Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.

Surapong rsi 2009

Audiolibros relacionados

Gratis con una prueba de 30 días de Scribd

Ver todo
  • Sé el primero en comentar

Surapong rsi 2009

  1. 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
  2. 2. Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007 Oct;21(5):636-43. Hemodynamic Effects Painful stimulus
  3. 3. Lorsomradee, et al: Anaesthesia. 2007 Oct;62(10):979-83. Vasoconstrictor Phenylephrine
  4. 4. Reversible myocardial ischemia Stunning A transient period of depressed myocardial function that follows a period of ischemia, not sufficient to result in cell death
  5. 5. Cardioprotection: Myocardial oxygen balance O2 supply O2 demand < ischemia supply demand Heart rate contractility afterload CBF: normal region CBF: ischemic region subendocardium
  6. 6. 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
  7. 7. Chiang Mai Medical Journal 2008;48(3suppl)
  8. 8. Rapid Sequence Intubation experience in Emergency Department Maharaj Nakorn Chiang Mai นพ.บวร วิทยชำนำญกุล Emergency Medicine Chiang Mai University Hospital
  9. 9. History • Awake intubation • Diazepam ??? • Midazolam
  10. 10. • Establish Training EM in 2548 • Workshop RSI in January 2551 • • RSI in ER October 2551 • Etomidate + Succinylcholine • Etomidate + Rocuronium • Propofol
  11. 11. 28 20 3 12 1 4 0 5 10 15 20 25 30 1 attempt 2 attempt 3 attempt RSI 32 non RSI 36
  12. 12. 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
  13. 13. Now • More than 150 experience of RSI • Staff attending 24 hr • ER staff in morning shift and some noon – night shift
  14. 14. Quality Control • Resident 2 : training, coaching, direct observe • Difficult airway cart • No serious adverse event
  15. 15. 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”
  16. 16. Preparation • Evaluate – LEMON • Equipment Check • Positioning • Drug Selection • IV’s, monitor, oximetry • Ancillary Staff • Anticipate alternative airway maneuver
  17. 17. • LEMON –L-look –E-evaluate the 3-3-2 rule –M-Mallampati –O-Obstruction –N-Neck mobility
  18. 18. 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
  19. 19. Troubleshoot • Hypotension after procedure • > 1 attempt –Non experience –Position
  20. 20. Prepare : sniff position
  21. 21. Prepare : sniff position
  22. 22. Troubleshoot • Hypotension after procedure • > 1 attempt –Non experience –Position –Not wait til onset of drugs • Myoclonus 1 time • Drug preparation time
  23. 23. Tip & Trick in RSI
  24. 24. Airway Assessment
  25. 25. Emergency Airway
  26. 26. Muscle Relaxation
  27. 27. Succinylcholine Rapid onset Profound depth of NMB Short duration of action
  28. 28. Succinylcholine’s weaknesses Cardiovascular effects sinus bradycardia nodal rhythm ventricular dysrhythm Increase IOcP Increase IGP Increase ICP
  29. 29. Succinylcholine’s weaknesses • Myalgia • Masseter spasm • Fasciculations • Anaphylaxis • Abnormal plasma cholinesterase • Hyperkalemia
  30. 30. 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
  31. 31. Contraindications • MH • Burn • UMNL • Severe muscle trauma • Disuse atrophy
  32. 32. Is Suxamethonium Really Safe ? Morbidity  Fasciculation  C-spine
  33. 33. Comparative Intubating Doses and Time to Intubation of NDMRs
  34. 34. 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
  35. 35. 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.
  36. 36. 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
  37. 37. 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)
  38. 38. 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
  39. 39. 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)
  40. 40. 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
  41. 41. Rocuronium bromide 0.6 mg/kg spontaneous recovery
  42. 42. Rocuronium bromide 0.6 mg/kg reversal of block
  43. 43. 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
  44. 44. หลับ
  45. 45. -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
  46. 46. -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
  47. 47. 0 20 40 60 80 100 BIS 0 1 2 3 4 5 CePropofol (mcg/ml) mean BIS mean Ce Propofol
  48. 48. Multi-compartmental pharmacokinetic models
  49. 49. Comp2 24 L Comp1 4.3 L Comp3 238 L Multi-compartmental pharmacokinetic models
  50. 50. Propofol Bolus 2 mg/kg
  51. 51. 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
  52. 52. IV Bolus Personnel Controlled Infusion • Drop counting • Intermittent manual injection
  53. 53. IV line Trouble Shooting • Occlusion • Air in line • Position • Technique
  54. 54. Infusion Devices
  55. 55. Pre-load
  56. 56. Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007 Aug;21(5):492-6. Leg Elevation
  57. 57. Response to increased cardiac load, obtained by leg elevation
  58. 58. The End Thank you for your attention

    Sé el primero en comentar

    Inicia sesión para ver los comentarios

  • raveeshsharm

    Sep. 19, 2012
  • ushasehrawat1

    Mar. 12, 2018

Vistas

Total de vistas

1.620

En Slideshare

0

De embebidos

0

Número de embebidos

222

Acciones

Descargas

29

Compartidos

0

Comentarios

0

Me gusta

2

×