Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction

Emergency medicine updates: Endotracheal intubation

INTRODUCTION

Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI.

OBJECTIVE

This paper evaluates key evidence-based updates concerning ETI for the emergency clinician.

DISCUSSION

ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients requiring emergent intubation.

[Update: Neuromuscular Blockade during General Anesthesia]

The correct use of muscle relaxants and neuromuscular monitoring during anesthesia has been subject of controversial discussions for decades. Particularly important in clinical practice are identification and management of residual neuromuscular blockages and avoidance of associated complications. Despite the differences in the molecular mechanisms of action between depolarizing and non-depolarizing muscle relaxants the blockade of the postsynaptic nicotinic acetylcholine receptor remains a common ending pathway. Due to its unfavorable side effect profile, succinylcholine should only be used in justified exceptional cases. The use of muscle relaxants generally reduces the complication rate in airway management. However, even the single use of muscle relaxants increases the likelihood of postoperative pulmonary complications. These complications associated with the use of muscle relaxants, such as residual neuromuscular blockade, must be anticipated. The application of guideline-based approaches, including continuous neuromuscular monitoring and the application of muscle relaxant reversal agents, may significantly reduce the rate of adverse events associated with the use of muscle relaxants.

Advances in foetal anaesthesia

Nowadays, widespread antenatal ultrasound screenings detect congenital anomalies earlier and more frequently. This has sparked research into foetal surgery, offering treatment options for various conditions. These surgeries aim to correct anomalies or halt disease progression until after birth. Minimally invasive procedures can be conducted under local anaesthesia (with/without maternal sedation), while open mid-gestational procedures necessitate general anaesthesia. Anaesthesia serves to prevent maternal and foetal pain, to provide immobilization, and to optimize surgical conditions by ensuring uterine relaxation. As early as 12 weeks after conception, the foetus may experience pain. Thus, in procedures involving innervated foetal tissue or requiring foetal immobilization, anaesthetic drugs can be administered directly to the foetus (intramuscular or intravenous) or indirectly (transplacental) to the mother. However, animal studies have indicated that exposure to prenatal anaesthesia might impact foetal brain development, translating these findings to the clinical setting remains difficult.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting

OBJECTIVE

Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades.

METHODS

We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events.

RESULTS

Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64-1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20-36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases.

CONCLUSIONS

Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

RATIONALE

Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI).

OBJECTIVES

To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI.

DESIGN

A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process.

METHODS

Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist.

RESULTS

From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence.

CONCLUSIONS

Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange Versus Conventional Facemask Breathing for Preoxygenation During Rapid Sequence Induction

INTRODUCTION

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), if used for pre-oxygenation and apnoeic oxygenation, has the propensity to extend the safe apnoea time and thereby decrease the incidence of desaturation during rapid sequence induction (RSI) for emergency surgeries. Hence, we proposed to evaluate the comparative efficacy of pre-oxygenation with the use of conventional facemask breathing versus THRIVE during RSI in patients undergoing general anaesthesia (GA) for emergency surgeries.

MATERIALS AND METHODS

Eighty patients undergoing RSI under GA for emergency abdominopelvic surgery were divided randomly into two groups. Patients were preoxygenated for three minutes with 100% oxygen via either a high-flow nasal cannula at a flow of 60 L/minute using THRIVE or a tightly-held, snuggly-fitting facemask at a flow of 12L/minute using a circle system. RSI was administered followed by laryngoscopy and endotracheal intubation. Arterial partial pressure of oxygen (PaO2) measured immediately after successful endotracheal intubation was our primary outcome. The lowest peripheral oxygen saturation (SpO2), apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and any adverse event were also recorded. Data thus collected were statistically analysed.

RESULTS

No statistically significant difference in PaO2 value was observed after successful intubation, lowest SpO2, apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and adverse event between both the groups (p>0.05).

CONCLUSION

We conclude that though not superior to conventional facemasks, THRIVE is a safe, practicable, and efficient pre-oxygenation tool during RSI of GA for patients undergoing emergency surgeries.

[Prehospital emergency anesthesia in adults : Current recommendations for performing prehospital emergency anesthesia based on the recommendations for prehospital emergency anesthesia in adults]

The frequency of prehospital emergency anesthesia in Germany is around 2-3% of all emergency medical missions. The Association of the Scientific Medical Societies of Germany (AWMF) has published guidelines for the implementation of a prehospital emergency anesthesia. The purpose of this article is to highlight important aspects from these guidelines and to present the implementation and special features for specific patient groups. A case study is intended to illustrate that the preclinical setting can provide various facets that make a certain amount of experience and expertise indispensable. The article emphasizes that clear standard situations are not always present and that there are some challenges in the preclinical setting. Therefore, mastering the content of prehospital emergency anesthesia and the manual skills of induction of anesthesia are essential and obligatory for the emergency team.

