Rapid Sequence Intubation of Patient with Bleeding Tonsillitis - Essay Example

Rapid Sequence Intubation (Patient with bleeding tonsillitis) Number of words 316 Rapid Sequence Intubation (Patient with bleeding tonsillitis) Tonsillectomy is one of the most common surgical procedures performed. Over 144000 such surgeries have been performed in the US alone. One of the most feared complications of this surgery includes post surgical bleeding. About 1% -4% of patients are reported to have a complications related to bleeding after tonsillectomy. As the bleeding causes obstruction of airway passage, tubulation is indicated. Rapid Sequence Intubation (RSI) is a commonly used technique for managing airway emergencies. The technique involves tabulating the patient along with the use of anaesthetics, muscle relaxants and paralytic agents. Pre-treating patients with a number of agents to counteract the potential adverse effects of intubulation is also adopted. The basic tenet behind application of RSI is the assumption that the patient has a full stomach and therefore would face dangers from aspiration. In the case cited, the patient is being wheeled in for readmission due to bleeding after tonsillectomy. Choice of RSI would be ideal for this patient because: The patient may not have an empty stomach and an ideal candidate for RSI. The conscious patient may become combative during the intubation and the phamacological agents will ease the patient and make the process easier. The patient is apneic and cannot maintain, ventaillate or protect airway Cannot be oxygenated Is being wheeled back into Operation Room (OR) for specific procedure to correct bleeding. When applied by skilled technicians RSI shows an intubation success rate of 98% and reduces complications. Schwartz et al report that 3% of intubation in the critically ill are fatal within30 minutes and as high as 8%-18%intubations get misplaced in the esophagus. About 4%-5% result in incidents of aspiration. This data highlights the importance of assessment prior to intubation and the importance of correct pharmacological interventions before RSI. While assessments are important it has been highlighted by studies that in 70% of situations it practically impossible to conduct assessments in the critically ill. The American Society of Anaesthesiology has classified clinical factors in tabulating patients in terms of "airway difficulties." Accordingly: Difficult to ventilate: When a trained physician is unable to maintain an oxygen concentration > 90%. Difficult to tubulate: When more than three attempts lasting >10 minutes are needed for intubation. It has been found that 78% of tubulation attempts in emergencies resulted in complications. The need for proper assessments before tubulation is therefore imperative.(Amer.soct.Anaesth.2003) There can be anatomical and functional impediments for placing a face mask. Anatomical barriers include abnormal anatomy of the face upper or lower airways, compliance of the thoracic and abdominal cavities and so on. Functional problems include obesity, chest and diaphragm restriction, decreased respiratory compliance and the like. During RSI, the soft palate tissue rather than the tongue offer the most resistance. This phenomenon is further enhanced by relaxation of this tissue by the agents used in RSI. The excess secretion like saliva and in this case the blood may be aspirated. "Ventilation is assisted by a jaw thrust or head tilt, the placement of either a nasopharyngeal or oropharyngeal airway, and the application of positive-pressure assisted ventilation." (Stuart. F. Raynolds, John Heffner.2003) Visual Indicators of a difficult tubulation are: Short, fat neck Small, receding chin Presence of a beard Large tongue Poor mouth opening, and/or neck mobility Facial injury with excess oral secretions Facial and/or neck burns Fractured mandible Laryngeal injury (Robert M Pousman, DO.2000) Patient Assenssment: Forms an important component in the success of the procedure. The Mallampati system is the usual assessment system for menatlly alert patients requiring elective procedures. A Mallampatti value of I or II predicts ease of operation. A value above II predicts difficulties. Models using multivariant analysis taking multiple clinical factors have also been used for patients in elective situations. (Stuart. F. Raynolds, John Heffner.2003) The stages of tubulation through RSI include functions: Preoxygenation (using 100% oxygen to purge Nitrogen) . pretreatment to counter effects of intubulation are also administered at this time Induction to induce sedation Administering paralytic agents for muscle relaxation.