1. ผศ.นพ.สุรพงษ์ หล่อสมฤดี
TIVA Center
Division of Cardiothoracic and Vascular Anesthesia
Division of Transplantation Anesthesia
Chiang Mai University Hospital
Why do we need NMBAs
for RSI

4. Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007
Oct;21(5):636-43.
Hemodynamic Effects
Painful stimulus

5. Lorsomradee, et al: Anaesthesia. 2007
Oct;62(10):979-83.
Vasoconstrictor
Phenylephrine

6. Reversible myocardial ischemia
Stunning
A transient period of
depressed myocardial function
that follows a period of ischemia,
not sufficient to result in cell death

7. Cardioprotection: Myocardial oxygen balance
O2 supply
O2 demand
<
ischemia
supply demand
Heart rate
contractility
afterload
CBF: normal region
CBF: ischemic region
subendocardium

8. 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

9. Chiang Mai Medical Journal 2008;48(3suppl)

10. Rapid Sequence
Intubation experience in
Emergency Department
Maharaj Nakorn Chiang Mai
นพ.บวร วิทยชำนำญกุล
Emergency Medicine
Chiang Mai University Hospital

11. History
• Awake intubation
• Diazepam ???
• Midazolam

12. • Establish Training EM in 2548
• Workshop RSI in January 2551
•
• RSI in ER October 2551
• Etomidate + Succinylcholine
• Etomidate + Rocuronium
• Propofol

13. 28
20
3
12
1
4
0
5
10
15
20
25
30
1 attempt 2 attempt 3 attempt
RSI 32 non RSI 36

14. 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

15. Now
• More than 150 experience of RSI
• Staff attending 24 hr
• ER staff in morning shift and
some noon – night shift

16. Quality Control
• Resident 2 : training, coaching, direct
observe
• Difficult airway cart
• No serious adverse event

17. 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”

18. Preparation
• Evaluate
– LEMON
• Equipment Check
• Positioning
• Drug Selection
• IV’s, monitor, oximetry
• Ancillary Staff
• Anticipate alternative airway maneuver

19. • LEMON
–L-look
–E-evaluate the 3-3-2 rule
–M-Mallampati
–O-Obstruction
–N-Neck mobility

20. 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

21. Troubleshoot
• Hypotension after procedure
• > 1 attempt
–Non experience
–Position

22. Prepare : sniff position

23. Prepare : sniff position

24. Troubleshoot
• Hypotension after procedure
• > 1 attempt
–Non experience
–Position
–Not wait til onset of drugs
• Myoclonus 1 time
• Drug preparation time

25. Tip & Trick in RSI

26. Airway Assessment

31. Emergency Airway

35. Muscle Relaxation

38. Succinylcholine
Rapid onset
Profound depth of NMB
Short duration of action

39. Succinylcholine’s weaknesses
Cardiovascular effects
sinus bradycardia
nodal rhythm
ventricular dysrhythm
Increase IOcP
Increase IGP
Increase ICP

40. Succinylcholine’s weaknesses
• Myalgia
• Masseter spasm
• Fasciculations
• Anaphylaxis
• Abnormal plasma cholinesterase
• Hyperkalemia

41. 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

42. Contraindications
• MH
• Burn
• UMNL
• Severe muscle trauma
• Disuse atrophy

43. Is Suxamethonium Really Safe ?
Morbidity
 Fasciculation
 C-spine

44. Comparative Intubating Doses and
Time to Intubation of NDMRs

45. 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
HeartRate(beats/min)
Levy et al. Anesth Analg 1994;78,318-321.
600 mcg/kg
900 mcg/kg
1200 mcg/kg

46. 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
MeanArterialPressure(mmHg)
600 mcg/kg
900 mcg/kg
1200 mcg/kg
Levy et al. Anesth Analg 1994;78,318-321.

47. Effects of Rocuronium on Histamine Release
Time (minutes)
0.0 1.0 2.0 3.0 4.0 5.0
PlasmaHistamine(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

48. 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)

49. 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

50. 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)

51. 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 3
http://www.thecochranelibrary.com

52. Rocuronium bromide 0.6 mg/kg
spontaneous recovery

53. Rocuronium bromide 0.6 mg/kg
reversal of block

54. Sugammadex
Org 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

55. หลับ

56. -50
-40
-30
-20
-10
0
10
20
Heartrate(%frombaseline)
TIVA VIMA
Baseline Before
Intubation
After
Intubation
Before
Incision
After
Incision
Before
Extubation
After
Extubation
* *
+
+
+ + +
+
+
Heart Rate

57. -50
-40
-30
-20
-10
0
10
20
MAP(%frombaseline) TIVA VIMA
Baseline Before
Intubation
After
Intubation
Before
Incision
After
Incision
Before
Extubation
After
Extubation
+
+ +
+
+ +
+
+
+
*
Blood Pressure

58. 0
20
40
60
80
100
BIS
0
1
2
3
4
5
CePropofol
(mcg/ml)
mean BIS mean Ce Propofol

60. Multi-compartmental pharmacokinetic models

61. Comp2
24 L
Comp1
4.3 L
Comp3
238 L
Multi-compartmental pharmacokinetic models

62. Propofol
Bolus 2 mg/kg

63. Propofol Bolus 2 mg/kg
3020100
10
9
8
7
6
5
4
3
2
1
0
1000
900800700600500400300200100
0
3020100
10
9
8
7
6
5
4
3
2
1
0
1000
900800700600500400300200100
0
3020100
10
9
8
7
6
5
4
3
2
1
0
1000
900800700600500400300200100
0
3020100
10
9
8
7
6
5
4
3
2
1
0
1000
900800700600500400300200100
0

64. IV Bolus
Personnel Controlled Infusion
• Drop counting
• Intermittent manual injection

65. IV line Trouble Shooting
• Occlusion
• Air in line
• Position
• Technique

66. Infusion Devices

69. Pre-load

70. Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007
Aug;21(5):492-6.
Leg Elevation

71. Response to
increased
cardiac load,
obtained by
leg elevation

72. The End
Thank you
for your
attention