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病房插管小筆記 (Note about Rapid sequence intubation)
- 1. INTUBATION Yuan Chieh Chang 2016. September
- 2. 插管時機 病人無法 Matintain Airway 通氣和氧合不足 預期病程發展 • Gag reflex ：at risk • GCS • 應綜合評估 • SaO2 • PETCO2 例: • SCI 需要配合及輸送 • 預期進行手術等治療
- 3. 一次就要插上 • Complications ： once in every 8patients • adverse event rate Ｘ3 • 1 attempt: 14.2% vs >1 attempt: 53.1%
- 5. Difficult Airway Time + Coperation ? Time avalilable Surgical and rescue Awake intubation N Delayed sequence intubation? Rapid sequence intubation Y Y N Y N
- 6. Time + Coperation ? Surgical and rescue Awake intubation Delayed sequence intubation? Y Y N Difficult Airway Time avalilable N Rapid sequence intubation Y N Difficult Airway Time avalilable N Rapid sequence intubation Y
- 7. Time + Coperation ? Surgical and rescue Awake intubation Delayed sequence intubation? Y Y N Difficult Airway Time avalilable N Rapid sequence intubation Y N Difficult Airway Time avalilable N Rapid sequence intubation Y Difficult Airway 所以…要如何判斷？
- 11. Look Evaluate Mallampati Obstruction Neck mobility Evaluate 3-3-2 Rule 躺著時，可以把嘴完全打開後，拉出舌頭，用喉 頭鏡的光預測
- 14. Cricothyrotomy 也可能失敗？ • 手術(Surgery)影響解剖構造 • 佔據空間的病灶(Mass): 血腫 • 碰不到呼吸道(Access)：極度胖，外部固定等 • 放射治療(Radiation) • 腫瘤(Tumor)：影響凝血
- 15. -10 min -8 min -3 min 0 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation
- 16. -10 min -8 min -3 min 0 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation -10 min Preperation • Team: • “Appropriate Nurses”, RT • Back up • Equipment: • Peripheral Line x 2 • Fluid x 1 先掛起來 • 升壓劑：Bosmin, Phenylephrine • BP monitor, EKG monitor Ringer IV
- 17. -10 min -8 min -3 min 0 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation -8 min Preoxygenation • FiO2=90 NRM 要開到 30 lpm 才有 • 3 mins of tidal breathing; either 4 or 8 rapid deep breaths of FiO2 = 1.0 • 時間不夠： • 4 or 8 maximal breaths over 30 to 60 seconds Nitrogen washout
- 18. -10 min -8 min -3 min 0 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation -8 min Preoxygenation • FiO2=90 NRM 要開到 30 lpm 才有 • 3 mins of tidal breathing; either 4 or 8 rapid deep breaths of FiO2 = 1.0 • 時間不夠： • 4 or 8 maximal breaths over 30 to 60 seconds Nitrogen washout Preoxygenation 好了 好了 撐多久？ • 93%< critical desatureation • Critical Patient
- 19. -10 min -8 min -3 min 0 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation • 在特定的病人避免過度的刺激pharynx • ACS, ICP, ICH • 並無很強的證據支持使用 -3 min Pretreatment
- 20. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction facilitate laryngoscopy, prevent laryngospasm, and enable passage of the ETT Ideal Intubating Conditions, Prevent Hemodynamic Instability, Analgesia and Amnesia
- 21. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium
- 22. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium Etomidate • Minimal cardiovascular effect • No↑ myocardial O2 comsumption • Neuroprotective • Lower ICP • Adrenal insufficiency • Inhibit 11 β-hydroxylase enzyme • critical ill septic patient • No solid proof of an absolute morality GABA Not BZD Metabolism (Portency): primarily hepatic strongly protein bound
- 23. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium Tendency to cause: • Hypotension: up to 30% • Myocardial depression • Limited use in intubation Bronchodilator Neuroprotective Immunosupression Propofol hepatic Conjugation Renal excretion CI 會影響代謝速率
- 24. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium • dissociative anesthetic + analgesic • sympathomimetic effects • ↑HR, BP, ICP • Bronchodilator • ↑ Airway secretion, preserved reflex • neuroprotective when • in concert with other agents (BZD, Prop.) • ↓ICP Katemine M Opiod NMDA Metabolism : hepatic P450 Excretion by kidney (inactive) Not a significant concern
- 25. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium • Sedation + Amnesia + Anxiolysis + muscle relaxation (some) • Rapid onset • 10%↓BP (SVR); ↑HR • apnea • independent of neuromuscular blocker Midazolam • Metabolism: P450 system • Excretion: kidney
- 26. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium • rapid onset of action • neuromuscular blockade for 6 to 10 minutes • Adverse effects Succnylcholine
- 28. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 0 Paralysis and Induction Etomidate Propofol Midazolum Katemine Succnylcholine Rocuronium • nondepolarizing NMB • rapid onset of action (60 seconds) • paralysis for up to 60 minutes Rocuronium
- 29. 1 Min 4 Min0 2 Min 3 Min 10 Min > 1hr
- 30. 1 Min 4 Min0 2 Min 3 Min 10 Min > 1hr 別這樣出現空窗期...
- 32. In Sepsis Patient 23sec Desaturation Limited TIME Hypotension Shock Metabolism Organ Failure
- 33. In Sepsis and unstable Patient Ketamin Etomidate 小心CAD的病人，會 增加心臟負荷 Adrenal insufficiency 的風險要準備好，肝 臟疾病或蛋白質代謝 都會影響強度
- 34. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation 15-30 sec Posotioning Sniff position
- 35. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation +45 sec Pass the tube with Verification Cormack and Lehane
- 36. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation +45 sec Pass the tube with Verification Cormack and LehaneCormack and Lehane Gr. III Gr. IV 迅速思考替代方案
- 37. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation +45 sec Pass the tube with Verification Cormack and LehaneCormack and Lehane Check position PE: not collectively reliable Most accurate: PETCO2 Ultrasound
- 38. -10 min -8 min -3 min 15-30 sec +45 sec +90 sec Preperation Preoxygenation Pretreatment 0 Paralysis and Induction Posotioning Pass the tube with Verification Post intubation care 7 Ps of Rapid Sequence Intubation +90 sec Post intubation care
- 39. Post intubation care induction agentsLaryngeal manipulation hypoxia hypercapnea negative to positive pressure ventilation Unstable Condition Myocardial depression ↓vascular tone in lower extremities
- 40. Hypotension Normal : 0.5- 0.7 More than 0.8 predict Hypotension shock index = Heart rate / SBP • Fluid Resusitation • Avoid in Congestive patient • Pure Vasocontrictor: Phenylephrine
- 41. Other complication • Tachycardia • Bradycardia • Hypertension
- 42. Keep Light Sedation Vital sign changes do Not correlate with pain experienced by intubated patients and are unreliable in determining the need for pain medication
- 43. Referance • Emerg Med Clin N Am 34 (2016) 97–127 Airway Management of Respiratory Failure Michael C. Overbeck, MD • Book: Sepsis - An Ongoing and Significant Challenge Edited by Luciano Azevedo, ISBN 978-953-51-0780-4, 420 pages, Publisher: InTech, Chapters published • Imange: FreeImages.com