Use Of Rapid Sequence Induction Research Articles

Establishing quality indicators for pre-hospital advanced airway management: a modified nominal group technique consensus process

BackgroundPre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. MethodsWe used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. ResultsSeventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. ConclusionsWe identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

Surgeries in asymptomatic carriers during SARS-COV-2 pandemic: Challenges and future.

Sir, The outbreak of severe acute respiratory syndrome coronavirus (SARS-CoV-2) pandemic lead to around 5,400,000 confirmed cases in more than 210 countries all over the world (26thMay 2020).[1] To avoid burden on the health care system and to avoid disease transmission, most of the hospitals suspended all the elective procedures and are undertaking only emergency procedures. A suspected/confirmed COVID-19 patient for an emergency procedure may be treated with strict adherence to standard operating procedure (SOP) with enhanced personal protective equipment (PPE) put forth by various agencies.[23] If they are symptomatic or with contact history, we will proceed after testing for COVID-19. But what if the patient is an asymptomatic carrier?[4] Does every patient need to undergo “COVID-19” screening for an elective procedure? Even after the COVID-19 screen, are we sure the test result is not false-negative?[3] Are the health care workers always at risk after this pandemic? So, the answer would be to do the best of the best cost-effectively. Firstly, there is around 10–20% chance of false-negative results.[3] Secondly, it is not cost-effective to carry out every elective procedure with SOP in all asymptomatic patients with negative contact history. A better way would be to emphasise on areas where the chances of transmission are more, use equipment which can be reused and sterilised. The most common mode of transmission in the operating area is by aerosol-generating procedures (AGP), that is, intubation, extubation, suction and manual ventilation. Few precautions may be followed while executing these procedures: The term “elective and emergency” needs to be well understood and balanced with the health of the patient in this time of crisis. Indication of surgery needs to be evaluated against the resources. Emergency surgeries in asymptomatic carriers also stand as a risk during the pandemic Symptomatic suspected/confirmed COVID-19 cases posted for elective procedures should be done only after considering the need for surgery. Cosmetic surgeries may be avoided Pre-anaesthetic check-up also needs to be done with N95 masks, goggles, and hand hygiene. Proper history taking and informed consent (regarding asymptomatic carriers and hospital staff is not responsible if they are detected later) should be done[5] The person handling the airway may use a set of seven to eight N-95 masks/month (reused after “mask quarantine” for 3 days or sterilised with ultraviolet radiation or hydrogen peroxide vapor),[6] goggles (reusable), face shield (reusable), and standard PPE in place of enhanced PPE Use a plastic box with preferably suction/vacuum port or two holes in plastic cover, making a room for two hands, over the patient to be intubated or extubated. The mask may also be covered with plastic cover to limit the spread of aerosol. Avoid manual ventilation as and when possible. If required, small tidal volumes with heat moisture exchanger filter (HMEF) may be used[7] Preoxygenation before induction gives some time during desaturation. It reduces mistakes during induction and hence decreases aerosol generation. The routine use of rapid sequence induction using intubating dose of rocuronium or succinylcholine should be encouraged, unless contraindicated. Routine use of videolaryngoscope is preferable Limit the number of people during AGP to two-three (including a trained assistant) to minimise the exposure to AGPs. Safe extubation practices should be adopted (use of intubation box or plastic drapes) Conduct the elective surgeries under regional anaesthesia (sub-arachnoid block, regional blocks) as and when possible. Use second generation supraglottic airway devices whenever feasible Minimise the number of ventilator disconnections to avoid the operating theatre pollution and aerosol spread. A negative pressure operation theatre (OT) is preferable or if not possible increase the number of air exchanges per hour[3] Use of HMEF may be encouraged at the patient end and at the expiratory limb. Routine use of videolaryngoscopes may be encouraged Hand-hygiene before and after the procedure and social distancing need to be followed in OTs. The surgeons performing open abdominal surgeries, ophthalmological surgeries, oropharyngeal surgeries, etc. may also use the N-95 mask with goggles and face shield. Hence, considering precautionary measures would be a better choice for all asymptomatic cases, as the risk of false-negative tests cannot be negated. This adds to the safety along with COVID screening. Although the spread of the virus to people not performing AGP is not guaranteed, this is the best that can be done cost-effectively. However, for any suspicion of COVID-19 status or a confirmed case, PPE is a must. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Peroral endoscopic myotomy-initial experience with anesthetic management of 24 procedures and systematic review.

