First, I think it needs to appreciated that the Sedation Facilitated Intubation (SFI) procedure is not meant for a crash intubation – if the patient is in arrest or peri-arrest and needs an airway now (i.e. can’t simply be bagged), then messing around with pharmacology which is likely unneeded for the patient’s comfort in the state the patient is in is, time consuming and takes you off the task at hand. However, I have found that BVM technique alone often works in situation like this and a tube does not have to happen immediately.
I think the most important thing to realize that Sedation Facilitated Intubation (SFI) should not be thought of as Rapid Sequence Intubation (RSI) without the paralytic. As per the presentation, SFI in my opinion is inducing a moderate level of sedation with significant anesthetic topicalization of the highly innervated structures of the anatomy in an effort to reduce the response to a noxious procedure with the intent to intubate the patient (whew… that was long winded but I think that is the gist of it).. The way I think of an awake intubation is inducing a mild sedation to cause anxiolysis in an attempt to intubate a patient with cooperation. An awake approach is used when the patient can be cooperative with such an approach and/or you are concerned that more pharmacology to induce a deeper level of sedation may compromise the patient (making them hypotensive or worsening a pathological obstruction, for example). Topicalization is the key to making SFI and awake intubation work. Using lidocaine and giving the drug time for it to work is key.
Deep sedation as outlined in the presentation is an incredibly dangerous place to go – it has none of the protective benefits of RSI and SIGNIFICANT risk. In many services, Midazolam and Morphine are used as anxiolytics/inductive agents and analgesic agents, respectively. The inductive dose of Midazolam is often quoted as 0.1-0.3 mg/kg. If you are giving 21 mg to induce the average 70kg patient, in my opinion, you doing it wrong. As detailed in my talk, there is no good reason to use that much drug – you either don’t need that much drug as the intubation is elective or semi elective or you should be cricing the patient because they are crashing due to hypoxia. The hypotension you are causing will cause patient harm (remember in the study by Chestnut you double mortality for each episode of hypoxia and hypotension, for example. See http://www.ncbi.nlm.nih.gov/m/pubmed/8459458/). In addition, there is no guarantee this high dose will make intubating condition any better (it might not remove trismus, may cause more hypotension, or may worsen any protective airway reflexes, for example)
I can’t say this emphatically enough – you should not be performing an intubation without the NODESAT technique. Here is the original paper on NO DESAT by Weingart and Levitan
Here is the research study on Delayed Sequence Intubation (DSI) by Weingart
As I mentioned in the presentation, I have laid down the gauntlet with my fellow blogger Tomato (my nickname for Mike) and challenged him to a debate on prehospital RSI. We’ll do it in the first week of January. Mike will take the affirmative arguing for giving all ALS paramedics RSI and I will argue against it. At the end we will have a discussion around the literature and reveal our real positions. In the meantime, if you want to watch a great debate, see the following debate about RSI in the hospital ICU environment: http://emcrit.org/podcasts/paralytics-for-icu-intubations/ (see the bottom for the actual debate – it’s pretty hilarious)
As to all of the documents I have referenced in the presentation, please see:
Here is the stuff from the ASA
Here is the info on levels of sedation and risk
Here is the info on stages of anesthesia
Here are the current NAEMSP info on DAI http://www.naemsp.org/Documents/Position%20Paper/POSITION%20Drug%20Assisted%20Intubation%20New.pdf
Here is the DSI page on EMCRIT http://emcrit.org/podcasts/dsi/
Again, I welcome your input