refers to the use of a sedative only (without a paralytic) to pharmacologically assist with intubation. Facilitated intubation, also referred to as \u201cpharmacologically assisted intubation,\u201d has been recommended by some clinicians in specific circumstances because it does not involve neuromuscular blockade. Some advocate the avoidance of a neuromuscular paralysis and the use of sedation alone (\u201cfacilitated intubation\u201d) in clinical scenarios in which a difficult airway is anticipated.[21]<\/p>\n
For facilitated intubation, the most common sedative used has been etomidate, although midazolam has also bee used. [60] , [61] , [62] Proponents of facilitated intubation suggest that there may be clinical scenarios in which paralysis is not an option.<\/p>\n
A study in the prehospital air medical setting, using 0.3 mg\/kg of etomidate as their sedative without any NMB reported an 89% rate of successful intubation, difficult intubation in 16%, and episodes of clenched jaws and orofacial muscle spasm.[60] A later study from the same investigators (an air medical transport service) prospectively compared facilitated intubation using etomidate versus RSI using etomidate and succinylcholine. The results were: 63% (15 of 24) of the facilitated intubation (etomidate only) group received additional medications versus 4% (1 of 25) in the RSI group, and laryngoscopic conditions using several scoring systems was significantly more difficult for the facilitated intubation (etomidate only) versus RSI.[61] The conclusion was that facilitated intubation (etomidate only) had a decreased rate of success when compared with RSI (etomidate + succinylcholine). A prehospital study of facilitated intubation using midazolam alone noted a successful intubation rate of only 62.5%, which is less than the usual success rate for prehospital RSI.[62] When comparing successful rates of intubation, based on these studies, RSI has higher success rates than facilitated intubation.<\/p>\n
For ED intubations, the results of the NEAR studies confirm the superiority of RSI over facilitated intubation. [6] , [34] The successful intubation rate for first attempt was RSI = 85%, and sedative only (no NMB) = 76%. The successful rate for first intubation was RSI = 91%, and sedative only (no NMB) = 88%.[34] For pediatric patients, the first attempt intubation success rates were RSI, 78%; sedative only, 44%; and no medication 47%.[6]<\/p>\n
1 Murphy M.F., Walls R.M.: Rapid sequence intubation. In: Mace S.E., Ducharme J., Murphy M.F., ed. Pain management and sedation emergency department management, McGraw-Hill Co.New York2006: 211-218.[Chapter 28]
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\n8 Brimacombe J.R., Berry A.M.: Cricoid pressure. Can J Anaesth 44. (11): 1219.1997; Abstract
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\n11 Salhi B., Stettner E.: In defense of the use of lidocaine in rapid sequence intubation. Mower III W.R., Knopp R.K., ed. Clinical controversies: lidocaine administration before rapid sequence intubation in patients with traumatic brain injuries Ann Emerg Med 49. (1): 84-86.2007; Full Text
\n12 Vaillancourt C., Kapur A.K.: Opposition to the use of lidocaine in rapid sequence intubation. Mower III W.R., Knopp R.K., ed. Clinical controversies lidocaine administration before rapid sequence intubation in patients with traumatic brain injuries Ann Emerg Med 49. (1): 86-87.2007; Full Text
\n13 Zelicof-Paul A., Smith-Lockridge A., Schnadower D., et al: Controversies in rapid sequence intubation in children. Curr Opin Pediatr 17. 355-362.2005; Abstract
\n14 Wang H.E., Davis D.P., Wayne M.A., et al: Prehospital rapid-sequence intubation – what does the evidence show?. Prehosp Emerg Care 8. (4): 366-377.2004; Citation
\n15 Kovacs G., Law J.A., Ross J., et al: Acute airway management in the emergency department by non-anesthesiologists. Can J Anaesth 51. (2): 177-180.2004; Abstract
\n16 ACEP Policy Statement. Rapid-sequence intubation. Approved by ACEP Board of Directors – October 2006, Available at: www.ACEP.org Accessed 7\/02\/08.
\n17 Walls R.M.: Rapid sequence intubation. In: Walls R.M., Murphy M.F., Luten R.C., Schneider R.E., ed. Manual of emergency airway management, Lippincott Williams and WilkinsPhiladelphia2004: 22-32.[Chapter 3]
\n18 Reynolds S.F., Heffner J.: Airway management of the critically ill patient. Chest 127. (4): 1397-1412.2005; Full Text
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\n20 Davis D.P., Fakhry S.M., Wang H.E., et al: Paramedic rapid sequence intubation for severe traumatic brain injury: perspectives from an expert panel. Prehosp Emerg Care 11. (1): 1-8.2007; Abstract
\n21 Decker J.M., Lowe D.A.: Rapid sequence induction. In: Henretig F.M., King C., ed. Textbook of pediatric emergency procedures, Williams & WilkinsBaltimore (MD)1997: 141-159.
\n22 Caplan R.A., Benumof J.L., Berry F.A., et al: Practice guidelines for the management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 98. 1269-1277.2003; Full Text
\n23 Gerardi M.J., et al: Evaluation and management of the multiple trauma patients. In: Strange G.R., Ahrens W.R., Lelyveld S., et al ed. Pediatric emergency medicine, McGraw-HillNew York1996: 37-57.[Chapter 8]
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\n25 Murphy M.F., Doyle D.J.: Airway evaluation. In: Hung O.R., Murphy M.F., ed. Management of the difficult and failed airway, McGraw-HillNew York2008: [Chapter 1]
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\n29 Mace S.E.: Barbituartes. In: Mace S.E., Ducharme J., Murphy M., ed. Pain management and sedation: emergency department management, McGraw HillNew York2006: 125-131.[Chapter 19]
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\n33 Mace S.E.: Benzodiazepines. In: Mace S.E., Ducharme J., Murphy M., ed. Pain management and sedation: emergency department management, McGraw HillNew York2006: 139-147.[Chapter 21]
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\n61 Bozeman W.P.: A comparison of rapid sequence intubation and etomidate only intubation in the prehospital air medical setting. Prehosp Emerg Care 4. (1): 14-18.2000; Abstract
\n62 Wang H.E., O’Connor R.E., Megargel R.E., et al: The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 4. 14-18.2000; Abstract<\/p>\n","protected":false},"excerpt":{"rendered":"
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