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May.22.2020

Elsevier Clinical Skills

Drug Assisted Intubation - CE

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus 2019 (COVID-19) or a person under investigation (PUI) (Box 1)Box 1.10

Because neuromuscular blocking agents (NMBAs) can cause respiratory arrest, health care team members skilled in intubation must be present and ready at the bedside before the medication is administered. Ensure that an alternative airway is immediately available in case intubation fails.

A personal or family history of malignant hyperthermia is an absolute contraindication to succinylcholine.7 Relative contraindications include conditions that increase the risk of succinylcholine-induced hyperkalemia (e.g., hyperkalemia; myopathies or neuromuscular disorders; or burns, crush injuries, or severe infections that are more than 5 days old).7

Take steps to eliminate interruptions and distractions during medication preparation.

This skill is performed by health care professionals with additional knowledge, skills, and demonstrated competence, and in accordance with the professional’s regulatory scope of practice and the organization’s practice.

OVERVIEW

NMBAs (also called paralytics) are the foundation of emergency airway management. They allow placement of the oral endotracheal (ET) tube while minimizing potential complications, such as aspiration. There are two classes of NMBAs.

  • One class is the noncompetitive depolarizing agents, of which succinylcholine is the most common; succinylcholine depolarizes the endplates and renders muscles unable to respond to acetylcholine (ACh). Depolarizing agents are rapid in onset and short acting.7
  • The second class is the competitive, nondepolarizing NMBAs, which compete with and block the action of ACh at the postjunctional nicotinic receptors in the neuromuscular junction. This class includes vecuronium and rocuronium.7

Drug Assisted Intubation (DAI) is performed for these purposes:

  • To facilitate ET intubation by inducing unconsciousness and motor paralysis5
  • To augment intubation of combative patients with head injuries
  • To minimize the risk of aspiration in nonfasting patients with complex airway emergencies5

If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the intubator notified, and the order verified.

SUPPLIES

Click here for a list of supplies.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Instruct the patient regarding the potential side effects of the medication. Inform the patient that he or she will be given medications that relax the muscles temporarily so the machine will breathe for him or her. Tell the patient that team members are present to provide care and to keep him or her safe.
  • Reassure the family that the patient’s inability to move and any new decrease in level of consciousness are the desired effect of the medications.
  • If the sedation is inadequate, the patient may experience awareness, fear, and discomfort. Until adequate sedation can be attained:
    • Reassure the patient that medications will be administered to help decrease his or her discomfort.
    • Tell the patient that he or she will not be able to speak while the tube is in place.
    • Instruct the patient not to move or manipulate the tube in any way.
    • Inform the patient that swallowing may help diminish gagging.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene and don PPE as indicated for needed isolation precautions.
  2. Introduce yourself to the patient.
  3. If time allows, verify the correct patient using two identifiers.
  4. Assess the patient for specific contraindications to receiving sedation and NMBAs, and advise the practitioner accordingly.
  5. Complete a brief neurologic assessment of the patient, including movement of the extremities.
  6. The intubator assesses the patient’s airway for potential difficulties.
  7. Ensure that alternative airway equipment per the intubator’s preference is available in case intubation fails.
    1. Supraglottic airway (laryngeal mask airway [LMA], intubating laryngeal mask airway [ILMA], i-gel® supraglottic airway)2
    2. Retroglottic airway (laryngeal tube airway [King airway, LTA], intubating laryngeal tube airway [ILTA])2
    3. Cricothyroidotomy equipment
    4. Fiberoptic scope
    5. Eschmann tracheal tube introducer (gum elastic bougie)2