Background:Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter.Methods:In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted.Results:Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen.Conclusion:As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.

Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation.

Rapid sequence induction (RSI) for endotracheal intubation is a technique widely used in anaesthesia, emergency and intensive care medicine to secure an airway in patients deemed at risk of pulmonary aspiration. Cricoid pressure is conceptually used to reduce the risk of aspiration by compressing the oesophagus. To identify and evaluate all randomized controlled trials (RCTs) involving participants undergoing elective or emergency airway management via RSI and compare participants who have cricoid pressure administered with participants who do not have cricoid pressure administered. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 4), MEDLINE via OvidSP (1946 to May 2015), EMBASE via OvidSP (1980 to May 2015), ISI Web of Science (from 1940 to May 2015) and CINAHL via EBSCOhost (1982 to May 2015). We included all RCTs comparing people undergoing RSI who have cricoid pressure applied, either intermittently or continuously, with people undergoing RSI who do not have cricoid pressure applied in the context of endotracheal intubation using a direct laryngoscopic technique. We included both elective and emergency cases. We included studies of blinded and unblinded participants. Participants (male or female) were involved in any type of procedure where general anaesthetic utilizing RSI or emergency airway management utilizing RSI and endotracheal intubation was undertaken. We expected the control arm to be the absence of cricoid pressure at any stage during RSI. The primary outcome of interest was the reported event rate or prevalence of aspiration determined by a) documented gastric aspiration determined by visual inspection of aspirated stomach contents on laryngoscopy; b) pepsin detection in tracheal aspirate using the Ufberg method; c) post-anaesthetic radiographic changes suggestive of aspiration pneumonitis or d) any combination of a to c. Secondary outcomes of interest included documented impaired visualization of the airway by a treating laryngoscopist, force applied during cricoid pressure, the direction of application of force of applied cricoid pressure, independent risk factors for aspiration and whether the person applying cricoid pressure had previously done so in an emergency airway context. Two review authors independently screened the titles and abstracts of all the studies obtained from the search using recognition of words such as 'cricoid pressure', 'rapid sequence intubation', 'emergency airway management' and 'aspiration'. Two authors independently determined the study inclusion by using a study eligibility form that we developed for the purpose of this review. We also reported the decisions regarding inclusion and exclusion in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. We assumed that studies that did not describe the use of RSI in their title, abstract or methodology used an alternative method of anaesthetic induction or emergency airway management and thus we excluded them. Data extracted from included studies comprised study characteristics, participant demographics, intervention and comparison details plus outcome measures and results. We contacted primary authors of studies with missing or unreported but potentially relevant data to obtain missing data. Of 493 records that we identified from databases as a result of the search (excluding duplicates), we regarded 70 abstracts/titles as potentially relevant studies. Independent scrutiny of these 70 titles and abstracts identified 29 potentially relevant studies. Of the 29 potentially relevant studies, one study met the criteria for inclusion. This study was a RCT that compared participants undergoing RSI and endotracheal intubation in the context of elective surgery requiring a general anaesthetic. Forty participants were recruited, 20 of whom had cricoid pressure applied and 20 of whom had cricoid pressure simulated. The main outcomes reported were systolic arterial pressure and heart rate after laryngoscopy and tracheal intubation. We did not consider these outcomes relevant for the purposes of this systematic review. The search also identified one study that could potentially be included in an updated systematic review in the future, but was at the time of the search a proposal for a trial only and had no reported outcomes at this time. There is currently no information available from published RCTs on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI in the context of endotracheal intubation. On the basis of the findings of non-RCT literature, however, cricoid pressure may not be necessary to undertake RSI safely, and therefore well-designed and conducted RCTs should nonetheless be encouraged to properly assess the safety and effectiveness of cricoid pressure.

