Ver el código de «Delayed sequence intubation»

==Background==
*Maximizes preoxygenation in an effort to minimize hypoxemia and adverse events related to the apneic period during intubation.<ref>Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med. DOI: http://dx.doi.org/10.1016/j.annemergmed.2014.09.025</ref>
*Similar to [[Procedural sedation|procedural sedation]], except the procedure is preoxygenation itself.

==Indications==
*Patients requiring intubation but are unable to tolerate preoxygenation due to altered mental status, severe hypoxemia, agitation, or other reasons
**Likely safe for use in pediatrics<ref>Löllgen RM, Webster P, Lei E, Weatherall A. Delayed sequence intubation for management of respiratory failure in a 6-year-old child in a paediatric emergency department. Emerg Med Australas. 2014 Jun;26(3):308-9. doi: 10.1111/1742-6723.12196. Epub 2014 Apr 8. PubMed PMID: 24712856.</ref>
*Patients who require an additional procedure prior to intubation (i.e. NGT placement for [[GI bleed]])<ref>Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. Epub 2011 Nov 3. Review. PubMed PMID: 22050948.</ref>

==Contraindications==
*No absolute contraindications when performed urgently

==Equipment Needed==
*Medications
**Induction agent
**Paralytic agent
*Laryngoscope (type based on clinical indication and provider preference/experience)
**[[Direct laryngoscope]] with blade of provider's choice '''or'''
**[[Video laryngoscope]] (Glidescope, C-Mac, KingVision, etc.) '''or'''
**Fiberoptic device
*Endotracheal tube
*End-tidal CO2 device (colorimetric or quantitative)
*Ventilator
*Suction
*Intubation adjuncts ([[bougie]], lighted stylet, etc)
*BVM
*[[OPA]]/NPA
*Method of preoxygenation (NC, NRB, C-PAP, etc)
*Nonrebreather mask and nasal cannula for apneic oxygenation

==Procedure==
*Assemble required equipment and staff
*Be prepared for failed airway/deterioration
*Patient on cardiac monitor with pulse oximetry (preferably waveform [[Capnography|capnography]])
*Apply non-rebreather mask at flush rate and nasal cannula to 15 L/min each
*Administer induction agent, 
**Ideally [[Ketamine|ketamine]] 1-2mg/kg given mp blunting of patient respirations or airway reflexes<ref>Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J Emerg Med. 2011 Jun;40(6):661-7. Epub 2010 Apr 8. Review. PubMed PMID: 20378297.</ref>
**In hypertensive and tachycardic patients, [[Dexmedetomidine|dexmedetomidine]] can be administered at 1 mcg/kg. It is a α-2 agonist, which provides sedation with no blunting of respiratory drive or airway reflexes<ref>Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. J Clin Anesth 2007;19:370–3.</ref>
**If SpO2 is <95% then use NIPPV or bag-valve mask with PEEP valve at 5-15 cmH20 
**If no improvement within 10 minutes, consider proceeding to intubation with suboptimal pulse oximetry reading
*Administer neuromuscular blocker and wait 45-60 seconds
*Perform apneic oxygenation using 15 L/min O2 via nasal prongs +/- continue CPAP
*Intubate patient

==Complications==
*Same as [[Noninvasive ventilation|NIPPV]]
*Medication reaction/side-effects

==Other Considerations==
*Other medications (remifentanil) may be considered but lack evidence and do not have the same characteristics of ketamine (preserved airway protective reflexes, preserved respiratory drive, rapid onset)
*Weingart<ref>Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med. DOI: http://dx.doi.org/10.1016/j.annemergmed.2014.09.025.</ref> found that a small subset of patients (severe [[Asthma|asthma]]) improved sufficiently as to no longer require intubation.  In these cases, avoid neuromuscular blockade, allow the induction agent to wear off (or administer further boluses to preserve oxygenation)

==See Also==
{{Related Difficult Airway Pages}}

==References==
<References/>

[[Category:Critical Care]]
[[Category:Procedures]]