Preparation

  1. Maintain the patient in a supine position with spinal protection, if indicated.
  2. Attach oxygen saturation and cardiac monitors.
  3. Ensure that the patient has at least one functioning IV line; two is preferable.5
  4. Preoxygenate the patient with supplemental oxygen for at least 5 minutes.8 If possible, avoid bag-mask ventilation to prevent gastric distention, which increases the risk of vomiting and aspiration.5
    Noninvasive positive pressure ventilation (NIPPV) such as bag-mask ventilation or bilevel positive pressure ventilation (BiPAP) should be avoided as much as possible to prevent aerosolization in patients with a known or suspected airborne transmitted infectious illness. 8,9,10
    For patients with a known or suspected airborne transmitted infectious illness, preoxygenation should be initiated using nonaerosol generating approaches such as: elevating the head of the bed, airway maneuvers, and positive end expiratory pressure (PEEP) valves. 8,9,10
    Oxygen delivery devices providing 6 L or more of oxygen per minute (e.g., high-flow nasal cannula) are considered high flow and should be avoided as much as possible to prevent aerosolization in patients with a known or suspected airborne transmitted infectious illness. If a high-flow nasal cannula must be used for preoxygenation, a surgical mask can be placed on the patient over the device. 8,9,10
  5. Ensure that all necessary medications, needles, and syringes are close at hand, whether in a kit (Box 2)Box 2 or assembled separately.
  6. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.11 Stated, estimated, or historical weight should not be used.11
  7. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.
    Do not use any medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe; this may lead to harmful reactions.
  8. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications, if needed.

PROCEDURE

  1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions. Don gown, mask, and eye protection or face shield if the risk of splashing exists.
  2. If time allows, verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  4. Draw up the prescribed medications (Box 3)Box 3. Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.12
  5. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the medication administration record to the patient’s identification band.
  6. Administer premedications as prescribed.
    1. Administer lidocaine to attenuate the increase in intracranial pressure associated with intubation if prescribed.
    2. Administer fentanyl or etomidate to patients with increased intracranial pressure or cardiovascular disease who could be negatively impacted by increased blood pressure.7 Etomidate is also an induction agent and therefore serves a dual purpose.
  7. Administer the induction agent (sedative) as prescribed.
  8. Administer the NMBA as prescribed.
    The induction agent should always be administered before the NMBA.
  9. Assess the patient’s level of sedation and muscle tone, allowing for sufficient onset of action per medication, route, and the patient’s condition.
  10. Assist the intubator with bimanual laryngoscopy if requested; for example, by placing pressure on the thyroid cartilage with the thumb and index finger as directed.
    Rationale: This maneuver can allow a better view of the glottis.
    The routine use of cricoid pressure (Sellick maneuver) for DAI or during cardiac arrest is not recommended. 3,5 Cricoid pressure (Sellick maneuver) can worsen the laryngoscopic view. 6
    For patients with a known or suspected airborne transmitted infectious illness, video laryngoscopy is preferred over direct laryngoscopy to increase the distance between the patient and the intubator. 1,8,10
  11. The intubator orally intubates the patient.
  12. Verify the ET tube placement, inflate the cuff, and ventilate the patient with 100% oxygen while manually maintaining the tube placement.
    For patients with a known or suspected airborne transmitted infectious illness, the cuff should be inflated right after the ET tube is placed. The ET tube should then be connected to the ventilator via high-efficiency particulate air (HEPA) filter and capnography waveform device. Ventilations should start upon confirmation of ET tube cuff inflation. ET tube placement should be initially verified by capnography waveform, followed by five-point auscultation. 9
  13. Secure the ET tube.
  14. Initiate continuous waveform capnography to monitor ET tube placement.3,4
  15. If intubation is unsuccessful, anticipate that the intubator may insert a supraglottic airway (laryngeal mask airway), a retroglottic airway (laryngeal tube airway), or may perform a needle or surgical cricothyroidotomy.
    For patients with a known or suspected airborne transmitted infectious illness, gentle ventilations with a supraglottic airway (e.g., laryngeal mask airway) has been recommended as an option for preoxygenation in place of bag-mask ventilation to decrease the need for additional manpower and to reduce exposure. Currently, there is no concrete evidence to support this practice. 9
  16. Ensure adequate sedation and analgesia in conjunction with NMBAs.
  17. Assess the patient’s level of sedation and muscle tone, allowing for sufficient onset of action per medication, route, and the patient’s condition.
  18. Decompress the stomach with a gastric tube.
  19. Discard supplies, remove PPE, and perform hand hygiene.
  20. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Confirm ET tube location with a chest radiograph.
  2. Monitor the patient for adverse and allergic reactions to the medications. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
  3. Assess, treat, and reassess pain.
  4. Assess and adjust the level of sedation, as ordered and indicated.
  5. Continue to monitor ET tube placement, pulse oximetry, and continuous waveform capnography. Reassess tube placement every time the patient is moved.
    Rationale: The AHA recommends continuous waveform capnography in addition to clinical assessment to monitor tube placement. 3,4

