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快速程序诱导 Rapid Sequence Induction. 南京市第一医院 鲍红光. 病 例 ( Case Insert ). A 38 year old female ,女性 38 岁 Peritonitis for 3 days 腹膜炎 3 天 Shocked with: 休克: 1. T: 38 o C 体温: 38℃ 2. Pulse:120/minute 脉搏: 120 次 / 分 3. BP: 70 mmHg systolic 血压:收缩压 70mmHg - PowerPoint PPT Presentation
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Rapid Sequence Induction
Case InsertA 38 year old female 38Peritonitis for 3 days 3Shocked with: 1. T: 38 o C 38 2. Pulse:120/minute 120/ 3. BP: 70 mmHg systolic 70mmHg 4. Poor nail bed capillary return 5. Respiratory rate 30/ 6. Confused 7. Urinary: 20mL of concentrated urine : 20mL The surgeon wants to operate immediately
Anesthesia ?regional anesthesia?
General anesthesia?
Induction Fentanyl Propofol Rocuronium RSI
Rapid Sequence Intubation INTUBATION
CasesAdult patient Child
Main complications of GA Regurgitation Vomiting Aspiration Desaturation, Laryngospasm , Airway obstruction, Bronchospasm, Cardiac arrest
GOAL of RSI Protect airway
Facilitate intubations
Rapidly induce anesthesiaACEP, 2000
HistoryCricoid cartilage pressure to prevent regurgitation- Sellick1961.First series of ED intubations Taryle, 1979First series of intubations using succinylcholine in the ED Thompson, 1982American College of Emergency Physicians (ACEP) RSI policy statement(1997):- Reaffirmed, 2000physicians performing RSI should possess training, knowledge, and experience in the techniques and pharmacologic agents used to perform RSI
Today 1.RSI resides in the domain of emergency medicine practice
2. Key in the successful management of the A of ABCsABCA
3. Increases the chance of successful intubation and minimizes the risks
COMPLICATION:: 15% aspiration, 28% airway trauma, 3% death 1999 Li et.al.
Chart1
0.28
0.78
Complication
Sheet1
MethodComplication
RSI28%
Without Paralysis78%
78%*
WITHOUT PARALYSISn=67
28%
RSI n=166
COMPLICATIONS
METHOD
Sheet1
0
0
Complication
Sheet2
Sheet3
National Emergency Airway Registry (NEAR)Series of > 6000 ED intubations26 teaching hospitals88.1% adult and 81.1% pediatric intubations
(Indication)Full stomach ().
Gastric content aspiration risk (,
Contraindications
The predicted difficult airway Inexperience Inadequate difficult airway tools and techniques
RSI: Rapid Sequence Induction (Preparation) (Preoxygenation) (Premedication) (paralysis) (Pass the tube)
Preparation for RSIS: Suction)O: OxygenA: Airway EquipmentP: PharmacologyME: Monitoring Equipment
Head positioningMaintaining a patent airway Chin lift / jaw thrust The patient is /
Preoxygenation Preoxygenated for a full three minutes
Wash all of the nitrogen out of the lungs
Create a resevoir of O2
PRESSURE GOAL: REDUCTION OF RISK OF ASPIRATION: Sellick maneuverTechniqueRisk reductionPassive regurgitationGastric insufflation Cricoid pressure
No positive pressure ventilationImportant !Risk reductionPassive regurgitation Gastric insufflation
(paralysis)Muscle relaxation in Succinylcholine occurs in just 30 seconds, with total paralysis in 45 seconds (1.5 mg/kg-2.0 mg/kg). 3045 (1.5 mg/kg-2.0 mg/kg)
Muscle relaxation in Rocuronium occurs in 60-90 seconds (0.6 mg/kg ) 6090 (0.6 mg/kg )uscle relaxation
Anaesthesia
The anaesthetist is happy that the airway is intact Administers the remainder of the anaesthetic agents - fentanyl, nitrous oxide and the volatile agent (Sevoflurane). , () A non depolarising neuromuscular blocker
fter intubation
ET tube Chest X Ray X
At the completion of surgeryThe risk of aspiration of gastric contents is as high now as at the beginning:: The anaesthetic agent is turned off 100% oxygen is administered 100% Neuromuscular blockade is reversed The airway is carefully cleaned with suction Ett remains in situ until the patient is fully awake, lying on their side,
Conclusion RSI could provide a safe airway and Minimizing any possible complications during intubation.RSI successful avoid aspiration in full-stomach patients. Dronen,S.C., 1999Whereas anaesthesiologists use RSI to intubate patients requiring anaesthesia, emergency physicians commonly use RSI to induce anaesthesia in patients requiring intubationRSI RSI.
RSIWhat are the difference between the RSI and traditional rapid induction RSI?
Differences are An organized approach to endotracheal intubationRapidly induce anesthesia facilitate intubationsNo positive pressure ventilation Cricoid pressure to protect airway Avoid aspiration in full-stomach patients
ACEP, 2000
VS point 2 could read : rapidly create the ideal intubating conditionsDronen,S.C., 1999VS point 2 could read : rapidly create the ideal intubating conditions