Rapid Sequence Induction e Sugammadex

Transcript

1 Rapid Sequence Induction e Sugammadex Giannone S, Castagnoli A Scuola di Specializzazione in Anestesia, Rianimazione e Terapia Intensiva, Università di Bologna Dir. Prof.ssa R.M. Melotti

2 Rapid Sequence Induction Scopo: Minimo intervallo di tempo tra perdita di coscienza e intubazione oro tracheale (sicurezza vie aeree) Indicazioni: Pz a rischio di aspirazione (urgenze, ascite, parto cesareo) Stept, W. and P. Safar, Rapid induction-intubation for prevention of gastric-content aspiration. Anesthesia and analgesia, (4): p

3 Rapid Sequence Induction Pre-ossigenazione Oppiaceo-ipnoinduttore-miorilassante NO ventilazione in maschera Pressione cricoidea Intubazione oro tracheale entro 60 El-Orbany M and Connolly LA, Rapid Sequence Induction and Intubation:Current Controversies. Anesthesia & Analgesia,

4 Rapid Sequence Induction: Rapido onset Rapido offset Sicurezza Basso costo Miorilassante ideale

5 Rapid Sequence Induction: Miorilassante ideale Rapido onset Rapido offset SUCCINILCOLINA Sicurezza Basso costo

6 Rapid Sequence Induction: Miorilassante ideale Rapido onset Rapido offset Sicurezza Basso costo SUCCINILCOLINA ROCURONIO SUGAMMADEX

7 Rapid Sequence Induction: Miorilassante ideale Rapido onset Rapido offset Sicurezza Basso costo

8 Rapido onset Obiettivo: intubazione entro 60 Gold Standard storico : Succinilcolina 1 mg/kg Alternativa: Rocuronio 0,9-1,2 mg/kg Perry, J., J. Lee, and G. Wells, Are intubation conditions using rocuronium equivalent to those using succinylcholine? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, (8): p

9 Scala di Goldberg per le Condizioni di Intubazione Punteggio Facilità della Laringoscopia Posizione Corde Vocali Risposta motoria all intubazione 1 Buona Aperte Nessuna 2 Accettabile Paramediana Movimento diaframmatico 3 Difficile In movimento Tosse leggera 4 Impossibile Chiuse Tosse forte/sussulti Totale Punti 3: condizioni di intubazione ottimali 4-6: accettabili 7-9: scadenti 10-12: inadeguate/impossibile

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11 Perry, J., et al., Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane database of systematic reviews, 2008 (n = 2690)

14 Rocuronium specific dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions Dose Rocuronio RR [IC 95%] n Peso mg/kg 0.81 [ 0.73, 0.90 ] % mg/kg 0.96 [ 0.89, 1.02 ] % 1.2mg/kg 0.93 [ 0.75, 1.15 ] % totale 0.87 [ 0.81, 0.93 ] % Perry, J., et al., Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane database of systematic reviews, 2008

15 Perry, J., et al., Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane database of systematic reviews, 2008 Overall, succinylcholine was superior to rocuronium We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.

16 Perry, J., et al., Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane database of systematic reviews, 2008 Overall, succinylcholine was superior to rocuronium We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.

18 Rapido offset Succinilcolina 1 mg/kg: 6-10 min Rocuronio 1,2 mg/kg: min Perry, J., J. Lee, and G. Wells, Are intubation conditions using rocuronium equivalent to those using sucinylcholine? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, (8): p

19 Quando è necessario un rapido offset? Procedure brevi??? Imprevista difficoltà di intubazione?

20 Quando è necessario un rapido offset? Procedure brevi? Imprevista difficoltà di intubazione?

21 Lee, C., et al., Reversal of profound neuromuscular block by Sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology, (5): p

22 Bisschops, M., C. Holleman, and J. Huitink, Can Sugammadex save a patient in a simulated 'cannot intubate, cannot ventilate' situation? Anaesthesia, (9): p We would warn against a false sense of security developing from the knowledge that sugammadex is available in the theatre complex, should problems arise when using high dose rocuronium for rapid sequence induction; the mean time to administer sugammadex in our study was 6.7 min following which one could predict that a further 2.2 min would be required to achieve a TOF ratio of

23 Benumof, J., R. Dagg, and R. Benumof, Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology, (4): p

24 Curtis, R., S. Lomax, and B. Patel, Use of sugammadex in a 'can't intubate, can't ventilate' situation. Br J Anaesth, While sugammadex can be relied upon to reverse rocuronium-induced neuromuscular block, it should not be relied upon to rescue all CICV events, especially where airway instrumentation has led to airway swelling. The availability of sugammadex does not obviate the need for emergency tracheal access in the event of failed oxygenation.

