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The data were assessed and prepared by a statistician to enable a comparison between adult and paediatric RSI practices. Overall, colleagues completed the survey, of whom were anaesthesiologists who had completed training The invitation to take part in the survey was sent to members of the ESA, and of ESA members opened the e-mail. Of those who opened the e-mail, the response rate was We received responses from more than 58 countries Supplemental Digital Content 1.
In adult practice, the majority of respondents used RSI in high-risk patients: acute abdomen Head-up was the preferred patient position for anaesthesia induction in adults The majority of respondents considered that a gastric tube for RSI in adults was unnecessary Opioids were used during anaesthesia induction by The preferred choice of RSI induction agents for haemodynamically stable patients were propofol For haemodynamically unstable adult patients, ketamine Monitoring the onset of neuromuscular blockade was considered unnecessary by In paediatric practice, RSI was chosen for the majority of high-risk patients: acute abdomen The majority of respondents used RSI in older children only The preferred position was supine A cuffed endotracheal tube was used for all children by The drugs of choice for RSI induction in haemodynamically stable paediatric patients were propofol In the case of haemodynamic instability, the preferred drugs were ketamine Manual ventilation via face mask before anaesthesia induction was not performed by Detailed results are accessible in Supplemental Digital Content 1.
Do you ventilate the patient via face mask before anaesthesia induction before first intubation attempt? RSI, rapid sequence induction. The primary aim of the survey was to evaluate the actual clinical practice of RSI in adult and paediatric patients.
Our results confirmed the significant heterogeneity both in the components of RSI and in RSI practice between adults and paediatric patients. Although the majority of respondents used RSI in patients with a risk of aspiration, the number of respondents who did not do so in different situations varied from 5.
This could be considered a dangerous practice as pulmonary aspiration remains the most common cause of death associated with anaesthesia. In addition, RSI should be performed in pregnant women after the third trimester and during labour. In our survey, the head-up position was preferred by The risk of atelectasis formation is outweighed by the increase in patient safety.
Preoxygenation with a tight-fitting face mask is considered a standard part of anaesthesia induction. In recent years, high-flow nasal oxygen cannulae HFNC have been tested as a potential upgrade of standard preoxygenation to prolong the time to desaturation during apnoea , but the results are conflicting. There are only limited data about the requirement for a gastric tube before anaesthesia induction. However, leaving the gastric tube in situ during the induction of anaesthesia compromises the lower oesophageal sphincter creating a risk of regurgitation.
Evidence-based data does not specify the correct gastric tube management in RSI. Still, it should always be considered whether the gastric tube can reduce the associated risk.
Overall, Nowadays, one of the most controversial parts of RSI is the Sellick manoeuvre cricoid pressure. The effectiveness and safety of Sellick manoeuvre has never been proven in a well designed, adequately powered, randomised controlled trial. The recently published IRIS trial 21 was the first-ever randomised, double-blind noninferiority trial to compare a sham Sellick manoeuvre with cricoid pressure.
The results failed to prove the noninferiority between sham Sellick manoeuvre and cricoid pressure, but the study was underpowered. Pulmonary aspiration was comparable between the groups 0. Although the debate about Sellick manoeuvre in the anaesthesiology community is ongoing, there are several national guidelines no longer recommending Sellick manoeuvre as a part of RSI in clinical practice. Opioids were not considered as a part of classical RSI.
However, opioids during RSI reduce the cardiovascular response to laryngoscopy and can reduce the dose of the induction agent. Overall use of opioids in RSI was In classical RSI, the drug of choice for anaesthesia induction was thiopentone in combination with suxamethonium.
This has changed over the past two decades. Currently, there are two drugs ketamine, etomidate that are considered safer during the induction of anaesthesia in haemodynamically unstable patients, or in patients with a high risk of hypotension. Etomidate is linked with the suppression of corticosteroid synthesis after administration and could be dangerous in patients with sepsis or septic shock. Unlike other intravenous anaesthetics, ketamine can even lead to the elevation of blood pressure and heart rate.
The majority of respondents selected ketamine Propofol or thiopentone were selected in However, as these drugs can lead to a further deterioration of the circulatory status, many consider them to be dangerous in haemodynamically unstable patients.
Suxamethonium is a part of the classical RSI technique but rocuronium 1. Worldwide, suxamethonium remains the first-choice drug for neuromuscular blockade induction during RSI. However, the availability of suggamadex, a selective antidote for rocuronium, has increased the use of rocuronium for RSI over the past few years. This situation was reversed in paediatric patients, where This could be explained by the fear of malignant hyperthermia in children, or by the availability of sugammadex for rapid reversal of rocuronium and the additional possibility of minimising the incidence of residual neuromuscular blockade postoperatively.
In , the Food and Drug Administration FDA published a warning regarding serious adverse effects and fatal cases of malignant hyperthermia after suxamethonium administration. Considering the serious side effects, the role of suxamethonium in paediatric RSI is debatable. This could be a possible area for improvement. The majority of aspiration episodes during RSI have been linked to attempts to intubate the trachea during light anaesthesia before the onset of neuromuscular blockade.
