Here is a shortish lecture on the commonly used RSI drugs with handout on the common drugs.
This is from an ED and critical care perspective, which is quite different than what anaesthetics uses. We recommend different doses and considering different agents than have been commonly used in New Zealand.
Which sedative and which paralytic to use is a complicated decision, but it is a body of knowledge that ED physicians should be expert.
As always, double-check your doses with some "Official" source. At the end, we give little example of how an RSI checklist can be used.
Pretest #5: Airway Pharmocology
- Which patients normally require standard RSI medications?
- Review the advantage/disadvantages of each of these sedatives
- Review the advantage/disadvantages of each of these paralytics
- List the common dosage of these sedatives and paralytics for RSI
- Describe the timing of giving RSI drugs. How long will sux and/or rocuronium last?
---for full clarity: click through to watch in Vimeo
Here is a recent discussion on intubating the hypotensive patient on Life In the Fast Lane with many of the recent references: http://lifeinthefastlane.com/education/ccc/rapid-sequence-induction-of-the-shock-patient/
Here is a great lecture on intubating hypotensive patients. I hope this can convince some people to start avoiding those big doses of thio and propofol that are recommended in the Anesthetics textbooks. http://emcrit.org/podcasts/intubation-patient-shock/
Up-to-Date- : Sedation or induction agents for rapid sequence intubation in adults: http://www.uptodate.com/contents/sedation-or-induction-agents-for-rapid-sequence-intubation-in-adults
Chris Nickson of Life in the Fast Lane (of course) has a great post on the eternal Rox vs Sux debate titled Does Roc rock? Does Sux suck? (http://lifeinthefastlane.com/ruling-the-resus-room-004/).
Life in the Fast Lane has another post on ketamine in head injuries: http://lifeinthefastlane.com/education/ccc/ketamine-rsi-for-head-injury/
Walls RM. Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF. (Eds), Lippincott Williams and Wilkins, Philadelphia 2012
Morris et al Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009 May;64(5):532-9.
CJEM. 2012 Mar;14(2):74-82.
Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability.
Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.
A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≤ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.
Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01-1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19-7.57), and pre-emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27-4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16-0.75).
Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.
[PubMed - indexed for MEDLINE]
Anaesthesia. 2009 May;64(5):532-9. doi: 10.1111/j.1365-2044.2008.05835.x.
Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?
In rapid sequence induction of anaesthesia in the emergency setting in shocked or hypotensive patients (e.g. ruptured abdominal aortic aneurysm, polytrauma or septic shock), prior resuscitation is often suboptimal and comorbidities (particularly cardiovascular) may be extensive. The induction agents with the most favourable pharmacological properties conferring haemodynamic stability appear to be ketamine and etomidate. However, etomidate has been withdrawn from use in some countries and impairs steroidogenesis. Ketamine has been traditionally contra-indicated in the presence of brain injury, but we argue in this review that any adverse effects of the drug on intracranial pressure or cerebral blood flow are in fact attenuated or reversed by controlled ventilation, subsequent anaesthesia and the greater general haemodynamic stability conferred by the drug. Ketamine represents a very rational choice for rapid sequence induction in haemodynamically compromised patients.
- Training in the use of ketamine. [Anaesthesia. 2009]
J Crit Care. 2014 Aug;29(4):517-22. doi: 10.1016/j.jcrc.2014.02.002. Epub 2014 Feb 14.
Effects of etomidate on vasopressor use in patients with sepsis or severe sepsis: a propensity-matched analysis.
The safety of single-bolus etomidate to facilitate intubation in septic patients is controversial due to its potential to suppress adrenal steroidogenesis. The purpose of this study was to evaluate the effects of etomidate on the development of shock when used as an induction agent to facilitate intubation in septic patients.
A multicenter, retrospective, propensity-matched cohort study comparing patients with sepsis or severe sepsis who either received etomidate or did not receive etomidate for intubation was conducted. The primary outcome was the difference in the need for vasopressor support within 72 hours after intubation. Secondary outcomes included the use of multiple vasopressors, intensive care unit length of stay, and in-hospital mortality.
A total of 411 patients were analyzed. Eighty-three patients were matched by propensity score. There was no difference in the matched cohort in regards to vasopressor use within 72 hours of intubation (odds ratio, 0.95; 95% confidence interval, 0.52-1.76; P=.88). Furthermore, there were no significant differences observed with regard to secondary outcomes, including in-hospital mortality (P=.76).
The use of etomidate for intubation in septic patients did not increase vasopressor requirements within 72 hours after intubation.
J Burn Care Res. 2014 Jul 22. [Epub ahead of print]
Suspected Adrenal Insufficiency in Critically Ill Burned Patients: Etomidate-Induced or Critical Illness-Related Corticosteroid Insufficiency?-A Review of the Literature.
Adrenal insufficiency (AI) whether etomidate-induced or secondary to critical illness related corticosteroid insufficiency (CIRCI), is a common and under appreciated problem in the ICU. However, AI is often difficult to identify and diagnose in the critically ill. The pathophysiology and ideal management of etomidate-induced AI and CIRCI, especially in burn patients, is unknown. Many studies, however, have examined the prevalence of and risk factors for developing AI in critically ill populations as well as the effect of AI on morbidity and mortality. Observing a seemingly increased number of patients with suspected AI in our burn ICU, we sought to evaluate and summarize the current literature relating to adrenal insufficiency in the critically ill. We performed an electronic literature search on the PubMed and Ovid Medline databases using the key words "etomidate," "adrenal insufficiency," "CIRCI", and "burn injury." Relevant studies from the current burn and ICU era were selected to be included in this review of the literature. Among the critically ill, burn patients are at increased risk for developing adrenal insufficiency and the risk is greatest for elderly patients with large burns and inhalation injury. Both CIRCI and etomidate-induced AI are associated with high morbidity and mortality, therefore avoiding preventable causes of AI, such as choosing alternatives to etomidate for rapid sequence intubation (RSI) in the severely burn injured patient should be encouraged. Further research is indicated to investigate the biological relationship between AI and associated morbidity and mortality, whether etomidate-induced or secondary to critical illness; as well as how best to identify and diagnose patients with suspected adrenal insufficiency in the burn intensive care unit.