( Ezir T, Szmu P, Warters RD, Katz J, Hagberg CA.2003) The 3 phases of RSI are pre-oxygenation, pretreatment and induction, and paralysis. In certain situations, clinicians may then administer one or more of a number of pretreatment medications to counteract potential adverse effects of intubation. Following this, an induction agent is administered to provide sedation and amnesia, and a paralytic agent is usually administered to provide muscle relaxation. (Textbook of Trauma Anesthesia and Critical Care. Grande CM, ed., St. Louis, Missouri: Mosby - Yearbook, Inc. 1993.) The direct use of laryngoscpe, stimulating the larynx witha blade and insertion endotracheal during RSI causes a rise in Mean Arterial pressure(MAP) and an increase in heart rate (HR), intraocular, intragastric, and intracranial pressures (ICP). This has to be managed using suitable pharmacological agents. Selection of pharmaceutical agents are an integral part of the success of the procedure. (Textbook of Trauma Anesthesia and Critical Care. Grande CM, ed., St. Louis, Missouri: Mosby - Yearbook, Inc. 1993.) Pretreatment agents Lidocain- Useful in reducing ICP. This has to be administered 2 to 3 minutes before the procedure > Shown through have an adverse effect on HR and BP. This may not be the agent of choice for the case as the wait is impractical, owing to the haemodynamic profile may not be safe. Beta-adrenergic antagonists (Esmolol)- Does not significantly increase BP or HR. Contraindicated in patients with broncho spasms, aortic valve disease and in children as they shown more bradycardic response. As tonsillectomy is usually performed in children, this may not be the agent of choice for the case. Opioids- Used for RSI conscious sedation. Shows attenuation of BP but unable to affect tachycardia. Synthetic opioids have rapid onset and short duration of action and are widely used in ER. It increases ICP and stiffening of chest wall. The agent will not give specific advantages to this case and need not be chosen. Atropine: May be the agent of choice as it is safe for administration in children (the usual tonsillectomy patient) by blunting vagal response, has a good haemodynamic profile (as the patient is bleeding) and has the additional benefit of drying oral secretions. The last property allows better visualization of the throat and reduces the risk of aspiration. Induction agents Benzodiazepines- They are sedative -hypnotic agents that have anxiolytic and amnestic properties. Rapid onset and short duration of action makes them a popular choice. However, contraindicated in patients having blood loss and hence unsuitable for the case. Etomidate- The Pharmodynamic profile is similar to barbiturates. Has a stable cardiovascular profile and is cerebroprotective. Some studies have demonstrated adrenal insufficiency induce by the agent. A popular choice especially in head injuries. Is a good contender to be used in the case in question. Ketamine- Has rapid onset and prolonged adequate sedation. Excellent for producing conscious sedation and useful for children. It is an effective analgesic and produces amnesia. Is ideal for asthmatic patients and should be administered if the patient is an asthmatic. However, it has an adverse effect of ICP. To be avoided if this is a danger with the patient. Propofol- Ideal for elective intubation. However, it is rarely used because physicians are unfamiliar with it. Opiods- Can also be used for sedation. The adverse effects (mentioned above) does not make it the ideal chice for this situation. (Robert M Pousman, DO.2000), (Ted Stettner.MD, Jacob.W Ufberg. MD. Feb 2004) Neuromuscular blockers The generally accepted choice is Succinylcholine. The agent is contraindicated in cases of head injury, hyperkalemia, ESRD, CVA, spinal cord injury, history of malignant hyperthermia, eye injury, high ICP, rhabdomyolysis. As the present case does not have these problems it may be the NMB of choice. (Sanjiv. J Shah. M.D. Gurpreet Dhaliwal.) Conclusion The case definitely calls for the use of RSI for the reasons mentioned earlier in the paper. As there is blood loss atropine may be the agent of choice for pre-treatment, Etomidate, Propofol or Ketamine may be used for induction and Succinylcholine to be used as NMB. Citation 1. American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98,1269-1277 2. Stuart. F. Raynolds, John Heffner. April 2005. Airway Management of the critically ill patient. Chest. 127:1397-1412. 3. Ezir T, Szmu P, Warters RD, Katz J, Hagberg CA. Sept. 2003. Difficult airway management practice patterns among anesthesiologists practicing in the United States: have we made any progress J.Clinical Anaesth. 15(6): 418-22. 4. Robert M Pousman, DO.2000. Rapid Sequence Induction for Prehospital Providers. The Internet Journal of Emergency and Intensive Care Medicine. Volume 4 Number 1 5. Textbook of Trauma Anesthesia and Critical Care. Grande CM, ed., St. Louis, Missouri: Mosby - Yearbook, Inc. 1993. 6. Ted Stettner.MD, Jacob.W Ufberg. MD. Feb 2004. Rapid Sequence Induction - Induction and Pretreatment Medications. May 25th , 2005. emedicine.WebMD. 7. Rodricks MB, Deutschman CS: Emergent airway management. Indications and methods in the face of confounding conditions. Crit Care Clin 2000 Jul; 16(3): 389-409[Medline]. 8. Walls RM: Airway Management. In: Emergency Medicine Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Yearbook; 1998: 2-24. 9. Wadbrook PS: Advances in Airway Pharmacology: Emerging Trends and Evolving Controversy. Emergency Medicine Clinics of North America Nov 2000; 18:[Medline]. 10. Sanjiv. J Shah. M.D. Gurpreet Dhaliwal. M.D. Critical care. [URL] http://cardio.ucsf.edu/housestaff/handbook/HospH2002_C3.htm#ARDSNET Read More