In this episode, I’ll discuss best practices in airway management in critically ill adults.
Pharmacists who work in critical care areas have tremendous opportunities to help the care team and patient whenever tracheal intubation takes place, from preventing awareness with paralysis to managing post-intubation cardiovascular complications as has been discussed in numerous episodes of this podcast from #15 all the way to #1059.
A recent article published in the journal Intensive Care Medicine discusses the Best practices in airway management in critically ill adults. Among these best practices are several regarding medications.
First, when it comes to the choice of sedation for induction so the patient can tolerate intubation, the authors review the INTUBE study which in a post hoc analysis showed that the use of propofol for induction was the only modifiable independent predictor of cardiovascular collapse in patients undergoing intubation. Therefore the recommended best practice is to use medications with a more stable hemodynamic profile such as ketamine and etomidate. Pharmacists who practice in institutions where propofol is a common induction agent would do well to have discussions with providers about sedative choice well before the need for intubation arises and ideally on a committee or department meeting level, so that agreement on when to use alternative sedatives can be made without the acute stress of a decompensating patient needing urgent intubation.
Second, the authors emphasize that using neuromuscular blockade during intubation is associated with greater first-pass intubation success and fewer complications. The authors discuss evidence suggesting that there is no clinically meaningful difference between succinylcholine and rocuronium for tracheal intubation in critically ill patients. They highlight how when using rocuronium, higher doses of at least 1.2 mg/kg are required to produce faster time to optimal intubating conditions. The authors also acknowledge that while sugammadex may have a narrow role in reversing paralysis in a “cannot intubate, cannot ventilate” situation, it will not reverse the need for intubation.
When it comes to hemodynamic optimization before the procedure, the authors were not able to identify a best practice based on available literature, with conflicting results on pre-emptive fluid boluses and no completed trials about pre-emptive vasopressor use.
Finally, when discussing respiratory optimization the authors note that in agitated patients, a sub anesthestic dose of ketamine may be used to facilitate preoxygenation – this is the practice otherwise known as delayed sequence intubation. Many clinicians have supported this technique for use in select agitated patients who cannot comply with standard preoxygenation, most notably Scott Weingart of emcrit.org. I have discussed evidence that supports this technique most recently in episode 816.
These best practices are in line with recommendations from other expert societies including the SCCM guidelines which I discussed in episode 1059 that also recommend delayed sequence intubation, and routinely using a neuromuscular blocking agent.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply