• Etomidate + Rocuronium
• Propofol
28
20
3
12
14
0
5
10
15
20
25
30
1 attempt 2 attempt 3 attempt
RSI 32 non RSI 36
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
Now
• More than 150 experience of RSI
• Staff attending 24 hr
• ER staff in morning shift and some noon –
night shift
Quality Control
• Resident 2 : training, coaching, direct
observe
• Difficult airway cart
• No serious adverse event
Troubleshoot
• Hypotension after procedure
• > 1 attempt
– Non experience
– Position
Prepare : sniff position
Prepare : sniff position
Troubleshoot
• Hypotension after procedure
• > 1 attempt
– Non experience
– Position
– Not wait til onset of drugs
• Myoclonus 1 time
• Drug preparation time
The End
Thank you
for your
attention