26 Neuromuscular block by depolarisation of muscle cells is, in a sense, like general anaesthesia by depolarisation of cerebral neurons. It is intuitively a bad idea. Lee, C., Goodbye suxamethonium! Anaesthesia, Suppl 1: p

27 Succinilcolina Effetti collaterali: mialgie, fascicolazioni, effetti muscarinici, aumento della pressione endocranica/endooculare, spasmo del massetere, liberazione di K +, anafilassi, ipertermia maligna Controindicazioni: Traumi, ustioni estese presenti da > hr, malattie neuromuscolari, allettamento prolungato, lesioni bulbo oculare Lee, C., Goodbye suxamethonium! Anaesthesia, Suppl 1: p

28 Rocuronio Effetti collaterali: transitoria liberazione di istamina, non emodinamicamente significativa, anafilassi Controindicazioni: Allergia accertata nei confronti del farmaco. Engbaek, J. and J. Viby-Mogensen, Can rocuronium replace succinylcholine in a rapid-sequence induction of anaesthesia? Acta anaesthesiologica Scandinavica, (1): p. 1-4.

29 Sugammadex Effetti collaterali: ipotensione, dolore,nausea, vomito, disgeusia, reazioni da ipersensibilità Controindicazioni: insufficienza renale grave con ClCr < 30 ml/min (non raccomandato) Yang, L.P. and S.J. Keam, Sugammadex: a review of its use in anaesthetic practice. Drugs, (7): p

31 Adulto 70 kg: Rapid Sequence Induction Induzione: Succinilcolina 70 mg: 1,70 euro Rocuronio mg: 14 euro Antagonizzazione: Sugammadex dopo 3 (16mg/kg): 732 euro Sugammadex dopo 30 (4 mg/kg): 366 euro

32 Chambers, D., et al., Sugammadex for reversal of neuromuscular block after rapid sequence intubation: a systematic review and economic assessment. British Journal of Anaesthesia, (5): p Costo di 1 minuto in sala operatoria : 5,30 euro Costo di un minuto in recovery room: 0,39 euro Valore di 1 QALY (Quality Adjusted Life Year): euro Perdita economica per decesso pz 20 anni: 22.9 QALY ( euro) Perdita economica per decesso pz 60 anni : QALY ( euro)

33 Chambers, D., et al., Sugammadex for reversal of neuromuscular block after rapid sequence intubation: a systematic review and economic assessment. British Journal of Anaesthesia, (5): p

34 RSI in ostetricia The consultants and ASA members agree that GA reduces the time to skin incision when compared with either epidural or spinal anesthesia; they also agree that GA increases maternal complications. The consultants are equivocal and the ASA members agree that GA increases fetal and neonatal complications. American Society of Anesthesiologists Task Force on Obstetric, A., Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology, (4): p

35 RSI in ostetricia The major disadvantage of general anaesthesia is the risk of failure and the dramatic consequences of a potential cannot intubate, cannot ventilate situation. The risk of failed intubation is at least eight times higher in the obstetric population Tracheal intubation after rapid sequence induction remains the approach to airway management during general anaesthesia. Dahl, V. and U.J. Spreng, Anaesthesia for urgent (grade 1) caesarean section. Curr Opin Anaesthesiol, (3): p

36 RSI in ostetricia There is now a possibility that SCh might be rendered obsolete by the combination of rocuronium and sugammadex. High-dose rocuronium offers as swift an onset of NMB than SCh, and a cleaner side-effect. Sugammadex can cater for both routine reversal of NMB at Caesarean section and, at higher doses, early reversal of profound blockade in the event of can t intubate, can t ventilate shortly after induction. Sharp LM, Levy DM, Rapid sequence induction in obstetrics revisited. Current Opinion in Anaesthesiology,

37 Conclusioni- 1 Il Rocuronio a dosaggio 0.9-1,2 mg/kg permette di ottenere condizione di intubazione ottimali in 60, al pari della Succinilcolina. Dopo una RSI con Rocuronio, il Sugammadex a 16 mg/kg permette una antagonizzazione del blocco neuromuscolare più rapida della risoluzione spontanea da Succinilcolina. Il Rocuronio può essere un alternativa alla Succinilcolina anche in ambito ostetrico.

38 Conclusioni- 2 Il Rocuronio presenta un profilo farmacologico superiore rispetto alla Succinilcolina, per quanto riguarda gli effetti collaterali e le controindicazioni. L elevato prezzo del Rocuronio/Sugammadex può essere compensato dal risparmio di tempo in sala operatoria e dalla riduzione dei costi legati alla morbidità/morbilità da Succinilcolina.

39 Quando succinilcolina? RSI a < 24 hr da somministrazione di Sugammadex (es. revisione chirurgica) RSI in pz con allergia accertata nei confronti del Rocuronio Procedure ultrabrevi? (costo/beneficio)

40 Rapid Sequence Induction e Sugammadex Giannone S, Castagnoli A Scuola di Specializzazione in Anestesia, Rianimazione e Terapia Intensiva, Università di Bologna Dir. Prof.ssa R.M. Melotti

41 Sorensen, M.K., et al., Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth, 2012.