Should non-anaesthetists perform pre-hospital rapid sequence induction? an observational study

IntroductionThe use of rapid sequence induction and tracheal intubation (RSI) in the pre-hospital environment is controversial. Currently, it is felt that competence to perform RSI should be defined by skills...

Aspiration Prophylaxis and Rapid Sequence Induction for Elective Cesarean Delivery

Aspiration of gastric contents is a rare but feared and potentially fatal complication of anesthesia. In Mendelson’s landmark article on the pathophysiology of pulmonary aspiration in obstetric patients, he recognized that the clinical presentation is different depending on whether the aspirate is solid or liquid. Solid material resulted in suffocation and death, whereas liquid material resulted in “asthma-like” symptoms. Subsequently, he not only demonstrated that lung injury is secondary to gastric acid but also made 2 critical observations: gastric emptying time is delayed during labor, and aspiration occurs when airway reflexes are obtunded by anesthesia. Since 1946, these observations have been considered valid for every parturient who presents for labor and delivery; however, a question arises when caring for the fasted patient who presents for elective cesarean delivery. Does she have the same risk of aspiration as her laboring counterpart? We suggest that she may not be at as high risk as previously thought. This issue emerged when we cared for a primigravida with cardiomyopathy, severe global biventricular hypokinesis, and a left ventricular ejection fraction of 20%. Our decision to proceed with general anesthesia forced us to confront the issue of airway management. Traditional and contemporary teaching considers all obstetric patients to be at increased risk for pulmonary aspiration compared with patients scheduled for nonobstetric elective surgical procedures, mandating pharmacological prophylaxis as well as rapid sequence induction of anesthesia with cricoid pressure. However, the requirements of a patient at risk for aspiration are difficult to reconcile with a judicious, titrated induction of anesthesia that is ideal for a patient with severely compromised cardiac function. Faced with this choice, we opted for a careful induction of anesthesia with mask ventilation before endotracheal intubation, omitting cricoid pressure. This case made us reconsider long-held beliefs about the risk of aspiration in a subset of obstetric patients and specifically ask ourselves whether an appropriately fasted patient presenting for elective cesarean delivery is indeed at increased risk for aspiration compared with patients scheduled for non-obstetric elective procedures. Defining the full stomach has proven difficult. Many investigators have shown that lung injury increases markedly when the pH of the aspirate is 3. The oft-quoted threshold values for defining a full stomach and increased risk of aspiration are gastric volume 0.4 mL/kg with a pH 2.5. These data come from an experiment in a single rhesus monkey in which the investigators directly instilled liquid of varying volumes and acidity into the mainstem bronchus. Lung injury occurred with a volume 0.4 mL/kg and a pH 2.5. This experiment has led to considerable confusion about gastric volume and the risk of aspiration. The authors defined only the amount of aspirate necessary to cause lung injury if the pH was suitably low. The value 0.4 mL/kg has been erroneously interpreted as the amount of gastric volume that puts a patient at risk of aspiration when in fact it is the volume that produced lung injury in a highly contrived laboratory experiment. The more important question is what amount of gastric volume results in regurgitation. Animal data suggest that the residual gastric volume required to produce regurgitation under general anesthesia is much larger than 0.4 mL/kg. As the volume of liquid gastric contents increases, the risk of regurgitation also increases. At some currently unknown volume, this risk may become unacceptably high. There is, however, much evidence showing that if gastric emptying is normal and patients are appropriately fasted, the risk of significant aspiration is extremely low. The critical question to be answered is whether obstetric patients have normal gastric emptying. Mendelson studied laboring patients whom he correctly identified as having delayed gastric emptying. Since then, delayed gastric emptying has frequently been attributed to all obstetric patients. The presumed mechanisms are a hormonally induced decrease in gastric motility and the mechanical and anatomic effect of cephalad displacement of the stomach with distortion of the gastroesophageal From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.

