In this episode, I’ll discuss the SCCM Rapid Sequence Intubation Guidelines.
The SCCM recently published Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.
While any pharmacist that works in a critical care setting should take the time to read these new guidelines, there are three aspects that I’d like to highlight:
First, the guidelines give a conditional recommendation in support of delayed sequence intubation, although they refer to it as medication-assisted preoxygenation. Delayed sequence intubation or medication-assisted preoxygenation is essentially treating the preoxygenation period as a procedure that requires sedation for the patient to tolerate. This is usually accomplished by giving dissociative sedation with ketamine so the patient can receive preoxygenation followed immediately by the rest of a typical rapid sequence intubation process. 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. The guideline suggestion is as follows:
We suggest using medication-assisted preoxygenation to improve preoxygenation in patients undergoing RSI who are not able to tolerate a face mask, NIPPV, or HFNO because of agitation, delirium, or combative behavior (conditional recommendation, very low quality of evidence).
Second, in critically ill adults who receive etomidate for induction during RSI, the guideline authors come out against giving steroids out of concern for adrenal insufficiency in patients who received etomidate. Whether or not etomidate-induced adrenal enzyme inhibition is clinically significant has been debated by clinicians for many years however the guideline authors conclude there is a lack of evidence that etomidate is any different than other induction agents when it comes to mortality rates or rates of hypotension or vasopressor use in the peri-intubation period. For this reason, the authors also suggest not giving corticosteroids for the purpose of countering adrenal suppression from etomidate.
And third, the guideline authors take a stand on the use of a neuromuscular blocking agent in RSI. This too has been a matter of debate among clinicians for a long time with those that prefer using a neuromuscular blocker to have the highest first pass success and those that fear that muscle relaxation will cause them to not be able to recover from a scenario in which a secure airway is not able to be placed right away.
The authors examined 5 trials and concluded that neuromuscular blocker use offers the best chance of first pass success with few associated complications. The recommendation is the only strong recommendation made in the guidelines and it reads as follows:
We recommend administering an NMBA when a sedative-hypnotic induction agent is used for intubation (strong recommendation, low quality of evidence).
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