General anesthesia: Intravenous induction agents. Induction of general anesthesia: Overview. See individual drug monographs for pediatric and expanded dosing strategies. Consider the use of:Īdult doses are shown in the table below. Deep sedation does not result in areflexia, but rather suppresses any response to stimulus. It also lowers the required dose of sedation. Autonomic stability can be achieved through the use of:Īreflexia produces the best laryngoscopic views possible, however it is also fraught with complications and potentially dire consequences. Use of tools such as the shock index, in conjunction with clinical judgement, can identify patients at risk of hypotension in the context of endotracheal intubation. Hypotension is associated with an increased morbidity and mortality, which is especially true in patients with traumatic brain injuries or right heart syndromes. Most patients will require some form of hemodynamic resuscitation in the peri-intubation phase. Agents used in maintaining analgesia include: It can be achieved with the use of:Įffective analgesia not only makes the patient more comfortable, but also decreases the amount of post-intubation sedation required to maintain the desired clinical state through pharmacological synergy. Induction and maintenance of amnesia is incredibly important to the long-term psychological outcomes of patients who undergo ETI. Any patient that is hemodynamically unstable or likely to become unstable.Any patient that is difficult or likely difficult to ventilate.
Signs of a difficult airway and whether the patient recently ate should be considered before sedation (these are not contraindications but considerations).Elements to consider when evaluating an individual patient's risks include: The complexity of risk stratification revolves around whether airway control is emergent, urgent, or elective. Lack of trained personnel to perform the procedure safelyĬautions should be based around a risk stratification.Lack of equipment necessary to intervene, monitor, and maintain the airway, respirations, hemodynamics, and for any potential interventions.Allergy or sensitivity to the medication.Patients who will not tolerate an RSI procedure due to an inability to preoxygenate, or tolerate peri-intubation procedures including hemodynamic consequences.Clinical scenarios where a difficult airway is suspected.Rapid sequence intubation is indicated for any patient who is at risk of aspiration with induction.Any patient requiring anesthesia for the purpose of intubation, maintenance, or emergence.The sequencing of medications and the procedure performed is based on the individual patient’s needs and risk factors. These phases can be further divided into the four A’s of anesthesia planning: anesthesia, analgesia, autonomic stability, and areflexia. This anesthesia guideline is design around the three phases for intubation: induction, maintenance, and emergence. No induction agent is ideal for all patients and all medications have side effects. The ideal induction agent has a rapid onset of action, minimal side effects, and is cleared quickly so that recovery is rapid. Provision of anesthesia is one of the cornerstones of critical care practice. For ACP-level anesthesia planning for intubation, see PR18: Anesthesia Induction.
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