From the Guidelines
Paralytic administration is recommended during re-intubation after self-extubation to optimize intubation conditions and reduce the risk of airway trauma. A typical approach would be:
- Preoxygenate the patient
- Administer a sedative like propofol (1-2 mg/kg IV) or etomidate (0.3 mg/kg IV)
- Give a fast-acting paralytic such as rocuronium (1-1.2 mg/kg IV) or succinylcholine (1-1.5 mg/kg IV)
- Wait 45-60 seconds for paralysis to take effect
- Proceed with intubation Using paralysis helps relax the jaw and vocal cords, reducing the gag reflex and eliminating patient movement, which increases the likelihood of first-pass success and reduces the risk of trauma to the airway 1. It is essential to be prepared for a potentially difficult airway, as the reason for self-extubation may have been due to airway edema or other complications, and have backup airway equipment readily available. Additionally, addressing the underlying cause of the self-extubation is crucial to prevent recurrence.
The Difficult Airway Society guidelines for the management of tracheal extubation emphasize the importance of planning and executing extubation well, with a focus on uninterrupted oxygen delivery, avoiding airway stimulation, and having a backup plan for ventilation and re-intubation 1. While these guidelines do not specifically address the use of paralytics during re-intubation after self-extubation, the principles of ensuring a safe and controlled airway management process support the use of paralytics in this context.
In real-life clinical practice, the use of paralytics during re-intubation after self-extubation is a common approach, as it helps to minimize the risk of airway complications and ensures a smooth and efficient intubation process. However, it is crucial to consider the individual patient's circumstances and adjust the approach accordingly, taking into account factors such as the patient's medical history, current condition, and any potential contraindications to paralytic use.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Paralytic Administration During Re-intubation
- The use of paralytic agents during re-intubation after self-extubation is a critical consideration in patient care.
- A study published in the Journal of emergencies, trauma, and shock 2 compared the safety of succinylcholine and nondepolarizing paralytic agents, such as rocuronium and vecuronium, during rapid sequence intubation.
- The study found that while succinylcholine has a higher adverse effect profile, the mortality rate among patients receiving succinylcholine was lower than that of patients receiving non-depolarizing agents.
Re-intubation After Self-Extubation
- Re-intubation after self-extubation is a complex process that requires careful consideration of the patient's respiratory status and the potential risks and benefits of different oxygenation strategies.
- A study published in Respiratory care 3 discussed the use of noninvasive ventilation (NIV) after failing a spontaneous breathing trial, highlighting the importance of careful monitoring and timely re-intubation if necessary.
- Another study published in Journal of intensive medicine 4 reviewed oxygenation strategies after extubation, including the use of high-flow nasal oxygen and NIV, and emphasized the need for individualized approaches based on patient risk factors.
Noninvasive Respiratory Support
- Noninvasive respiratory support, including NIV, CPAP, and high-flow nasal cannula, can be effective in managing postextubation respiratory failure and preventing re-intubation.
- A study published in Respiratory care 5 analyzed the effectiveness of these therapies in patients at high risk of re-intubation, highlighting the importance of early intervention and careful patient selection.
- A more recent study published in Respiratory care 6 evaluated the effect of re-intubation within 48 hours on mortality in critically ill patients after planned extubation, finding that re-intubation was associated with higher mortality rates.