Tayal- Intubacion Secuencia Rapida Medicina Emergencia de Urgencias – Download as PDF File .pdf), Text File .txt) or read online. series clínicas de medicina de urgencia secuencia rápida de intubación en el servicio de urgencia felipe maluenda pablo aguilera cristóbal kripper oscar navea. La secuencia de intubacion rapida (SIR) es un procedimiento disenado para disminuir el riesgo de broncoaspiracion mientras se asegura la via aerea mediante.
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Received 21 March – Accepted 5 July Abstract. The Intensive Care Unit ICU physician should have the skill to successfully manage patients requiring airway insulation on account of their poor ventilatory condition. The purpose of this article is to review the current knowledge regarding rapid sequence intubation in the ICU patients and to summarize the procedure to maximally reduce the risks of intubating a critical patient.
Clinical trials, meta-analysis, practicing guidelines, randomized controlled trials, reviews, case reports, classical articles, comparative studies, consensus conferences, and keynote speeches.
Published articles on intubation, rapid sequence intubation and ICU intubation were included, all focusing on orotracheal intubation of the critical patient and strategies for optimization of the maneuver. The search yielded 1, studies.
The abstracts were reviewed and those referring to the key review criteria were chosen: Fifty monographs met the selection criteria. A summarized presentation of the results is made and an approach to a modified rapid sequence intubation is suggested, based on the review accomplished. Intubation, Intratracheal intubation,Intensive care unit, Anesthesia. Unidad de cuidados intensivos.
Todos los derechos reservados. The first records about airway approach were found in Egyptian tablets dating back to b. Over three thousand years later, Alexander the Great saved one of his soldiers from asphyxia by making a small tracheal incision with the tip of his spade. InEugene Bouchut, a French pediatrician, developed a non-surgical blind orotracheal intubation technique: His technique was introduced at the Conference of the French Academy of Sciences in September 18, and was strongly opposed by the French surgeon Armand Trousseau, who promoted tracheostomy for airway obstruction.
Trousseau was the first surgeon to perform tracheostomies in Paris and who wrote a treaty encouraging its use. The goal of this paper is to review the current status of knowledge related to rapid sequence intubation in patients in the Intensive Care Unit, and to summarize what needs to be done in order to reduce risks during intubation of a critically ill patient to the greatest extent possible.
The search included clinical trials, meta-analyses, practice guidelines, randomized clinical trials, reviews, case reports, classic articles, comparative studies, consensus conferences and lectures. Published articles on intubation, rapid sequence intubation and ICU intubation that focused on the approach to the airway with orotracheal tube in critically ill patients and the strategies for optimizing the maneuver, were included.
My Emergency Medicine (): Secuencia de intubación rápida: controversias
The search resulted in 1, studies Fig. The abstracts were reviewed and the core criteria of the review were used for the final selection, namely, intubation protocols for ICU patients. Fifty essays fulfilled the selection criteria Table 1. The results are summarized, and a modified rapid sequence intubation sequence is proposed on the basis of the review.
Prior to the advent of the modern laryngoscope, the only way to visualize the larynx was through indirect techniques: Its importance lies in providing a safe intubation in patients at high risk of bronchoaspiration.
In Jaber et al. The main complications of intubation – cardiovascular collapse and hypoxemia – were cut in half in the intervention group.
According to the research it can be concluded that the protocols, conceived as orderly and sequential actions, as is the case in cardiovascular resuscitation, also improve morbi-mortality of the critical patient requiring intubation. Its protocol includes 10 steps Table 2. The short time available in the ICU and the critical scenario make it difficult to properly assess the airway. The nitubacion of a senior physician next to the person doing the intubation has secuenciq to reduce the complications associated with the procedure: The global rate of complications also decreased significantly 6.
Volume expansion There is no evidence to date of the administration of a fluid bolus prior to intubation; however, it is logical to think that this could be beneficial for the critical patient pre-intubation – except for patients with cardiogenic pulmonary edema – due to the following reasons: During pre-oxygenation, the nitrogen contained in the pulmonary alveoli is exchanged by oxygen, providing the patient with an additional oxygen reserve; hence, maneuvers such as laryngoscopy and intubation may intubaclon done avoiding deoxygenation.
It has been usually argued that during RSI positive pressure ventilation PPV should be avoided because rrapida insufflation favors bronchoaspiration. Stept and Safar published in July the iconic protocol for induction – intubation to prevent gastric aspiration. There has been considerable controversy about the best hypnotic agent for RSI.
Two aspects should then be considered: It should be kept in mind that the ideal hypnotic agent for an ICU patient is one that leads to minimum change in the hemodynamic parameters; however, contrary to our objectives, thiopental and intubacon, cause marked hypotension.
Etomidate and ketamine are effective hypnotic agents in patients hemodynamically compromised, 1718 and hence intuvacion the agents of choice in ICU patients. Please keep in mind that etomidete’s ability to induce adrenal failure and thus its use is contraindicated in septic patients.
