Optimise don’t compromise, peri-intubation physiology
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Optimise don’t compromise, peri-intubation physiology
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Health & Medicine
Crystalloids and colloids used in critically ill patients have different fluid composition. The composition may affect many things, including response to administration, clinical outcomes, and adverse effects. This talk with discuss the evidence behind the different types of fluids in critically ill patients, including a discussion of pros and cons of each fluid type.The session will be an interactive discussion led by investigators who have conducted randomized trials of different types of intravenous fluids.
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Optimise don’t compromise, peri-intubation physiology
- Optimise, Don’t Compromise: Peri-Intubation Physiology Todd W. Rice, MD, MSc Associate Professor of Medicine Vanderbilt University School of Medicine
- Mort, TC, et al. J of Cli Anes, 2004 Jaber S, et al. Int Care Med, 2010 Cook TM, et al. BJA, 2011Severe Complications = cardiac arrest, death, new SBP <65, new hypoxemia <80% ICU Intubation Severe Complication Rate OR Intubation Severe Complication Rate ICU Intubations are Complicated
- Death or Neurologic Injury 1 in 3 Complication Rate Procedure Variables • Multiple Attempts • Poor oxygenation strategy • No airway evaluation • Inexperienced Operators • Lack of equipment • No capnography use Patient Variables • Critically ill • Severe physiologic derangements • Acute decompensation Interventions • Video Laryngoscopy • Apneic Oxygenation • Drug Selection • Experts only • Pre-procedure Checklists • Patient Positioning Out-of-OR Endotracheal Intubations Cook TM, et al. BJA, 2011
- Case: 45 y.o. male presents with H1N1 ARDS and worsening hypoxia. His oxygenation deteriorates and he is currently saturating 89% on 100% non-rebreather mask. You make the decision to intubate him: How will you optimise peri-intubation physiology?
- Is this patient at risk for peri- intubation complications?
- Case: 45 y.o. male presents with H1N1 ARDS and worsening hypoxia. His oxygenation deteriorates and he is currently saturating 89% on 100% Non- Rebreather Mask. You make the decision to intubate him: How will you optimise peri-intubation physiology? Will You use VL or DL?
- Video Laryngoscopy Improves Glottic Visualization Janz DR, et al. Crit Care Med. 2016.
- Video Laryngoscopy Does NOT Increase First Attempt Success Janz DR, et al. Crit Care Med. 2016.
- Lascarrou JB, et al. JAMA. 2017. OR 1.12; (95% CI: 0.71-1.78) P=0.63
- Lascarrou JB, et al. JAMA. 2017.
- Huang HB, et al. Chest. 2017. First Pass Success RR: 1.08 (0.92-1.26); P=0.35
- Huang HB, et al. Chest. 2017. Time to Intubation Mean Difference: 4.12 (-15.86-24.09); P=0.69
- Huang HB, et al. Chest. 2017. Complications RR: 0.72 (0.30-1.70); P=0.45
- Is it better to have seen and failed, or never to have seen at all? http://www.criticalcares.com/2017/01/ 25
- Case: 45 y.o. male presents with H1N1 ARDS and worsening hypoxia. His oxygenation deteriorates and he is currently saturating 89% on 100% non- rebreather mask. You make the decision to intubate him: How will you optimise peri-intubation oxygenation? How Will You PreOxygenate?
- Casey JD, et al. Lancet Resp Med. 2019;Epub March 18, 2019.
- Baillard C, et al. AJRCCM. 2006;174:171-177. Baillard C, et al. Br J Anesth. 2018;120:361-367. Frat J-P, et al. Lancet Resp Med. 2019;epub March 19, 2019
- Case: 45 y.o. male presents with H1N1 ARDS and worsening hypoxia. His oxygenation deteriorates and he is currently saturating 89% on 100% non- rebreather mask. You make the decision to intubate him: Once you push meds, how will you prevent hypoxemia during the procedure? Will You Use RSI or Bag Mask Ventilation?
- Casey JD, et al. NEJM. 2019; 380:811-821.
- Casey JD, et al. NEJM. 2019; 380:811-821.
- Apneic Oxygenation: Physiology FRC 2L O2 Weingart SD, et al. Ann Emerg Med, 2012
- Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494. Lowest Oxygen Saturation Mean Diff: 2.21 (0.81-3.61); P=0.002
- First Pass Success OR: 1.59 (1.04-2.44); P=0.03 Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.
- SpO2 < 93% OR: 0.66 (0.52-0.84); P=0.007 Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.
- Case: 45 y.o. male presents with H1N1 ARDS and worsening hypoxia. His oxygenation deteriorates and he is currently saturating 89% on 100% non- rebreather mask. You make the decision to intubate him: You’ve pushed meds, how will you optimise first pass success? Will You Use Bougie On First Attempt?
- Driver BE, et al. JAMA. 2018; 319:2179-2189.
- Driver BE, et al. JAMA. 2018; 319:2179-2189.
- Case: 45 y.o. male presents with H1N1 ARDS and worsening hypoxia. His oxygenation deteriorates and he is currently saturating 89% on 100% non- rebreather mask. You make the decision to intubate him: How will you optimise peri-intubation hemodynamics? Will You Try to Prevent Hypotension?
- 1. Have a plan 2. Have a back up plan 3. Have a back up to the back up plan 4. Pre-oxygenate with NIV 5. Use laryngoscope you are comfortable with (VL for view) 6. If able, bag-mask ventilate b/w induction & laryngoscopy 7. Routine use of bougie will improve first pass Summary
- QUESTIONS???? todd.rice@vanderbilt.edu @toddrice_icu
Editor's Notes
- You have pre-oxygenated for 3-5 minutes using NIV and now you are ready to intubate. What are you going to do after you push induction meds? Wait 15-40 seconds and proceed with laryngoscopy or perform bag-mask ventilation for a minute and then undertake laryngoscopy?
- What is you can’t do bag-mask ventilation? What if the patient is actively vomiting or has facial trauma and bag-mask won’t secure/fit? Second line would be apneic oxygenation. Apneic oxygenation physiology – provide reservoir of 100% oxygen in back of oropharynx – with CO2 in the alveoli, the diffusion gradient of oxygen will allow flow of oxygen from the oropharynx to the alveoli, even when the patient is apneic.