Resuscitation of the Obstetric Patient

Pregnancy is a time of tremendous physiologic change and vulnerability. At any point, symptoms and complications can prompt the need for emergency care, and these can range from minor to life-threatening. Emergency physicians must be prepared to treat any of these complications, in addition to rescucitating the critically ill and injured pregnant patient. To optimally care for these patients, it is paramount to be aware of the unique physiologic changes that occur during pregnancy. The focus of this review is to discuss illnesses unique to pregnancy and additional aspects of resuscitation that must be considered when caring for a critically ill pregnant patient.

Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.

Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update

PURPOSE

The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP).

SUMMARY

RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care.

CONCLUSION

While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.

General anaesthesia for nonobstetric surgery during pregnancy: A narrative review

Nonobstetric surgery may be required in up to 1% of pregnancies. Most common procedures are urgent abdominal surgeries requiring general anaesthesia. Maintaining normal maternal physiology during anaesthesia is vital. Left lateral tilt position prevents aortocaval compression and preserves normal venous return. Preparation for a difficult airway is required in all obstetric patients due to the known anatomical and physiological changes. Aspiration prophylaxis and a rapid sequence induction are traditionally recommended to avoid the (probably overestimated) risk of aspiration. Although the minimum alveolar concentration (MAC) of volatile anaesthetic agents is reduced by 30 to 40%, awareness occurs more frequently in the obstetric population. Maternal outcomes from surgery are comparable with those of nonpregnant women, but increased incidences of foetal loss, preterm delivery, low birth weight and caesarean section have been reported. Although animal studies have observed impaired foetal brain development after antenatal exposure to anaesthesia, the translational value of these studies remain controversial. Clinical evidence is nearly absent. Withholding urgent/essential procedures is certainly more threatening than proceeding with the surgery. To increase the safety of mother and foetus, nonurgent or nonessential procedures should be postponed until after delivery, and if procedures cannot wait, locoregional anaesthesia should be used if possible. Where general anaesthesia cannot be avoided, the duration of exposure should be kept to a minimum. This narrative review summarises the literature of the past 20 years concerning the anaesthetic management and outcomes of nonobstetric surgery under general anaesthesia during pregnancy.

A comparison of high-flow nasal cannula and standard facemask as pre-oxygenation technique for general anesthesia: A PRISMA-compliant systemic review and meta-analysis

BACKGROUND

Current practice guidelines recommend the use of nasal cannula as an alternative pre-oxygenation method for tracheal intubation. However, the efficacy of high-flow nasal oxygenation versus standard facemask oxygenation has not been fully evaluated.

METHODS

We searched PubMed, Cochrane Library, and ClinicalTrials.gov for English-language studies published from January 1, 2000 to November 30, 2021. We included randomized controlled trials which compared high-flow nasal oxygenation and facemask oxygenation as the pre-oxygenation maneuver. Primary outcome was arterial partial pressure of oxygen (PaO2) after pre-oxygenation. Secondary outcomes were safe apnea time, arterial desaturation during intubation, lowest peripheral capillary oxygen saturation during intubation, and patient comfort score. Random-effects models and Mantel-Haenszel method were used for data synthesis.

RESULTS

A total of 16 randomized controlled trials and 1148 patients were included. High-flow nasal oxygenation achieved a higher PaO2 compared with facemask, mean difference: 64.86 mm Hg (95% confidence interval [CI]: 32.33-97.40, P < .0001). Safe apnea time was longer in high-flow nasal oxygenation, mean difference: 131.03 seconds (95% CI: 59.39-202.66, P < .0001). There was no difference in the risk of peri-intubation desaturation or lowest peripheral capillary oxygen saturation between groups. Patient comfort score was higher in high-flow nasal oxygenation, mean difference: 1.00 (95% CI: 0.46-1.54, P = .0003).

CONCLUSION

High-flow nasal oxygenation better enhanced PaO2 and extended safe apnea time and is not inferior to facemask oxygenation in preventing desaturation during tracheal intubation. High-flow nasal oxygenation may be considered as an alternative method, especially for patients with a potential difficult airway.

