133: Rapid Sequence Intubation From the Patients' Perspective

Abstract

This study assesses the efficacy of the rapid sequence intubation (RSI) protocol in preventing patient recollection of resuscitative events and patient discomfort during intubation, as subjectively determined by the patient. Methods: This was a prospective study of all patients intubated at Los Angeles County, University of Southern California Medical Center from July 2009 to January 2010. Extubated patients were interviewed using a standard questionnaire and data collection tool. Results: Of 211 airway codes, 201 were excluded due to death before extubation, transfer, or persistent vegetative state, leaving 10 awake, alert subjects who were interviewed regarding their recollection of the RSI and resuscitation. Five had recollection of the event. Most patients recalling RSI described the event as painful or uncomfortable despite receiving the recommended doses of sedation/ induction agents. Conclusion: In this cohort of 10 patients intubated using typical agents, 5 remembered some details of their intubation and 2 described pain that was 10/10 on a verbal pain scale. Further work is indicated to ensure that the medications used during this procedure provide the appropriate sedation and amnesia.

Drug dosing in the critically ill obese patient—a focus on sedation, analgesia, and delirium

“…On the other extreme, under-dosing is a concern if ideal body weight (IBW) is inappropriately used for weight-based dosing regimens, since the calculation for IBW only considers height and not excess weight. This is particularly relevant for patients who receive etomidate prior to neuromuscular blocker therapy as under-dosing may lead an awake state during paralysis [5].…”

“…In light of etomidate's large volume of distribution, there is a concern of under-dosing in more obese patients, which could lead to patient awareness during concomitant paralysis with a neuromuscular blocker [62]. In one prospective study evaluating an RSI protocol, 5 of the 10 patients interviewed remembered aspects of the intubation procedure suggesting inadequate sedation [5]. Concerns of inadequate dosing would outweigh toxicity concerns of higher doses based on ABW in most obese patients.…”

To Intubate or Not to Intubate: Emergency Medicine Physicians' Perspective on Intubating Critically Ill, Terminal Cancer Patients

“…12 In reality, intubation can inflict a great deal of suffering on patients. 16 In a situation where a treating physician believes intubation will not likely provide survival benefits to a terminal patient, the physician would feel ethically uneasy to intubate the patient just to satisfy the demands of the family. Although EPs strive to do the ''right thing'' for dying terminal patients (e.g., allow natural death), not intubating and going against family's demands has the potential for negative consequences, from a simple complaint affecting satisfaction scores to a potential malpractice suit.…”

Awareness and bispectral index (BIS) monitoring in mechanically ventilated patients in the emergency department and intensive care unit: a systematic review protocol

“…Data from the ED domain are even more limited. Four small studies (n=123 patients total) showed an incidence of awareness with paralysis ranging from 5.9% to 50%,20–23 but this was restricted to the endotracheal intubation procedure only. One small cohort study showed no association between BIS values and recall of endotracheal intubation in the ED 21…”