Emergency Management of Pediatric Convulsive Status Epilepticus

To perform a multicenter study examining the presentations and emergency management of children with convulsive status epilepticus (CSE) to sites within the Paediatric Research in Emergency Departments International Collaborative. Retrospective review of children presenting to emergency departments (EDs) with convulsive seizures of at least 10 minutes' duration. Eight sites within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand participated. Patients were identified through a search of ED electronic records for the period January 2000 to December 2004. Data were obtained from 542 eligible episodes of CSE. Demographics and seizure history were similar across all sites. One third of children with CSE presented with their first seizure. A preexisting diagnosis that predisposed to seizures was present in 59%. Median duration of seizures before hospitalization was 45 minutes, and median duration of treatment in ED before termination was 30 minutes. Prehospital duration did not seem to influence the timing of key ED interventions such as the administration of second-line anticonvulsants or progression to rapid sequence induction (RSI) of anesthesia and intubation. Convulsive status epilepticus was terminated after first-line treatment in 42%, second-line treatment in 35%, and RSI in 22%. One third of the patients had persistent seizure activity beyond 40 minutes of ED treatment. Marked variation in the use of RSI for refractory seizures was observed between sites. Convulsive status epilepticus is an important neurological emergency, with many children experiencing prolonged seizures in both the prehospital and hospital phases. Persistent seizure activity beyond 40 minutes contrasts with current published guidelines. There is a need to adopt a widely accepted approach to the management of children who fail to respond to standard anticonvulsant therapy.

Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?

Use of rapid sequence induction for intubation was introduced to the prehospital environment in the hope of enhancing patient outcome by improving early definitive airway management. Varying success has been achieved in both air and ground transport emergency medical services systems, but concern persists about the potential to cause patients harm. Individual emergency medical services systems must determine the need for rapid sequence induction for intubation and their ability to implement a rapid sequence induction for intubation protocol effectively with minimal adverse events. Therefore, the value of rapid sequence induction for intubation is dependent on each emergency medical services system design in their ability to establish personnel requirements and ongoing training, expertise in airway management skills, medical direction and supervision, and a quality assurance program. If these principles are strictly adhered to, rapid sequence induction for intubation may be safely used as an advanced airway management technique in the prehospital setting.

The intubating laryngeal mask airway: suggestions for use in the emergency department.

With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.

Survey of the use of rapid sequence induction in the accident and emergency department

Objectives—To determine the current position regarding the use of rapid sequence induction (RSI) by accident and emergency (A&E) medical staff and the attitudes of consultants in A&E and anaesthetics towards...

Rapid sequence anesthesia induction for emergency intubation

Emergency intubations are done for a variety of reasons in the emergency department (ED). In some patients, a rapid, controlled induction of anesthesia is useful to facilitate intubation and to reduce the complications of intubation. This is referred to a rapid sequence induction (RSI) in the anesthesia literature. Atropine, thiopental, fentanyl, diazepam, ketamine, vecuronium, succinylcholine, other drugs and their applications for RSI are described. The purpose of this article is to describe the use of RSI in the airway management of ED patients. Nineteen pediatric patients requiring emergency intubation were intubated using RSI with vecuronium and thiopental. Actual intubation difficulty using RSI was significantly less than the anticipated intubation difficulty without RSI. There were no complications caused by intubation or RSI that had a significant impact on patient outcome. We feel that a sedative in combination with vecuronium represents the most optimal means of achieving RSI in the ED setting. Although the induction of general anesthesia is best done by anesthesiologists, emergency physicians are often the most experienced physicians immediately available to manage an airway in a critical emergency. An objective protocol such as that described will make it easier for emergency physicians to perform this procedure when needed.