Impact of Succinylcholine vs. Rocuronium on Apnea Duration for Rapid Sequence Induction: A Prospective Cohort Study

OBJECTIVE

The present study aimed to evaluate the impact of 1.5 mg/kg succinylcholine or 1.2 mg/kg rocuronium, vs. 1.0 mg/kg succinylcholine on apnea duration in patients underwent rapid sequence induction (RSI).

METHODS

This prospective cohort study was conducted in the Department of Anesthesiology in Shanghai General Hospital from July 2020 to November 2020. Apnea duration was defined as the time from apnea prompted by the PETCO2 waveform to the time the point of oxygen saturation declined to 90% (T90) and 95% (T95) after succinylcholine or rocuronium administration. The primary outcome included T90 and T95 changes in 1.5 mg/kg vs. 1.0 mg/kg succinylcholine groups and 1.5 mg/kg succinylcholine vs. 1.2 mg/kg rocuronium groups.

RESULTS

A total of 265 participants were subjected for analysis. The succinylcholine (1.0 mg/kg) group had a significantly longer T90 (50.72, 95% confidence interval [CI, 7.60, 94.38], P = 0.015) and T95 (48.09, 95% CI [7.11, 89.07], P = 0.012) than the succinylcholine (1.5 mg/kg) group. In addition, significantly longer T90 (56.84, 95% CI [16.24, 97.44], P = 0.003) and T95 (50.57, 95% CI [12.58, 88.57], P = 0.003) were observed in the rocuronium (1.2 mg/kg) group than those in the succinylcholine (1.5 mg/kg) group. No severe side events were observed during the operation.

CONCLUSION

Rocuronium and the lower dose of succinylcholine may be recommended to patients underwent RSI.

Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.

Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China

BACKGROUND This retrospective study was conducted at a single center in China and aimed to compare rocuronium with succinylcholine for rapid sequence induction intubation in the Emergency Department of a hospital. MATERIAL AND METHODS An orotracheal intubation procedure was performed in a total of 267 patients by direct laryngoscopy using an intravenous bolus injection of 1 mg/kg of succinylcholine (n=141; SY group) or 1.2 mg/kg of rocuronium (n=126; RM group) for a rapid sequence induction in the emergency department. The success of orotracheal intubation was evaluated by a capnography curve. The modified Cormack-Lehane score was used to grade the direct laryngoscopy. RESULTS There was no statistically significant difference in numbers of patients with successful first-attempt orotracheal intubation between the groups (112 vs. 87, P=0.067). Fewer intubation failures under direct laryngoscopy were reported in the SY group than in the RM group (23 [16%] vs. 34 [27%], P=0.037). The number of intubation attempts was higher in the RM group than in the SY group (1.52±0.87 per patient vs. 1.27±0.60 per patient, P=0.032). CONCLUSIONS The findings from this study support results from previous studies, showing that even in the Emergency Department setting, rocuronium was equivalent to succinylcholine in achieving rapid sequence induction intubation, when the dose was appropriate. However, as current clinical guidelines highlight, succinylcholine has more contraindications and adverse effects, including hyperkalemia, which should be monitored, and rocuronium has a longer duration of action.

High-dose rocuronium-induced paralysis of the adductor pollicis muscle facilitates detection of the timing for tracheal intubation in elderly patients: a randomized double-blind study

Purpose

Methods

Results

Conclusions

Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review

The coronavirus disease 2019 (COVID-19) pandemic is caused by a coronavirus that is transmitted primarily via aerosol, droplets or direct contact. This may place anesthetists at higher risk of infection due to their frequent involvement in aerosol-generating airway interventions. Many anesthethetic COVID-19 guidelines have emerged, whose underlying management principles include minimizing aerosol contamination and protecting healthcare workers. These guidelines originate from Australia and New Zealand, Canada, China, India, Italy, Korea, Singapore, the United States and the United Kingdom. Hospitalized COVID-19 patients may require airway interventions, and difficult tracheal intubation secondary to laryngeal edema has been reported. Pre-pandemic difficult airway guidelines include those from Canada, France, Germany, India, Japan, Scandinavia, the United States and the United Kingdom. These difficult airway guidelines require modifications in order to align with the principles of the anesthetic COVID-19 guidelines. In turn, most of the anesthetic COVID-19 guidelines do not, or only briefly, discuss an airway strategy after failed tracheal intubation. Our article identifies and compares pre-pandemic difficult airway guidelines with the recent anesthetic COVID-19 guidelines. We combine the principles from both sets of guidelines and explain the necessary modifications to the airway guidelines, to form a failed tracheal intubation airway strategy in the COVID-19 patient. Valuing, and a greater understanding of, these differences and modifications may lead to greater adherence to the new COVID-19 guidelines.