EXPECTED OUTCOMES

  • Effective ET tube placement
  • Correct medication administration according to the six rights of medication safety

UNEXPECTED OUTCOMES

  • Esophageal intubation
  • Vasodilation, resulting in profound hypotension
  • Dislodgment of the ET tube
  • Trauma to teeth, nasal mucosa, posterior pharynx, or larynx
  • Incorrect medication administration according to the six rights of medication safety

DOCUMENTATION

  • Name and dose of medications administered
  • Patient’s response to medication, including any adverse reactions
  • Patient’s vital signs, oxygenation, and ventilation before, during, and after the procedure
  • Size of ET tube placed
  • Position of the ET tube in relation to the teeth or gums (in centimeters)
  • Description of the method used to secure the tube
  • Validation of ET tube placement
  • Method of ventilation
  • Unexpected outcomes and related interventions
  • Education

PEDIATRIC CONSIDERATIONS

  • Atropine is no longer recommended as a routine premedication for children. It may be given to infants younger than 1 year old to prevent bradycardia associated with intubation and the administration of DAI agents.12,13
  • Either cuffed or uncuffed ET tubes are acceptable for intubating children and infants. Cuffed tubes may prevent aspiration. If the cuff is inflated, it should be closely monitored and pressure maintained between 20 and 25 cm H2O.4

REFERENCES

  1. Alhazzani, W. and others. (2020). Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Critical Care Medicine, Vol 1. Advance online publication. doi:10.1097/CCM.0000000000004363 (Level VII)
  2. American College of Surgeons (ACS). (2018). Chapter 2: Airway and ventilatory management. In Advanced trauma life support: Student course manual (10th ed., pp. 22-41). Chicago: ACS. (Level VII)
  3. American Heart Association (AHA). (2016). Part 5: The ACLS cases. In Advanced Cardiovascular Life Support Provider Manual (pp. 43-154). Dallas: AHA. (Level VII)
  4. American Heart Association (AHA). (2016). Part 12: Post-cardiac arrest care. In Pediatric advanced life support: Provider manual (pp. 277-298). Dallas: AHA. (Level VII)
  5. Brown, C.A., III, Walls, R.M. (2018). Chapter 20: Rapid sequence intubation. In C.A. Brown, III, J.C Sakles, N.W. Mick (Eds.), The Walls manual of emergency airway management (5th ed., pp. 235-249). Philadelphia: Wolters Kluwer.
  6. Carleton, S.C., Reardon, R.F., Brown, C.A., III. (2018). Chapter 9: Bag-mask ventilation. In C.A. Brown, III, J.C Sakles, N.W. Mick (Eds.), The Walls manual of emergency airway management (5th ed., pp. 87-97). Philadelphia: Wolters Kluwer.
  7. Caro, D.A., Laurin, E.G. (2018). Chapter 22: Neuromuscular blocking agents. In C.A. Brown, III, J.C Sakles, N.W. Mick (Eds.), The Walls manual of emergency airway management (5th ed., pp. 263-272). Philadelphia: Wolters Kluwer.
  8. Chavez, S. and others. (2020). Coronavirus disease (COVID-19): A primer for emergency physicians. The American Journal of Emergency Medicine. Retrieved April 29, 2020, from https://www.ajemjournal.com/article/S0735-6757(20)30178-9/pdf
  9. Chun-Hei Cheung, J. and others. (2020). Staff safety during emergency airway management for COVID-19 in Hong Kong. The Lancet, Respiratory Medicine, 8(4), e19. doi:10.1016/S2213-2600(20)30084-9 (Level VII)
  10. Edelson, D.P. and others. (2020). Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation. doi:10.1161/CIRCULATIONAHA.120.047463 Epub ahead of print. Retrieved April 29, 2020, from https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463 (Level VII)
  11. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication safety best practices for hospitals. Retrieved April 29, 2020, from https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf (Level VII)
  12. Joint Commission, The. (2020). National patient safety goals: Hospital accreditation program. Retrieved April 29, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf (Level VII)
  13. Luten, R.C., Mick, N.W. (2018). Chapter 24: Differentiating aspects of the pediatric airway. In C.A. Brown, III, J.C Sakles, N.W. Mick (Eds.), The Walls manual of emergency airway management (5th ed., pp. 283-299). Philadelphia: Wolters Kluwer.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports