The Papers
Discussion of the Recent DSI RCT
Always Add a Delay
Creating a standard pause before the administration of the muscle relaxant allows one last safety check. It can be 2 seconds or 4 minutes or be the point at which the decision is made not to administer the muscle relaxant at all.
Benefits must significantly exceed risks
Benefits
Just the Right Dose
Morbidly Obese Patients
Hemodynamics
Innate resistance
Last Minute Positioning and Preox
Switch to BVM
ETO2 Check
Position the patient exactly where you want
Hemodynamics
Allows you to see the result of induction before the admin of paralytics
Pain Relief
RCT demonstrated this
Actual Administration of the Intubation Meds
Better Respiratory Pattern
Train One Way
RSI with occasional DSI is a real problem
Risks
Vomiting
Not during the Ketamine
Place an NGT
Apnea
Not a thing, but if it ever occurred, just RSI
Laryngospasm
A thing in peds, not in adults
but if it occurs, just RSI
Hemodynamics
Worse with the standard RSI
Hypersalivation
Better with DSI
We wouldn't always have to DSI
Non-DSI would become a specialty intubation for situations where DSI is contra-indicated, though I am having trouble thinking of any
The U of Pittsburgh Trial I mentioned
Make an impact! Advance the development of high-quality, practice-changing medical education for physicians.
We want to change the paradigm of continuing medical education in the US, and need the participation of physicians who practice on the front lines to figure out what works best. As part of an NIH-funded trial, we will randomize ED doctors to play a customized trauma triage video game (Night Shift) or to a control.
Those in the game arm will be asked to play the game (2 hours in the first month; 20 minutes a quarter x 3 quarters) and complete a virtual simulation (<1 hour) and will receive an iPad, a $25 gift card/booster session, and 3 hours of CME.
Those in the control arm complete a virtual simulation (<1 hour) and will receive a $100 gift card.
If you triage adult injured patients at a Level 3-5 trauma center or a non-trauma center and are willing to complete all the study tasks, we would love your help.
You can find more information about the trial, and the consent form here: emcrit.org/pittstudy
Additional New Information
More on EMCrit
- Ketamine ……. then Rocuronium, DSI & The Timing Principle
- EMCrit 137 – Delayed Sequence Intubation ( DSI ) Update
- Delayed Sequence Intubation (DSI)
- EMCrit 40 – Delayed Sequence Intubation (DSI)
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Now on to the Podcast
- 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
Hi Scott! Great post, as always! I think DSI is great and I’ve used it in a lot of patients over the years. However, during the last year or so, I have mainly converted to a light DSI procedure for most of my critical care intubations. One of the most important findings of the Intube trial a couple of years ago was that circulatory compromise is really really common, and impacts mortality, in greater degree than hypoxia. So, what can we do to mitigate this problem: Do the intubation with as litte medication as possible. I do most of my… Read more »
Great this is perfect now, Scott! You have now had the opportunity via this episode to lay down the foundations and framework for your arguments to move to DSI as the new standard for critical care intubations. So I say publish our debate! Our actual recording time was a little over an hour but I’m sure you can shave it down just a bit and on the contrary I think people would enjoy listening to our back and forth! 🙂
Sam
I’d certainly grab a Porter or Stout and listen to the whole discussion! May need more than one!
Great episode. DSI is standard of care for me. I’m not sure there are any real downsides. You can always convert to RSI if needed. In my mind, the greatest benefit is allowing a team to focus outside the airway. The airway is usually the highest risk event of a resuscitation and demands well deserved respect. However, this often creates a tunnel vision phenomenon, leading some to miss hemodynamics or other important pieces. RSI compounds this error as it forces one to cross the Rubicon, whether they ready or not.
great points!
Thank you for this excellent discussion. I do agree that the benefits outweigh the risks. I will aim to use this method with most of my future intubations if possible. However, I would like to hear the counter arguments from Dr. Ghali and other colleagues. One possible reason for not proceeding with this paradigm shift would be the shortage / absence of ketamine. At Janus General on the West Coast, ketamine is on back shortage. It is only being used for some spinal surgeries and refractory status epilepticus. Thank you again for this excellent discussion and all of the wonderful… Read more »
Scott, Really nice discussion, as usual, with nuanced thought about risks and benefits. My anecdotal experience regarding the effects of ketamine in DSI on patients’ respiratory physiology is different from yours. I’ve found it to have patient-specific, differing effects depending on the underlying pathophysiology. For example, I agree that in patients with obstructive lung disease and hypercarbic respiratory failure, ketamine most often improves gas exchange by allowing for a breath rate/tidal volume pattern that improves alveolar ventilation and subsequent pre-oxygenation efficacy. However, in patients with primary hypoxic respiratory failure with high minute ventilation and high inspiratory flow (i.e. COVID-19 ARDS,… Read more »
Hey Byron, Oxygenation is flow independent past the 250 ml/min alveolar ventilation cutoff–meaning any decrease in minute ventilation (which occurs not due to intrinsic ketamine effects, but b/c ketamine lowers the “I am dying” minute vent increase) will have no effect on oxygenation at all. The only way ketamine could have an adverse effect on oxygenation is if the respiratory pattern somehow decreased recruitment and therefore increased physiologic shunt. This is unlikely, but shouldn’t even be relevant because the patients you describe should be either already on or transitioned as soon as you push the ketamine to some form of… Read more »
That’s a good point. The cases I’m remembering were all on HFNC prior to the DSI. Thanks!
DSI for all- even if the “delay” is 5 to 10 seconds to make sure everything is perfect. Very few patients who need RSI actually need the “rapid” part of it and we would more often benefit by taking a breath ourselves and making sure we are optimized before we start the intubation attempt.
Hi Scott! Great podcast, and I have been convinced that DSI is likely the way of the future. In your podcast, you did mention that you’ve rarely heard of laryngospasm in adults. I wanted to share an experience that I had recently with one of my residents, a case where an agitated patient was brought in via EMS combative and not better with prehospital benzos. The patient was administered 5 mg/kg IM, was moved from EMS gurney to our stretcher, placed on O2 and end-tidal as well as pulse oximetry. A few minutes after moving over, end tidal was lost… Read more »
thanks so much for sharing this case, Chris!
Hi Scott! Great discussion like usual. I am a Family Doc, but live in a very rural area and the system depends on me providing a great deal of ER care. Education from you and your guests has allowed me to provide the best care I can given my resource limitations. I would humbly argue that yes DSI should be the preferred initial approach, particularly in my setting where pre-intubation hemodynamic and oxygenation optimization is critical. I also do medical direction for rural EMS agencies that have transport times of up to 60 minutes even with some 911 calls, let… Read more »
Absolutely.
I used it in one situation and it worked perfectly.