Sedation for Rapid Sequence Induction and Intubation of Neurologically Injured Patients

There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.

Current practice of rapid sequence induction in adults: A national survey among anesthesiologists in Spain

BACKGROUND

Rapid sequence induction (RSI) in adults has undergone changes in recent years due to pharmacological and technological advances. The objective of this survey was to evaluate current practice among Spanish anesthesiologists.

METHODS

A 31-item questionnaire regarding RSI practice was sent to anesthesiologists working in Spanish public hospitals. Differences in responses according to the type of hospital or experience of the respondent were compared for all data using the chi-square and Fisher's exact test.

RESULTS

Approximately 15.89% of Spanish anesthesiologists participated in the survey (1002 questionnaires). The results show considerable heterogeneity in most aspects of RSI. Less than 20% of respondents administer sodium citrate. Sixty-four percent place a nasogastric tube in patients with intestinal obstruction. Gastric residue is assessed by ultrasound in 6% of cases. Only 25% of respondents measure ETO₂ to check the effectiveness of preoxygenation, and 22% use nasal oxygen insufflation with nasal prongs or THRIVE. Sixty two percent of respondents apply cricoid pressure, but only 50% release the pressure when encountering intubation difficulty. Up to 40% of respondents reported cases of aspiration despite applying cricoid pressure. Propofol was the most commonly used hypnotic (97.6%), but there was no clear preference in the choice of neuromuscular relaxant (suxamethonium versus rocuronium ratio of approximately 1:1). Only 44% of respondents calculated the dose of sugammadex that would be required for emergency reversal of rocuronium.

CONCLUSIONS

The survey showed significant variation in RSI practice, similar to that of other countries. Quality prospective studies are needed to standardize clinical practice.

Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis

BACKGROUND

Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI.

METHODS

This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period.

RESULTS

There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)).

CONCLUSIONS

This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial

IMPORTANCE

Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium.

OBJECTIVE

To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations.

DESIGN, SETTING AND PARTICIPANTS

Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016.

INTERVENTIONS

Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624).

MAIN OUTCOMES AND MEASURES

The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis.

RESULTS

Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group.

CONCLUSIONS AND RELEVANCE

Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02000674.

Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized trial

BACKGROUND

Onset times and conditions for intubation after rocuronium versus suxamethonium at cesarean section have been evaluated, but no study thus far has examined the influence of these neuromuscular blocking drugs on the surgical conditions or their effect on the duration of surgery and the ease of fetal delivery. We aimed to compare the surgical conditions for delivery in parturients who received deep neuromuscular block with rocuronium with those who had induction with suxamethonium.

METHODS

Ninety patients undergoing cesarean section under general anesthesia were randomized to receive either rocuronium 0.6 mg/kg or suxamethonium 1 mg/kg for tracheal intubation and delivery. Times to delivery and the quality of surgical conditions, using a five-point Surgical Rating Scale for Delivery (SRSD) ranging from 1 (poor) to 5 (excellent), were evaluated.

RESULTS

The median SRSD (range) was found to be significantly better in the rocuronium group [4 (3-5) points vs 3 (2-4) points with suxamethonium (P <0.001)]. Whereas the mean (SD) induction-to-intubation interval was longer with rocuronium [106 (34) s vs 68 (32) s with suxamethonium (95% CI of the difference 24 to 52 s, P <0.001)], the incision-to-delivery interval was shorter in the rocuronium group [147 (68) s vs 196 (51) s with suxamethonium (95% CI of the difference -75 to -24 s, P <0.001)]. The mean induction-to-delivery intervals were similar [268 (73) s vs 276 (63) s, respectively].

CONCLUSIONS

Whereas the induction-to-delivery intervals were comparable, we found rocuronium superior to suxamethonium in allowing better surgical conditions for fetal delivery, which enabled an easier delivery and a shorter incision-to-delivery interval.

Obesity and Obstructive Sleep Apnea in the Ambulatory Patient

Obesity and obstructive sleep apnea (OSA) are often associated with increased perioperative risks and challenges for the anesthesiologist. This article addresses the current controversies surrounding perioperative care of morbidly obese patients with or without OSA scheduled for ambulatory surgery, particularly in a free-standing ambulatory center. Topics discussed include preoperative selection of obese and OSA patients for ambulatory surgeries, intraoperative methods to reduce perioperative risk, and appropriate postoperative care.

