Post by Tony Held on Jan 29, 2017 1:46:20 GMT -6
The main concept lives here as it is Scott Weingart, MD who named it and proliferated it.
This is an interesting concept especially coming from an agency without paralytic capability. There are numerous articles and a couple studies that I won't bother referencing as they're very easy to obtain. But here's the nuts and bolts:
A patient presents in severe respiratory distress and is so agitated that they won't tolerate pre-oxygenation techniques.
Traditional RSI models would have you push your induction agent, push your paralytic shortly after so they take effect simultaneously, perform a first-pass intubation, hook up your BVM or your vent, live to fight another day.
Here's the problem: Your patient wouldn't tolerate pre-oxygenation. That means your patient did not benefit from a strong nitrogen flush-out. They didn't benefit from a maximal oxygen saturation. You were forced into a corner in which you had to intubate a patient with a 70% oxygen saturation. That leaves a very small window of success in that intubation before they either arrest or develop permanent brain damage.
So this is where DSI alters the flow a bit. Induction agent first, pre-oxygenate either with non-rebreather or non-invasive pressure ventilation (or BVM if you don't have access to true NIPPV), wait until you maximize nitrogen flush-out and oxygenation, THEN use your paralytic... Now you've got plenty of time to get your tube and you can even take a break in between to eat a sandwich.
This topic is especially interesting given that I recently had a case where this worked despite us not really trying to do it. Just took an extra bit of time for that Ketamine to really take ahold of him. We started with a sat of 74% before Ketamine. He was literally draining the BVM with his respirations and a solid mask seal. His sat immediately before our intubation attempt was 98%
This is an interesting concept especially coming from an agency without paralytic capability. There are numerous articles and a couple studies that I won't bother referencing as they're very easy to obtain. But here's the nuts and bolts:
A patient presents in severe respiratory distress and is so agitated that they won't tolerate pre-oxygenation techniques.
Traditional RSI models would have you push your induction agent, push your paralytic shortly after so they take effect simultaneously, perform a first-pass intubation, hook up your BVM or your vent, live to fight another day.
Here's the problem: Your patient wouldn't tolerate pre-oxygenation. That means your patient did not benefit from a strong nitrogen flush-out. They didn't benefit from a maximal oxygen saturation. You were forced into a corner in which you had to intubate a patient with a 70% oxygen saturation. That leaves a very small window of success in that intubation before they either arrest or develop permanent brain damage.
So this is where DSI alters the flow a bit. Induction agent first, pre-oxygenate either with non-rebreather or non-invasive pressure ventilation (or BVM if you don't have access to true NIPPV), wait until you maximize nitrogen flush-out and oxygenation, THEN use your paralytic... Now you've got plenty of time to get your tube and you can even take a break in between to eat a sandwich.
This topic is especially interesting given that I recently had a case where this worked despite us not really trying to do it. Just took an extra bit of time for that Ketamine to really take ahold of him. We started with a sat of 74% before Ketamine. He was literally draining the BVM with his respirations and a solid mask seal. His sat immediately before our intubation attempt was 98%
