delayed sequence induction

Introduction

A modification to usual RSI where procedural sedation is given to permit optimal pre-oxygenation
Ketamine is the prototypical agent used
Published by Weingart
A useful option in critically ill patients who are difficult to pre-oxygenate (ie due to agitation)
Low dose ketamine (eg 0.5mg/kg) is used to improve synchrony with non-invasive ventilation and to overcome some aspects of shunt physiology
Laryngeal reflexes are preserved until the neuro-muscular paralysis agent is given, which may be some minutes after the dissociative initial dose of ketamine (hence “delayed” sequence)
higher PEEP or CPAP can be delivered during the pre-ox phase because the patient is more manageable; this will in turn give higher oxygen saturations immediately prior to intubation and should improve the margin of safety
see: http://broadcomplex.com.au/wp-content/uploads/2016/06/KetamineplusNIVflowchart.pdf