4/6/2023 0 Comments Rapid sequence intubationIdeally, the patient would go directly from breathing deeply (recruiting their lungs and clearing carbon dioxide) to a state of unconscious paralysis (blue curve below). The entire concept behind rapid sequence intubation is that the sedation lag time should be as short as possible. A prolonged sedation lag time will cut into the safe apnea time, reducing the time available to perform laryngoscopy. During the sedation lag time, bad things are happening: the patient's respiratory efforts drop, the lungs start to de-recruit, PaO2 starts falling, and PaCO2 is increasing. The sedation lag time is the interval in between onset of sedation and when the patient reaches complete paralysis. Given his morbid obesity, he is likely to de-recruit, shunt, and desaturate rapidly. ![]() He is starting off with a saturation of 96%, near the steep portion of the desaturation curve. ![]() For this patient, the apnea time is probably closer to 2 minutes (yellow arrow above). For normal people undergoing elective anesthesia, this may be close to ten minutes (blue arrow above). The safe apnea time is the amount of time that a patient will tolerate apnea,īefore developing critical hypoxemia. (b) Push ketamine, then push rocuronium.ĭefining time intervals in RSI Safe Apnea Time.(a) Push rocuronium, then push ketamine.What is the best order of administration of medications? Even with perfect preoxygenation, you can't get his oxygen saturation above 96%. You need to perform RSI on a man with morbid obesity in hypoxemic respiratory failure. This post explores what might seem like a trivial detail: the ideal order of administration of rocuronium and ketamine for rapid sequence intubation (RSI). Optimizing each detail increases the likelihood of success. ![]() The difference between success and failure hinges on details. An endotracheal tube placed too deep can cause hypoxemia and pneumothorax. Failure to recognize and remove dentures is an enormous pitfall. Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache. Apneic oxygenation can improve first-pass success. Minor nuances of patient positioning can be essential. Airway management is a detail-oriented sport.
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