Why do we need NMBAs for RSI?

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Why do we need NMBAs for RSI?

  1. 1. Why do we need NMBAs for RSI ผศ.นพ.สุรพงษ์ หล่อสมฤดี TIVA Center Division of Cardiothoracic and Vascular Anesthesia Division of Transplantation Anesthesia Chiang Mai University Hospital
  2. 2. Hemodynamic Effects Painful stimulus Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007 Oct;21(5):636-43.
  3. 3. TIVA VIMA 20 Heart rate (% from baseline) 10 0 + + -10 + + + + + -20 * * -30 -40 -50 Baseline Before After Before After Before After Intubation Intubation Incision Incision Extubation Extubation Heart Rate
  4. 4. TIVA VIMA 20 * MAP (% from baseline) 10 0 -10 + + + + -20 + + + -30 + + -40 -50 Baseline Before After Before After Before After Intubation Intubation Incision Incision Extubation Extubation Blood Pressure
  5. 5. Multi-compartmental pharmacokinetic models
  6. 6. 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
  7. 7. Succinylcholine’s strengths Rapid onset Profound depth of NMB Short duration of action
  8. 8. Succinylcholine’s weaknesses Cardiovascular effects sinus bradycardia nodal rhythm ventricular dysrhythm Increase IOcP Increase IGP Increase ICP
  9. 9. Succinylcholine’s weaknesses • Myalgia • Masseter spasm • Fasciculations • Anaphylaxis • Abnormal plasma cholinesterase • Hyperkalemia
  10. 10. Contraindications • MH • Burn • UMNL • Severe muscle trauma • Severe intraabdomen infection • Disuse atrophy
  11. 11. 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
  12. 12. 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%)
  13. 13. ONSET OF ROCURONIUM BROMIDE Onset: rapid to intermediate (dose dependent)
  14. 14. 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
  15. 15. 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)
  16. 16. HISTAMINE RELEASING POTENTIAL Significant Insignificant Tubocurarine +++ Rocuronium bromide ± Metocurine ++ Vecuronium bromide ± Atracurium besylate + Pancuronium bromide ± Mivacurium chloride + Pipecuronium bromid Succinylcholine chloride + Doxacurium chloride ±
  17. 17. Effects of Rocuronium on Heart Rate 100 600 mcg/kg 900 mcg/kg Heart Rate (beats/min) 90 1200 mcg/kg 80 70 60 50 40 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Time (minutes) Levy et al. Anesth Analg 1994;78,318-321.
  18. 18. Effects of Rocuronium on Mean Arterial Pressure 600 mcg/kg Mean Arterial Pressure (mmHg) 100 900 mcg/kg 1200 mcg/kg 90 80 70 60 50 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Time (minutes) Levy et al. Anesth Analg 1994;78,318-321.
  19. 19. Effects of Rocuronium on Histamine Release 3.0 Plasma Histamine (ng/ml) 2.5 600 mcg/kg 900 mcg/kg 2.0 1200 mcg/kg 1.5 1.0 0.5 0.0 0.0 1.0 2.0 3.0 4.0 5.0 Time (minutes) Levy et al. Anesth Analg 1994;78,318-321.
  20. 20. ROCURONIUM BROMIDE: CARDIOVASCULAR PROFILE • Favorable cardiovascular profile • Histamine release unlikely • Mild vagolytic activity
  21. 21. Rationale for Selection of NMBs: • 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
  22. 22. Rapid Sequence Intubation experience in Emergency Department Maharaj Nakorn Chiang Mai นพ.บวร วิทยชำนำญกุล Emergency Medicine Chiang Mai University Hospital
  23. 23. History • Awake intubation • Diazepam ??? • Midazolam
  24. 24. • Establish Training EM in 2548 • Workshop RSI in January 2551 • RSI in ER October 2551 • Etomidate + Succinylcholine • Etomidate + Rocuronium • Propofol
  25. 25. 28 30 25 20 20 15 12 10 3 4 5 1 0 1 attempt 2 attempt 3 attempt RSI 32 non RSI 36
  26. 26. 6 6 5 4 4 4 3 3 2 2 2 2 2 2 1 1 0 0 0 Hypotension Desaturation Vomit prolonged Oral trauma Esophageal intubation intubation RSI non RSI
  27. 27. Now • More than 150 experience of RSI • Staff attending 24 hr • ER staff in morning shift and some noon – night shift
  28. 28. Quality Control • Resident 2 : training, coaching, direct observe • Difficult airway cart • No serious adverse event
  29. 29. Troubleshoot • Hypotension after procedure • > 1 attempt – Non experience – Position
  30. 30. Prepare : sniff position
  31. 31. Prepare : sniff position
  32. 32. Troubleshoot • Hypotension after procedure • > 1 attempt – Non experience – Position – Not wait til onset of drugs • Myoclonus 1 time • Drug preparation time
  33. 33. The End Thank you for your attention

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