AVOIDING THE CRASH: AVOIDING THE CRASH 3: OPTIMIZE YOUR PRE, PERI, - PDF document

2/16/2014 AVOIDING THE CRASH: AVOIDING THE CRASH 3: OPTIMIZE YOUR PRE, PERI, AND RELAX, OPTIMAL POST-AIRWAY POST AIRWAY MANAGEMENT MANAGEMENT Robert J. Vissers MD Robert J. Vissers MD Chief, Emergency Medicine, Chief, Emergency Medicine, Quality Chair, Legacy Emanuel Medical Center Quality Chair, Legacy Emanuel Medical Center Adjunct Associate Professor, OHSU Adjunct Associate Professor, OHSU Portland, OR Portland, OR Approach to the Decision to Intubating the critically ill Emergency Airway intubate • Planning is critical – no margin for error Near death? • Assess and plan for difficulty TIME Unresponsive? • Optimize physiology – focus on prevention of hypoxia and hypotension Difficult ANATOMY • Airway may come second Airway? • Use a checklist – inform the team RSI PHYSIOLOGY Post Intubation Management Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management Philadelphia, Lippincott, 2000. 1

2/16/2014 View from Haleakala Adult Learner • Focus on the life threat • Consider ketamine • Match ventilation to the disease • Prevent delayed complications Intubating the critically ill Septic shock • 32 yo male, hx of paraplegia from GSW, chronic “I need to intubate the decubitus ulcers, cocaine and non-compliance patient …but I know • In septic shock, maintaining oxygenation he’ll crash when I do.” • 2% risk of cardiac arrest during intubation of critically ill • Significant hypotension common after ETI, systolic < 80mmHg in 30%, < 70 mmHg in 10% Griesdale DEG, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008 2

2/16/2014 Intubating the critically ill: The Crash Intubating the shock patient Optimize physiology - Perfusion Mechanisms of the post- • Almost all patients need volume intubation crash: • 40mL/Kg in kids • 1-2 liters in adults • Medication induced vasodilatation • May delay intubation if • Reduced catecholamines with sedation and hypotensive, or hypovolemic and relaxation O2 OK – perfusion priority • Fluids/pressors Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation. J Emerg Med 2010 Adult Learner Airway in the shock patient • Focus on the life threat • Favorite pre-treatment drugs: • Consider ketamine • Match ventilation to the disease • Prevent delayed complications 3

2/16/2014 What about a “whiff” of pressor? What about a “whiff” of pressor? • Phenylephrine commonly used in ICU and OR for • Phenylephrine transient hypotension • Need to dilute 100/1 to get 100mcg/mL • Pure vasoconstrictor (no tachy) • Push 0.5-2 mL boluses (give it a minute) • Peripheral OK • Lasts 20 min Should I use it? Etomidate: Adrenal suppression? • Can use diluted epi (1:100,000) • No prospective studies showing increase in • http://www.acep.org/content.aspx?id=47948 mortality • ACEP Weingart March 2010 • No outcome data to suggest discontinuation in emergency RSI • Consider hydrocortisone in sepsis • Alternative agents may exacerbate shock Clinical controversies: Etomidate as an induction agent for intubation in patients with sepsis. Ann Emerg Med 2008 4

2/16/2014 Peri-Intubation: Induction agent Etomidate or ketamine? • Randomized, controlled study comparing Etomidate? etomidate and ketamine in critically ill • 5% decrease (3-8%) in MAP in critically ill patients, ASA 4 • 655 patients • Propofol causes 18% decrease (10-25%) • Higher percentage of adrenal insufficiency etomidate group (still 50% in ketamine) • No difference in mortality, or morbidity (organ • Probable associated catecholamine decrease failure) • Consider ketamine 2mg/kg as alternative Jabre, et al. Etomidate versus Ketamine for RSI in acutely ill patients: a multicentre randomised controlled trial. Lancet, 2009. Minor et al. Procedural sedation of critically ill patients in the emergency department. AEM 2005; 12:124-128. Adult Learner Induction: Why bother? • Focus on the life threat • 32 patients, 2.5 mg/kg ketamine or 5 mg/kg • Consider ketamine thiopental • Match ventilation to the disease • 0.6mg/kg rocuronium 2 minutes later • Prevent delayed complications • Intubating conditions at 60 s acceptable in 50% with thiopental, 100% with ketamine • Jaw relaxation excellent in both groups • Vocal cord position significantly worse with thiopental Hans P et al. Anaesthesia 1999 Mar; 54:276-9. 5

