So today we have our June-u-airway update… A bunch of papers and thoughts on how you should be intubating in 2023. DSI for everyone, induction agent choice, apox and much more!
Delayed Sequence Intubation (DSI) for Everyone?
RCT of DSI for Trauma Patients
Methods
Patients presenting to the Trauma ED needing intubation (most due to obtundation, not resp distress). Patients with anticipated difficult airway, extensive burns, active vomiting, crash intubations, or cardiac arrest were excluded from the study. All patients with unanticipated difficult airway encountered during the study were excluded from the primary analysis.
Intubations performed by Anesthesia Resident
RSI-3 min preox followed by ketamine 1.5/sux 1.5
DSI-0.5mg/kg aliquouts until dissociation, 3 min preox, 1.5 sux
Results
The primary outcome (ie, incidence of periintubation hypoxia) was significantly higher in group RSI (35 [35%]) than in group DSI (8 [8%]; P = <.001*;
The first-pass intubation success rate was significantly
higher in group DSI compared to group RSI (P
= .020); 83% of patients in group DSI and 69% patients
in group RSI were intubated on the first attempt
A multivariate analysis revealed technique
of intubation (DSI versus RSI) to be a significant
predictor of peri-intubation hypoxia (adjusted odds
ratio, 6.82 [2.82–16.48]; P = .001) among all other factors
If public, use the below and change member area from both to none
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
My theory on ApOx is that it was introduced at a time when ED RSI pre-ox was not great and it made up for crappy pre-ox. I started residency in 2009 and have informally polled others in my cohort inside and outside of my residency program and we came up with the same practice pattern that pre-ox wasn’t something we really payed a lot of attention to. It wasn’t uncommon to take a patient who was saturating normally (for example- an agitated trauma patient) and maybe put them on 15 L NRBM for a minute before the drugs got pushed.… Read more »
Hi Dr. Weingart, At my current shop, ketamine is in shortage until April 2024. There is some hesitancy from our pharmacy colleagues to approve use of ketamine as an induction agent (in order to preserve it for refractory status epilepticus). What are your thoughts on a second option induction agent for a patient with hypotension? Although we have reviewed the meta analysis showing etomidate’s worse outcomes, my colleagues and I are still using etomidate as an induction agent. We will also use fentanyl and midazolam although I do worry about the onset of action of these agents during RSI. Thanks… Read more »
I’d probably use propofol with push-dose pressors. Not crazy about fentanyl midazolam
That makes sense. Thank you.
-Pri
Nice review Do you think one unintended benefit of DSI could be nearly certain avoidance of patient awareness? I know the most important strategy there is to just make sure we adequately sedate the patient post intubation. Especially while paralyzed. And proper use of pressors to support the blood pressure you may get from adequately high doses of sedation post intubation. But do give one example. I’m imagining a young trauma patient who is altered, decreased loc, has some drastic number of traumatic injuries and you have decided they need to be intubated. Let’s also imagine he is hypotensive. That… Read more »
discussed this in the hemodynamically neutral intubation, the awareness after paralysis, and the bariatric critical care podcast. this is one of the primary advantages of DSI
So if I was going to review trauma airways retrospectively on video in the trauma bay what would be key things I would want to see that would demonstrate a well managed airway? What the things I wood not want to see?
Dr Weingart, can you please talk about ECLS ECMO and ECMO CS trails, and what it means for eCPR if it does ?
Always enjoy your work and find it very helpful.
Thank you