ผศ.นพ.สรุพงษ์ 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

Lorsomradee, et al: Anaesthesia. 2007

Oct;62(10):979-83.

Vasoconstrictor

Phenylephrine

Reversible myocardial ischemia

Stunning

A transient period of

depressed myocardial function

that follows a period of ischemia,

not sufficient to result in cell death

Cardioprotection: Myocardial oxygen balance

O2 supply

O2 demand<

ischemia

supply demand

Heart rate

contractility

afterload

CBF: normal region

CBF: ischemic region

subendocardium

Rapid Sequence Intubation (RSI)

• The induction of a state

of unconsciousness with

complete neuromuscular

paralysis to achieve

intubation without

interposed mechanical

ventilation in efforts to

facilitate the procedure

and minimize risks of

gastric aspiration

Chiang Mai Medical Journal 2008;48(3suppl)

Rapid Sequence

Intubation experience in

Emergency DepartmentMaharaj 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

Rapid Sequence Intubation

“6 P’s”

• Preparation: T-10”

–Positioning

• Preoxygenation: T-5”

• Premedication: T-3”

• Paralysis:T-0

• Placement of tube: T+45

• Post management: T+2”

Preparation

• Evaluate

– LEMON

• Equipment Check

• Positioning

• Drug Selection

• IV’s, monitor, oximetry

• Ancillary Staff

• Anticipate alternative airway maneuver

• LEMON

–L-look

–E-evaluate the 3-3-2 rule

–M-Mallampati

–O-Obstruction

–N-Neck mobility

Preoxygenation

• 100% O2 for 5 minutes of 5 vital

capacity breaths can theoretically

permit 3-5 minutes of apnea

before desaturation to less than

90% occurs

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

Tip & Trick in RSI

Airway Assessment

Emergency Airway

Muscle Relaxation

Succinylcholine

Rapid onset

Profound depth of NMB

Short duration of action

Succinylcholine’s weaknesses

Cardiovascular effects

sinus bradycardia

nodal rhythm

ventricular dysrhythm

Increase IOcP

Increase IGP

Increase ICP

Succinylcholine’s weaknesses• Myalgia

• Masseter spasm

• Fasciculations

• Anaphylaxis

• Abnormal plasma cholinesterase

• Hyperkalemia

Overview NMBAs

Arguments against Succinycholine

• Used just out of convenience

• Many contraindications in particular in certain

patient populations

• FDA Warning box for pediatrics

• Perceived advantage of fast spontaneous

breathing in “can’t intubate, can’t ventillate” is

not as fast in reality

• Severity of its side effects may increase costs of

prolonged hospital stay and treatment

Contraindications• MH

• Burn

• UMNL

• Severe muscle trauma

• Disuse atrophy

Is Suxamethonium Really Safe ?

Morbidity

Fasciculation

C-spine

Comparative Intubating Doses and Time to Intubation of NDMRs

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

He

art

Ra

te (

be

ats

/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

Me

an

Art

eria

l P

ressu

re (

mm

Hg

) 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

/ml)

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:

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)

LOW DOSE

PHARMACODYNAMICS:

CLINICAL PARAMETERS

Rocuronium br Dose: 0.45 mg/kg (n = 14)

Mean maximum blockade 96 ± 5%

Mean time to 80% blockade 117 ± 24

seconds

Mean time to maximum blockade 214 ± 25

seconds

Mean time to completion of intubation 159 ± 25

seconds

ROCURONIUM BROMIDE:

TRACHEAL INTUBATION

• Median time to 80% blockade with 0.9 mg/kg is 66 seconds (0.3-3.8 minutes)

• Median onset time with 0.9 mg/kg is 84 seconds (0.8-6.2 minutes)

• Median time to 80% blockade with 1.2 mg/kg is 42 seconds (0.4-1.7 minutes)

• Median onset time with 1.2 mg/kg is 60 seconds (0.6-4.7 minutes)

Rocuronium versus succinylcholine

for rapid sequence induction intubation (Review)

Succinylcholine created superior intubation

conditions to rocuronium when comparing both

excellent and clinically acceptable intubating conditions.

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2008, Issue 3http://www.thecochranelibrary.com

Rocuronium versus

Rocuronium bromide 0.6 mg/kg

spontaneous recovery

Rocuronium bromide 0.6 mg/kg

reversal of block

SugammadexOrg 25969-Rocuronium complex formation

Gamma cyclodextrin

Org 25969 dose 8 mg/kg

Outside ring :hydrophilic

with negative charge

Inside ring :hydrophobic

***Inside cavity specific only to Rocuronium

หลับ

-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

0

20

40

60

80

100

BIS

0

1

2

3

4

5

Ce P

ro

po

fo

l

(m

cg

/ml)

mean BIS mean Ce Propofol

Multi-compartmental pharmacokinetic models

Comp2

24 L

Comp1

4.3 L

Comp3

238 L

Multi-compartmental pharmacokinetic models

Propofol

Bolus 2 mg/kg

Propofol Bolus 2 mg/kg

3020100

Concentr

ation µ

g/m

l

10

9

8

7

6

5

4

3

2

1

0

Inf. R

ate

(ml/h

r) + D

ecr. T

ime

1000

900

800

700

600

500

400

300

200

100

0

3020100

Concentr

ation µ

g/m

l

10

9

8

7

6

5

4

3

2

1

0

Inf. R

ate

(ml/h

r) + D

ecr. T

ime

1000

900

800

700

600

500

400

300

200

100

0

3020100

Concentr

ation µ

g/m

l

10

9

8

7

6

5

4

3

2

1

0

Inf. R

ate

(ml/h

r) + D

ecr. T

ime

1000

900

800

700

600

500

400

300

200

100

0

3020100

Concentr

ation µ

g/m

l

10

9

8

7

6

5

4

3

2

1

0

Inf. R

ate

(ml/h

r) + D

ecr. T

ime

1000

900

800

700

600

500

400

300

200

100

0

IV Bolus

Personnel Controlled Infusion

• Drop counting

• Intermittent manual injection

IV line Trouble Shooting

• Occlusion

• Air in line

• Position

• Technique

Infusion Devices

Pre-load

Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007

Aug;21(5):492-6.

Leg Elevation

Response to

increased

cardiac load,

obtained by leg elevation

The End

Thank you

for your

attention