[PubMed - as supplied by publisher]
Crit Care. 2014 Jul 11;18(4):R150. [Epub ahead of print]
Comparison of clinical outcome variables in patients with and without etomidate facilitated anesthesia induction ahead of major cardiac surgery: a retrospective analysis.
It is well known that etomidate may cause adrenal insufficiency. However the clinical relevance of adrenal suppression after a single dose of etomidate remains vague. The aim of this study was to investigate the association between the administration of a single dose of etomidate or an alternative induction regime ahead of major cardiac surgery and clinical outcome parameters associated with adrenal suppression and onset of sepsis.
The anesthesia and ICU records from patients undergoing cardiac surgery over five consecutive years (2008 to 2012) were retrospectively analyzed. The focus of the analysis was on clinical parameters like mortality, ventilation hours, renal failure, and sepsis linked serum parameters. Multivariate analysis and Cox regression were applied to derive the results.
A total of 3,054 patient records were analyzed. A group of 1,775 (58%) patients received a single dose of etomidate; 1,279 (42%) patients did not receive etomidate at any time. There was no difference in distribution of age, American Society of Anesthesiologists (ASA) physical score, duration of surgery and Acute Physiology and Chronic Health Evaluation Score II (APACHE II). Postoperative data showed no significant differences between the two groups regarding mortality (6.8% versus 6.4%), mean of mechanical ventilation hours (21.2 versus 19.7), days in the ICU (2.6 versus 2.5), hospital days (18.7 versus 17.4), sepsis associated parameters, Sequential Organ Failure Assessment (SOFA) Score and incidence of renal failure. Administration of etomidate showed no significant influence (P = 0.6) on hospital mortality in the multivariate Cox analysis.
This study found no evidence for differences in key clinical outcome parameters based on anesthesia induction with or without administration of a single dose of etomidate. In consequence etomidate might remain an acceptable option for single dose anesthesia induction.
PMID: 25015112 [PubMed - as supplied by publisher]
Can J Anaesth. 2014 Jul;61(7):650-5. doi: 10.1007/s12630-014-0161-6. Epub 2014 Apr 11.
The impact of etomidate on mortality in trauma patients.
Etomidate has a neutral hemodynamic profile which has made it an attractive medication for emergent intubation. Despite theoretical advantages of etomidate administration in the trauma patient, there are incomplete data to support its use. This study examined the association of etomidate use for emergent intubation in traumatic illness with patient mortality.
This is a historical cohort study using the Nova Scotia Trauma Registry. It included all major adult trauma patients who required tracheal intubation at the Queen Elizabeth II Health Sciences Centre in Halifax, Canada from January 23, 2000 to March 25, 2012. Prospectively recorded data were analyzed, including patient demographics, presence of comorbidities, trauma specific variables, admission and discharge vitals, length of stay in the intensive care unit (ICU) and hospital, mechanical ventilation-free days, and mortality. Associations between the use of etomidate and 28-day mortality are presented as odds ratios. Multivariable logistic regression models were created adjusting for age, injury severity score (ISS), sex, comorbidities, presence of traumatic brain injury, and injury type. The effects of etomidate on other relevant outcome variables were assessed using unpaired Student's t-tests.
Three hundred eight patients were included in the study, and there were 42 deaths. Patients receiving etomidate were similar to those who did not, including ISS and pre-intubation blood pressure. The 28-day mortality was 18.7% in the etomidate group and 11.1% in the non-etomidate group (odds ratio = 1.85; 95% confidence interval [CI] 0.96 to 3.57; P = 0.07). After adjustment for age, female sex, ISS, and comorbidity, the odds ratio was 1.94 (95% CI 0.87 to 4.37; P = 0.11). There were no differences between the two groups in ICU length of stay, hospital length of stay, or number of ventilation-free days.
The association between use of a single dose of etomidate for emergency tracheal intubation in the trauma patient and mortality is inconclusive. Etomidate administration should be used with caution in trauma patients requiring tracheal intubation. Further data are required to determine the safety and risk-benefit of etomidate use in this patient population.
[PubMed - in process]
Acta Anaesthesiol Scand. 2014 Apr;58(4):380-9. doi: 10.1111/aas.12289. Epub 2014 Mar 3.
Etomidate--a review of robust evidence for its use in various clinical scenarios.
Etomidate is an intravenous hypnotic with a favourable clinical profile in haemodynamic high-risk scenarios. Currently, there is an active debate about the clinical significance of the drug's side effects and its overall risk-benefit ratio. Etomidate-induced transient adrenocortical suppression is well documented and has been associated with increased mortality in sepsis. In surgical patients at risk of hypotensive complications, however, a review of current literature provides no robust evidence to contraindicate a single-bolus etomidate induction. Large randomised controlled trials as well as additional observational data are required to compare safety of etomidate and its alternatives.
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
[PubMed - in process]