However, this practice is associated with a risk of hypoxaemia and cardiovascular complications. The standard care for patients at risk of aspiration is to secure the airway for general anaesthesia with a cuffed tracheal tube. Historically, in children under 8 years of age, an uncuffed tube has been used because of the fear of post-extubation stridor. Over the past decade, the practice of RSI has evolved with the availability of new drugs, equipment and knowledge.
A recent survey of both trainee and consultant anaesthetists showed that practice is varied. Several induction agents and several alternatives to succinylcholine are used by many anaesthetists.
These include non-depolarizing neuromuscular blocking agents and opioids. Indeed, this study suggested that many anaesthetists do not follow best practice. Rapid sequence induction is utilized less frequently in countries other than the UK. No comprehensive studies support the efficacy of RSI; nor do they demonstrate a contribution to reduction in morbidity or mortality. This article discusses the various aspects of RSI, and encourages the formation of a considered approach.
The sequelae of aspiration vary depending upon the pH and volume of fluid entering the bronchial tree. This was originally noted by Mendelson in ; he described two syndromes in response to aspiration of solid and liquid materials. Larger volumes of acidic stomach contents induce a more severe aspiration pneumonitis than smaller volumes of pH-neutral fluid.
Hydrochloric acid causes bronchiolar spasm and peribronchiolar congestive and exudative reactions that interfere with normal intrapulmonary circulation. The second pattern is typified by obstruction of a bronchus or bronchiole by solids and results in distal collapse and atelectasis. Massive lobar collapse ensues with cyanosis, tachycardia, dyspnoea, mediastinal shift, consolidation and greater morbidity.
Chemical pneumonitis impairs gas transfer, as do collapse, consolidation and oedema resulting from obstruction and the inflammatory response. An overall mortality after aspiration of 1 in 71 was reported for all elective and emergency cases by Warner and colleagues.
During emergency anaesthesia, aspiration of stomach contents is a potential risk in all patients with an incompetent larynx. Preoperative fasting and prokinetic agents reduce this risk but are not always appropriate or available before essential emergency surgery where there are time constraints on patient optimization.
Passing a nasogastric tube can allow removal of some of the stomach contents. Factors associated with a high risk of aspiration include: i abdominal pathology, especially obstruction or ileus; ii delayed gastric emptying e.
The risk of aspiration in these patients is present throughout the perioperative period, especially during induction and emergence from anaesthesia.
Performance of RSI requires prevention of aspiration, rapid achievement of intubation and preparation for the possibility of failure to intubate or prevent regurgitation. Because RSI involves loss of consciousness and neuromuscular block without assurance of the ability to mechanically ventilate the patient's lungs, the anaesthetist must be prepared for all eventualities before commencing RSI.
This should include good preparation for safe induction, equipment to remove secretions or vomit, and a pre-planned drill to follow should intubation fail. Full monitoring and an assistant, trained in the application of cricoid pressure, are essential. The equipment must be checked and include working suction, capnography, and an adequate selection of endotracheal tubes and laryngoscopes. The trolley must tip to a head-down position easily. A wide bore i. The patient should be positioned in the optimal intubating position.
A pre-calculated dose of induction agent is administered, followed immediately by a neuromuscular blocking agent. Cricoid pressure at 20—40 N or 2—4 kg is applied before loss of consciousness. After the jaw has relaxed and succinylcholine-associated fasciculations have ceased, the trachea is intubated. After tube position and adequate seal are confirmed the cricoid pressure may be released.
Intravenous induction facilitates loss of consciousness in one arm—brain circulation time, minimizing the time from loss of consciousness to intubation. Ideally, the chosen induction agent should provide a rapid onset and a rapid recovery from anaesthesia with minimal cardiovascular and systemic side effects. It is noticeably quicker than both etomidate and propofol.
However, it has a longer duration of action and its side effects are potentially life-threatening. Thiopental has a relatively high rate of anaphylaxis 1 in 20 Propofol has the advantage of suppressing laryngeal reflexes and, thus, potentially assisting intubation. It has a slower onset than thiopental and greater cardiovascular depression occurs. Etomidate has the major advantage of cardiovascular stability, so it is useful for the induction of anaesthesia in patients with severe cardiovascular disease.
However, the slow speed of onset and potential adrenal suppression limit its use. These disadvantages outweigh the benefits gained through its cardiovascular stability in the majority of patients. During emergency anaesthesia where there is circulatory collapse, ketamine should be considered. In summary, it is sensible to tailor the choice of induction agent to the patient to be anaesthetized.
The most rapidly-acting agent should be used where there is greatest risk of aspiration and etomidate should be reserved for patients with major cardiovascular co-morbidity. Historically, succinylcholine has been the agent of choice for neuromuscular block. The ideal characteristics of a neuromuscular blocking agent for RSI comprise a rapid onset of action to minimize the risk of aspiration and hypoxia, a rapid recovery to facilitate the return of ventilation if intubation fails and minimal haemodynamic and systemic effects.
Despite being the traditional choice, succinylcholine does not fulfil these criteria. It does have a rapid onset and offset of action, but unfortunately there are many side-effects, some of which are life-threatening. Succinylcholine can cause hyperkalaemia, muscle pains, bradycardia and malignant hyperpyrexia.
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