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critical care review: Stuart F. Reynolds and John Heffner Airway Management of the Critically Ill Patient: Rapid-Sequence Intubation Chest 2005; 127: 1397-1412 [Abstract] [Full text] [PDF]

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Communications to the editor_Airway Management of the Critically Ill Patient Rapid Sequence In

Cándido Pardo Rey   (20 May 2005)

Communications to the editor_Airway Management of the Critically Ill Patient Rapid Sequence In 20 May 2005
Cándido Pardo Rey Send letter to journal: Re: Communications to the editor_Airway Management of the Critically Ill Patient Rapid Sequence In candypar{at}eresmas.com Cándido Pardo Rey	To the Editor: Dr. Stuart in his article “Airway management of the critically ill patient: rapid-sequence intubation” emphasized the success rate of intubation with simultaneous use of induction agents, potent analgesics and neuromuscular blocking agents (NMBA). We disagree with the use of succinylcholine as the best NMBA in rapid-sequence intubation in critically ill patients.1 Most patients undergoing a rapid sequence intubation have altered mental status, respiratory insufficiency or are combative. Almost in most cases airway assessment is not feasible, therefore intubation would be more difficult in intensive care unit (I.C.U.). The imperious need of intubation in this situation is unquestionable. A blockade neuromuscular agent with a short half-life would not be justified because we need to oxygenate our patients and if the intubation wasn’t possible, the problem, would persist and we could use alternative techniques for airway management. Succinylcholine is the only depolarizing neuromuscular blocking agent used nowadays, despite its many well-known and partly life-threatening side- effects since its first use in the 50’s.2 More that 45% of patients, who need intubation in our I.C.U., haven’t got a medical history, or their personal antecedents are unknown [unpublished data, presented in Abstract]. So, we have the opinion that to use a drug with an unfavourable security profile is the worse choice. Rocuronium, since rapacuronium was withdrawn, is currently the best alternative to succinylcholine for rapid sequence induction.3 This new agent has an excellent security profile and little secondary effects in critically ill patients. At doses of 0,6 mg/kg, is the neuromuscular blocking agent that creates intubation conditions equivalent to those with succinylcholine. Even this new agent has an antagonist, Org 25969, in case we believe that reversion is neccesary.4 Finally, we think that it is very important to analyze which drug is the best for my patient, why to use this one and not another, and alternatives and dangers associated with the use of drugs. REFERENCES 1 Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest 2005; 127(4):1397-1412. 2 Sparr HJ, Johr M. [Succinylcholine--update]. Anaesthesist 2002; 51(7):565-575. 3 Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2003;(1):CD002788. 4 Pic LC. Novel pharmacological approaches for the antagonism of neuromuscular blockade. AANA J 2005; 73(1):37-40. 5 Hayes AH, Breslin DS, Mirakhur RK et al. Frequency of haemoglobin desaturation with the use of succinylcholine during rapid sequence induction of anaesthesia. Acta Anaesthesiol Scand 2001; 45(6):746-749.