Procedures Final Exam: RSI and procedural sedation

RSI is the simultaneous administration of induction agent and NMBA agent to induce unconsciousness and paralysis to facilitate endotracheal intubation (cannot be done emergent situations)

regular intubation causes:
- catacholamine release in awake pts (increased BP, ICP, HR)
- physical placement (emesis/aspiration, trauma, decreased BP)

RSI will paralyze and sedate the pt so catacholamine release side effects prevented (not physical placement) + prevents complications of combative pt
- undetected supra-glottic edema is another complication for intubation
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RSI is the simultaneous administration of induction agent and NMBA agent to induce unconsciousness and paralysis to facilitate endotracheal intubation (cannot be done emergent situations)

regular intubation causes:
- catacholamine release in awake pts (increased BP, ICP, HR)
- physical placement (emesis/aspiration, trauma, decreased BP)

RSI will paralyze and sedate the pt so catacholamine release side effects prevented (not physical placement) + prevents complications of combative pt
- undetected supra-glottic edema is another complication for intubation
RSI is the simultaneous administration of _____ agent and _____ agent to induce _______ and ______ to facilitate ______. Explain what complications this may prevent from occurring and whether or not this can be done in emergent situations.
catacholamine release - increased ICP, BP, tachycardia

physical placement - trauma, emesis/aspiration, decreased BP
What intubation complications are caused by catacholamine release vs. physical placement?
RSI medication sequence:
1. pre-induction - calms pt/makes them remember less
2. induction - sedates pt
3. NMBA - paralyzes pt (including diaphragm)

*recall: must pre-oxygenate patient for ~5 minutes prior to starting intubation (before pre-treatment with pre-induction/induction)
RSI optimizes the conditions to achieve rapid airway and decreases physiologic hemodynamic response to intubation (catacholeamine release). Explain the medication sequence for RSI.
pre-induction agents (calms pt)
- fentanyl (1-3 mcg/kg)
- lidocaine (1.5 mg/kg)
- atropine (0.02 mg/kg, max of 0.5 mg)

induction agents (sedates pt)
- etomidate (0.3 mg/kg)
- ketamine (1-2 mg/kg)
- midazolam (0.2-0.3 mg/kg)
- propofol (0.5-1.2 mg/kg)

NMBA (paralyses pt)
- succinylcholine (1-1.5 mg/kg)
- rocuronium (0.6-1.1 mg/kg)
- vecuronium 0.08-0.1 mg/kg)
List the pre-induction agents, induction agents, and NMBA agents used in RSI.
fentanyl - blunts HTN and ICP increase from intubation (good for hypertensive pts)

lidocaine - may reduce bronchospasms

lidocaine - prevents ICP increase by blunting cough reflex

atropine - good for pediatric pts

lidocaine - avoid in bradycardia or severe heart block pts

atropine - increases HR to avoid vagal induced bradycardia (vagal stimulation common in peds so this is why its good for them)

onset fastest to slowest: fentanyl > atropine > lidocaine
- fentanyl: < 30 seconds
- atropine: 30-60 seconds
- lidocaine: 45-90 seconds

duration longest to shortest: atropine and fentanyl > lidocaine
- fentanyl and atropine: 30 min-1 hour
- lidocaine: 10-20 minutes
For the pre-induction agents for RSI which:
- blunts HTN and ICP increase from intubation (good for hypertensive pts)
- may reduce bronchospasms
- prevents ICP increase by blunting cough reflex
- good for pediatric pts
- avoid in bradycardia or severe heart block pts
- increases HR to avoid vagal induced bradycardia

list the order of onset and duration for these drugs.
etomidate
- doesnt affect BP
- causes myoclonic jerks
- transient decrease in cortisol

*induction agent
pts given this agent during intubation will have myoclonic jerks as they come out of sedation or the drug wears off (not a seizure and is normal). What other responses will this drug cause? (RSI)
ketamine
- causes transient rise in BP and HR (caution in acute MI)
- does not affect respiratory drive
- amnestic, analgesic properties
- emergence delirium, hallucinations

*induction agent
pts (esp. children) given this agent during intubation may have delirium or hallucinations when they come out of sedation. What other responses will this drug cause? (RSI)
etomidate:
- doesnt affect BP
- transient decrease in cortisol
- myoclonic jerks

ketamine:
- transient increase in HR and BP (caution in AMI)
- no effect on respiratory drive
- delirium, hallucinations

midazolam:
- HOTN and respiratory depression (dose related)

propofol:
- HOTN, bradycardia, decreased ICP

duration (longest to shortest): midazolam > ketamine > etomidate and propofol
- midazolam: 1-4 hours (long term sedation)
- ketamine: 5-15 minutes
- etomidate and propofol: 4-10 minutes

*ketamine has fastest onset (15 sec), etomidate and propofol (45 sec) and midazolam (60-90 sec)
For the induction agents used in RSI, which:
- does not affect BP
- causes transient rise in BP and HR
- does not effect respiratory drive
- causes hypotension
- causes bradycardia
- may cause dose-related respiratory depression
- decreases ICP

how long do each of these agents last?
succinylcholine: depolarizing NMBA (has no reversal agent)

may increase K+ release so avoid in:
- MD
- burn pts
- spinal cord injury
- renal failure, hyperkalemia
- rhabdomyolysis
- prolonged bed rest or immobility at baseline

may elevate ICP, IOP, or cause regurgitation
- avoid in glaucoma due to IOP increase

succinylcholine is limited to use in RSI
This is a depolarizing NMBA agent used in RSI. Who should this be avoided in and why?
duration (longest to short): vecuronium > rcuronium > succinylcholine
- suucinylcholine: 3-5 minutes (popular for intubation since paralysis is short duration)
- rocuronium: 30 minutes
- vecuronium: 20-40 minutes