Should you administer a predetermined fixed dose of the hypnotic agent as suggested by Stept and Safar in their original paper or, on the contrary rapuda the agent be titrated until loss of consciousness is obtained? With the former approach there is a risk of under or over-dosing the patient allowing the patient to be conscious or inducing drastic hemodynamic changes with the latter.
Those who are against of the titration technique claim that the induction last longer as compared to the classic technique; however, some authors like Barr and Thornley 21 have shown that while total induction time is longer, the period of time between loss of consciousness and intubation remains unchanged.
In the RSI puzzle, succinylcholine is the key player: What makes succinylcholine so special? Studies show that when succinylcholine is used in RSI protocols, identical intubation conditions are achieved, regardless of the hypnotic agent selected. Up to this point, we have explained in detail why succinylcholine is the muscle relaxant of choice for rapid sequence intubation in the standard patient.
Additionally, the absolute rise in the number of receptors leads to an overproduction of potassium. Leiman showed that in addition to the raise intjbacion potassium following a succinylcholine injection, the automaticity of the cardiac cells increases and the threshold for ventricular fibrillation decreases as a result of the rise in catecholamines.
Succinylcholine briefly raises inutbacion levels of norepinephrine and epinephrine due to its impact 20110 the presynaptic nicotinic receptors rapiva the postganglionic sympathetic nerve endings. Then, what is the option to relax patients in the ICU? Rocuronium is a non-depolarizing muscle relaxant with sexuencia fastest onset of action.
Opioids were initially excluded from RSI due to their slow onset of action and extended effect.
Though Jaber failed to consider the use of opioids in his protocol, in view of the available evidence we suggest the inclusion of one of the fast-acting opioids in the RSI protocols for ICU patients. Whichever the choice, it should be administered before the hypnotic agent. By applying pressure over the cricoid cartilage against the cervical vertebrae of a corpse, Sellick realized that regurgitation of the gastric contents in the pharynx could be prevented. Then he applied the technique in 26 patients with high risk of aspiration during anesthetic induction, and none of them experienced regurgitation or vomiting.
Since then, Sellick’s maneuver SM is a must when intubating patients at high risk of aspiration. The current recommendation is to apply a pressure of 10 Newton N 1kg in the patient when awake and 30N 3kg 37 in the unconscious patient. There have been however several reports about fatal aspiration and regurgitation, despite the use of the SM. The most recent Cochrane review on hypotensive shock 45 23 clinical controlled, randomized studies including patients with hypotensive shock were analyzed.
The authors concluded that there is no difference among the six vasopressors norepinephrine, dopamine, epinephrine, vasopressin, terlipressin, dobutamine analyzed in terms of mortality and that probably, the choice of vasopressor does not affect the final result.
However, in one of the largest studies comparing norepinephrine versus dopamine, 46 the subgroup analysis according to the type of shock, showed a beneficial effect on the day mortality in patients with cardiogenic shock treated with norepinephrine; the drawback was that the randomization was not stratified and hence the differences could have been random.
Until additional information is made available, it is impossible to determine which is the vasopressor of choice for the management of persistent hypotension. What is protective ventilation? In an independent study, Ranieri showed that protective ventilation decreases the cellular inflammatory response. A major requirement is to preserve a low tidal volume. Based on the scrutiny of the available medical literature on RSI in the ICU, we would like to suggest a modified sequence Tabla 3convinced that only a rigorous follow-up of our will show the benefit of the technique.
Steps suggested by the authors for rapid sequence intubation in intensive care patients. The adoption of protocols is a strategy that has proven to be of lower mortality in medical practice, for reasons including the fact that our reasoning may get blurred under highly stressing situations.
Protocols are a tool to regain control of the situation and provide us with valuable time to analyze the circumstances surrounding the event. This modified Jaber’s protocol for rapid sequence induction – intubation in the intensive care unit is intended as a handy therapeutic tool for critical patients; we hope that, just as with the original protocol, the modified algorithm will contribute to reduce the morbidity and mortality in our patients.
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Guia para la secuencia de induccion e intubacion rapida en el servicio de emergencias.
Yearbook of Intensive Care and Emergency Medicine. United States of America: Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. Intibacion patients be manually ventilated during rapid sequence induction of anaesthesia? Br J Hosp Med Lond. Difficult Airway Society guidelines for management of the unanticipated difficult intubation.
Rapid sequence induction and intubation: Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients.
Stept WJ, Safar P. Rapid induction-intubation for prevention of gastric-content aspiration. Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia.
Comparative evaluation of intravenous agents for rapid sequence induction-thiopental, ketamine, and midazolam. A review of etomidate for rapid sequence intubation in the emergency department. Should etomidate be used for rapid-sequence seduencia induction in critically ill septic patients? Am J Emerg Med.
Thiopentone and suxamethonium crash induction. An assessment of the potential hazards. The neuromuscular effects and tracheal intubation conditions after small doses of succinylcholine.