2/16/2014 Induction: Good for you too Intubating the critically ill: The Crash Post-intubation ventilation • In RSI, we are intubating at the leading edge of causing: the effect of the NMBA • Both agent and dose are important • Air-trapping due to inadequate exhalation • Individualize agent to patient condition • Positive Pressure Ventilation causes decreased venous return Intubating the critically ill: The Crash Post-intubation in shock • Consider acid/base balance before you change Post-intubation ventilation the ventilation causing: • Acidosis associated with compensatory respiratory alkalosis (tachypnea, kussmaul ’ s) • Acidosis from failure to compensate for pre- existing metabolic acidosis • Post intubation ventilate at their RR, “ normal rate ” may lead to transient worsening of acidosis • Consider bicarb first in ASA poisoning 6

2/16/2014 Adult Learner Pediatric asthma • Focus on the life threat • Preparation critical! • Consider ketamine • Preoxygenation, fluids • Prevent dosing and equipment error – • Match ventilation to the disease Broeslow-Luten system • Prevent delayed complications • Checklist, team plan • Prepare for difficult bagging, NG • Ventilator settings – permissive hypercapnia, low rate and tidal volume Intubating the critically ill: The Crash Vent settings made simple Assist control Post-intubation ventilation • Preset rate and tidal volume causing: • Will deliver standard tidal volume • Initial mode of choice for respiratory • Elevated plateau pressures exacerbating failure (most ED patients) barotrauma and ARDS • Less work of breathing than SIMV or pressure support 7

2/16/2014 Vent settings made simple Vent settings made simple Oxygenation Ventilation (CO2) • Primarily a function of FiO2 and PEEP • Primarily a function of RR and tidal volume • Start FiO2 of 100% • Maintain pH 7.3-7.4 • Start PEEP at 5 cm H2O • Change in RR greater effect on pCO2 and pH than tidal volume • Increase PEEP 2-3 cm q 15 min to increase oxygenation Vent settings made simple Vent settings made simple Barotrauma/ARDS Barotrauma/ARDS • Primarily a function of plateau pressure (not • Primarily a function of plateau pressure (not peak) peak) • Keep plateau pressures below 30 cm H2O • Reduce tidal volume in asthma, ARDS, high plateau pressures (6 cc/kg IBW) • Increase peak flow (80-120 l/min) • Reduced RR to allow expiration, avoid air trapping (8-12 bpm) • Permissive hypercapnia may be needed 8

2/16/2014 Peri-intubation: Prevention Post Intubation Sedation • Fentanyl 2 mcg/kg IV bolus then Improve outcome beyond the ED • 1 mcg/kg/h OR ! • Elevate the head of the bed 30-45° • Hydromorphone 0.5-1 mg IV • Decompress stomach OG • bolus then repeat q10 min to • Sterile technique with procedures • effect • AND ! • Midazolam 0.05 mg/kg IV bolus • then 0.025 mg/kg/hr OR ! • Propofol 0.5 mg/kg bolus and 20 • mcg/kg/hr OR ketamine 1 mg/kg • bolus then 0.5 mg/kg/h Adult Learner Summary • Focus on the life threat • Plan and Prepare • Consider ketamine • Sometimes Airway comes second • Match ventilation to the disease • Assess and manage airway difficulty • Prevent delayed complications • Consider and optimize physiology • Favorite pretreatment? NS, O2, Plan • Optimize Post-Intubation management 9

2/16/2014 Thankyou! 10