Cite this post as:
Scott Weingart, MD FCCM. Response to a Letter to the Editor on DSI Study. EMCrit Blog. Published on December 18, 2015. Accessed on March 29th 2024. Available at [https://emcrit.org/emcrit/response-to-a-letter-dsi/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: December 18, 2015
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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The authors of this letter seem to be missing the point of DSI and airway management in the critically ill, most notably with their title “danger in delaying definitive airway.” A more apt title might be: “Delayed Sequence Intubation: Avoiding premature intubation.” It is uncommon that intubation is an immediate necessity. Delaying intubation a few minutes to allow for supporting the patient’s physiology (e.g. start pressors for hypotension, preoxygenation) and completing preparations for intubation is generally a very smart move. Alternatively, rushing to intubate an agitated patient prematurely is a formula for disaster. I’ve had great results with DSI. The… Read more »
thanks buddy. I think most intensivists agree on this. I think it was George Kovacs who came up with the slogan Resuscitate, THEN intubate.
Intubations in the ED, ICU, OR, PACU and in the field are all potentially complicated by factors unique to the their setting. I find that the cross analysis from those primarily in one arena can be biased with what I call the operators realm of perspective. Scott you bring up a great point describing that most intensivist agree on Josh’s comments. For me to go into the OR or come down to the ED and critique your practice (though welcomed from an academic perspective) may be misguided since I do not work in that environment. I find that the ICU… Read more »
Scott, great response, and thanks once again for the shout.
One uncertainty about DSI remains for me: the pt who’s not starting hypoxic, but of course I still want to denitrogenate him, and he won’t let me due to his deliurium. For instance, a combative TBI pt satting 97% on RA, who needs intubation to allow safe prehospital transport, or to facilitate timely CT in the ED setting. I’m still DSI-ing this patient, because I want both the added safety of full denitrogenation and the calm preparatory environment Josh talks about above. Are you with me?
Bill–a good number of the DSI patients in the study and subsequently were solely for denitrogenation. I want to say a 1/3 of them but I don’t have the study in front of me right now. So totally agree.
Hi Scott. Interesting argument for DSI and subsequent response to the somewhat confusing letter to the editor. My take is that the writers are concerned that procedural sedation pre-intubation has the potential to derecruit, cause bradypnea, etc., resulting in actually worsened intubating conditions, and that this caveat might not be universally appreciated. Conceptually, I think DSI is a reasonable approach (although I continue to be baffled by this insistence on nasal cannula :)). My style is slightly different – depending on the situation if I am not able to effectively preoxygenate the patient while spontaneously ventilating I will induce and… Read more »
When using DSI you carefully titrate ketamine which vitually never will induced apnoea or bradypnea. Inducing paralysis and ventilating is actually what we want to avoid in these patients and though you may feel comfortable with this approach the evidence speaks otherwise.
Thanks for the response. I don’t think the data is that strong advocating any particular approach – ketamine can certainly depress respiratory function if used incorrectly; I personally don’t like the “classic” RSI because then I’m just sitting there looking at the sats going down, which is why I tend towards a ‘modified’ RSI. Induction with your choice of drug (where knowledge of the pharmacokinetics and patient physiology are arguably more important than the particular drug selected), paralysis, and careful ventilation certainly obviate the need for pt buy-in, and rapidly achieve a definitive airway. That said, different patients may call… Read more »
Hey Erik. I think your method is what the vast majority of clinicians – especially anesthesiologists – do when confronted with these patient scenarios. I think this method can work if you are a very fast and the patient isn’t really really hypoxic. In short, for the patients with a pulse ox of 92% on a non rebreather (who are intermittently pulling it off ‘cuz they are delirious), your method usually works just fine (as long as the tube goes right in the first shot with no problems. The issue becomes more dangerous for the really really hypoxic patients though… Read more »
Sorry, I just saw this post today (5 months later!). Thanks for the thoughts – I’m always interested in maximizing patient safety – even tried the nasal cannula thing under the mask the other day – can’t say I’m a believer yet (and it screwed up my ETCO2) but I keep tinkering. Re the patient breathing with ketamine, a few things: ketamine has been around since the mid 60’s and it never really became ‘prime-time’, except for I suppose peds. People who have been around a while (and I mean like 40 years) seem to shy away from it –… Read more »
Hi Scott,
Thanks for DSI.
The essence of resus is delivering oxygen to the patient safely.
DSI, is a step in delivering effective oxygenation.If DSI allows an obtunded patient to come back from the brink as you have described and look after their own airway – that is the ultimate airway.
A definitive airway is just a method of delivering O2 and RSI is not the object of the exercise anymore than DSI.
Great job
I am a state EMS medical director and we have noticed a trend for pre RSI hypotension and or hypoxia to set up patients for a post RSI arrest. We are educating many pre hospital providers/ medical directors to try and maximize pre RSI resuscitation. We also really like the idea of using ketamine and then either bagging the patient up prior to paralytics if they are hypoxic as trying to get the BP up. We just got abstracts at SAEM accepted looking at vital signs prior to RSI how they can help predict who is more at risk for… Read more »
I am a Paramedic and an RN in rural Maine where we have been using these techniques discribed for in my opinion for years. Dr Peter Goth has validated these through the techniques of airway management. Airway management more specifically definitive management is not a rushed event but a very methodical decisive process there is nothing rapid about it, as it usually results in failure, where failure is not an option. The fact is this we in rural ER’s and in the pre hospital setting do not have resources to pull should things not go right, hence DSI prevents failure,… Read more »