*these cause paralysis, so if you use rocuronium or vecuronium may need to dose induction agent (etomidate/propofol and ketamine) multiple times since these last up to 10 and 15 minutes respectively. (recall: rocuronium/vecuronium can be reversed with sugammadex)
- inadequate sedation will cause amnesia/pt may remember being paralyzed but awake during procedure
what is the duration for the different NMBA agents used in RSI?
sugammadex (16 mg/kg IV, max dose: 96 mg/kg) can be given to reverse rocurnium and vecuronium to reverse paralysis (cannot be used for succinylcholine) succinylcholine is a depolarizing NMBA while the other two are non-depolarizing agents that compete with ACh to bind to AP receptorsIf you fail or have delayed intubation attempts, what agent can you use to reverse paralysis and when can this not be used? (RSI) ______ mg/kg IV with max dose of ____ mg/kgreduce sedative doses (induction agents: ketamine, etomidate, midazolam, propofol)you should reduce ____ doses when used in combo with opioids for RSInon-depolarizing NMBA need repeat induction agent doses - rocuronium or vecuroniumYou should NEVER allow a patient to be aware of their paralyzed state, which is why _____ (depolarizing/non-depolarizing) NMBA need repeat doses of sedative/induction agents during RSI.want moderate sedation (conscious sedation) for procedural sedation - moderate sedation means the pt can purposefully respond to verbal commands (even if drowsy) and pt will be able to breathe on their own (pt is awake but is sleepy and calm, may not remember everything) - reflex withdrawal to painful stimuli does NOT count as purposeful response for minimal sedation the pt would be awake (not sleepy) and calmProcedural sedation is used for patients undergoing uncomfortable procedures. What type of sedation do you want in these patients?-endoscopy -bronchoscopy -cardioversion (ablation, TEE too) - eye surgery - EM - obstetrics - MRI (clausterphobic pts)for procedural sedation, you want to have conscious sedation, where the pt is awake but sleepy and calm. they should be able to protect their own airway and be able to respond to verbal commands despite being drowsy. What are some example procedures that may require moderate-sedation?achieve shortest period of impaired consciousnessThe goal for procedural sedation is to achieve the ____ period of _____ consciousness. during this procedure you should continuously monitor the pt to ensure they can still respond to commands, their pain is controlled, and to monitor their vitals.-propofol (induction for RSI) -ketamine (induction for RSI) -midazolam (induction for RSI) -fentanyl (opioid, pre-induction for RSI) also etomidate (not used often so can skip) *recall procedural sedation is conscious sedation and the pt is still awake so lower doses than seen in RSIWhat agents are used for procedural sedation?see notes for dosing differences for RSI and procedural sedationpropofol: - adverse effects: decreased HR and BP (and SVR), respiratory suppression, injection site pain - avoid use: egg, peanut or soy allergy - MOA: GABA agonist same adverse effects for RSI except respiratory suppression and injection site pain dont matter for intubation (pt not expected to breath on their own due to other NMBA) +When used for procedural sedation, what are the adverse effects of propofol and when should use be avoided?ketamine: - ADR: emergency reactions such as delirium (tx with benzos), bronchospasms, HTN (caution in acute MI/high BP pts) - used more for pediatrics! bold = same ADR as when used for RSIWhen used for procedural sedation, what are the adverse effects of ketamine and when should use be avoided?ketamineWhat procedural sedation agent is used most often in children?midazolam - MOA: GABA agonist (recall propofol is also GABA agonist) ADR of midazolam: hypotension, respiratory depression caution use: renal failure, obesity, elderly, CYP3A4 BOLD = SAME ADR AS WITH RSI USEthis procedural sedation agent does not have analgesic properties so it is often used with fentanyl. What are the ADR of this drug and when should it be avoided?fentanyl (opioid) - can be used alone or with midazolam for procedural sedation (if used in combo, reduce fentanyl dose) ADR: HOTN, respiratory depression, chest wall rigidity caution: CYP3A4, chest wall rigidity ***try to use ketamine or propofol before resorting to opioid for procedural sedation BOLD = SAME ADR AS WITH RSI USEthis medication may be used alone or in combination with sedatives for procedural sedation. Explain the ADR, cautions, and recommended dosing when using alone and in combo.false -pt must be able to respond to verbal stimuli and follow commands (reflex withdrawal to pain does not count as purposeful response) must also monitor HR, BP, RR, O2, and capnography (end tidal CO2)T/F: For procedural sedation, the patient should at least be able to withdrawal hand when pinchedrescue therapy for HOTN: - phenylephrine 100 mcg IVP q 10 minutes PRN (max of 2-3 doses since repeated use may decrease cardiac output)After giving a patient 1 mg/kg with repeated 0.5 mg/kg every 5 minutes for procedural sedation they become hypotensive. What do you do?hydrocortisoneEtomidate can cause transient decreases in cortisol, if you are concerned for cortisol suppression what would you give the patient?benzosKnowing that patients on ketamine can have emergence phenomenon (wake up wild/delirious), what should you treat them with?for benzos/sedatives (midazolam, ketamine, propofol, etomidate): - flumazenil 0.2 IVP q 2 min (max 1 mg) - does not reverse respiratory depression and has seizure risk if pt on chronic benzos for opioid reversal (fentanyl): - naloxone 0.4 mg IVP every 2 minDuring the procedural sedation, the patient stops responding to verbal commands and only reflexes draws their arm away to painful stimuli. How do you reverse excessive sedation or delayed awakening?