Etomidate and Adrenocortical Suppression: Should We Take the Concerns to Heart?

Abstract

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Difficult Airway Management in Surgical Intensive Care Unit

“…A focused history and physical examination of the patient will guide us about the requirements of equipment and expertise needed for airway management (e.g., mental state, respiratory and hemodynamic status, time of last feeding, comorbidities that Rescue devices for front-of-neck invasive devices cricothyroidotomy sets and surgical tracheostomy sets 21 Self-inflating ambu bag with a reservoir bag attached or Jackson Rees breathing circuit to facilitate ventilation In the subset of patients with a suspected cervical spine injury, the head is to be maintained in a neutral position with a cervical collar or with manual in-line cervical stabilization at all times during airway manipulations Face masks of various sizes Sedatives as well as resuscitative drugs at the bedside. Induction agents and muscle relaxants (atracurium, cisatracurium, vecuronium or suxamethonium/rocuronium and sugammadex in patients with no fear of losing airway in patients with difficult airways) [17][18][19][20] Oropharyngeal and nasopharyngeal airways Lignocaine 4% with airway topicalization atomizer, 2% lignocaine with and without adrenaline Laryngoscopes-Miller and Macintosh blades Fluids, inotropes, and vasopressors to treat hypotension Endotracheal tubes-appropriately sized ones to be available are, that is, 7.0, 7.5 for women and 8.0 and 8.5 for men Endotracheal tubes with subglottic suction for all patients requiring term intubations or ventilation Drug therapy (preintubation): intravenous (IV) fentanyl, or morphine, and midazolam or propofol in hemodynamically stable and IV ketamine or etomidate in unstable patients Accessories, for example, water-soluble xylocaine jelly, 10 mL air syringe for inflating tracheal tube cuff, bougie, stylet, Magill's forceps, endotracheal tube fixation ties or tapes and end-tidal CO 2 monitoring unwanted effects such as severe bradycardia. 13,32,33 Other drugs used include propofol, sevoflurane, and opioids such as fentanyl and remifentanil.…”

“…In a patient with a known difficult airway, one should ensure that skilled airway help is readily available prior to extubation and extubation should preferably be performed over a tube excha nger. 1,7,20,35,36,38 Regular dry runs utilizing mannequin-based simulations are to be conducted for all the staff involved in the airway management of difficult airways. Thus appropriate training with the use of simulation is critical to all those who are involved in managing airway challenges in critically ill patients.…”