[Performance of prehospital emergency anesthesia and airway management : An online survey]

BACKGROUND

The goal of rapid sequence induction (RSI) in cases of emergency situations is to secure the airway as quickly as possible to prevent pulmonary aspiration of gastric contents; however, the technique itself is not standardized. For example, the choice of drugs, application of cricoid pressure and the patient position remain controversial. A survey of emergency medical services (EMS) physicians throughout Germany was carried out to assess the different RSI techniques used and with respect to complying with the national guidelines for emergency airway management anesthesia and local standard operating procedures (SOP).

MATERIAL AND METHODS

Between 1 April 2017 and 31 May 2017, EMS medical directors in Germany were contacted and asked to distribute a 28-question online questionnaire to local EMS physicians. Of the questions 26 were multiple choice and 2 with plain text. After 6 weeks an e‑mail reminder was sent. In addition, the survey was distributed via social media to EMS physicians.

RESULTS

In total the survey was opened 2314 times and 1074 completed responses were received (completion rate 46%). Most of the participants were male (78%) and anesthesiologists (70%) and only one quarter had a local SOP for RSI. The most frequently used muscle relaxant was succinylcholine (62%) and over half of the participants reported using cricoid pressure (57%). There was a distinction between the specialist disciplines in the selection of drugs. Propofol was used most by anesthesiologists, while the others still used etomidate on a larger scale. Nearly 100% could fall back on supraglottic devices (one third laryngeal mask, two thirds laryngeal tube) but only 32.8% with the recommended esophageal drainage. A video laryngoscope was available to 51% of all EMS physicians surveyed.

CONCLUSION

The results of the survey demonstrate heterogeneity in RSI techniques used by EMS physicians in Germany. Medical equipment and safe care practices, such as labeling of syringes varied considerably between different service areas. The recommendations of the S1 national guidelines on emergency airway management and anesthesia should be adhered to together with the implementation of local SOPs.

Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia

STUDY OBJECTIVE

Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation.

METHODS

We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt.

RESULTS

The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO₂, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO₂ values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]).

CONCLUSION

In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.

The obese patient undergoing nonbariatric surgery

PURPOSE OF REVIEW

This article provides the reader with recent findings on the pathophysiology of comorbidities in the obese, as well as evidence-based treatment options to deal with perioperative respiratory challenges.

RECENT FINDINGS

Our understanding of obesity-associated asthma, obstructive sleep apnea, and obesity hypoventilation syndrome is still expanding. Routine screening for obstructive sleep apnea using the STOP-Bang score might identify high-risk patients that benefit from perioperative continuous positive airway pressure and close postoperative monitoring. Measures to most effectively support respiratory function during induction of and emergence from anesthesia include optimal patient positioning and use of noninvasive positive pressure ventilation. Appropriate mechanical ventilation settings are under investigation, so that only the use of protective low tidal volumes could be currently recommended. A multimodal approach consisting of adjuvants, as well as regional anesthesia/analgesia techniques reduces the need for systemic opioids and related respiratory complications.

SUMMARY

Anesthesia of obese patients for nonbariatric surgical procedures requires knowledge of typical comorbidities and their respective treatment options. Apart from cardiovascular diseases associated with the metabolic syndrome, awareness of any pulmonary dysfunction is of paramount. A multimodal analgesia approach may be useful to reduce postoperative pulmonary complications.

Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department

Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. We sought to assess the effect AP OX on oxygen desaturation during the rapid sequence intubation (RSI) of patients with ICH in the emergency department (ED). We prospectively collected data on all patients intubated in an urban academic ED over the 2-year period from July 1, 2013 to June 30, 2015. Following each intubation, the operator completed a standardized continuous quality improvement (CQI) data form, which included information on patient, operator and intubation characteristics. Operators recorded data on the use of AP OX, the oxygen flow rate used for AP OX, and the starting and lowest saturations during intubation. Adult patients with ICH who underwent RSI by emergency medicine (EM) residents were included in the analyses. The primary outcome variable was any oxygen saturation <90 % during the intubation. We performed a backward stepwise multivariate logistic regression analysis to identify variables associated with oxygen desaturation. The primary independent variable of interest was the use of AP OX during the intubation. Inclusion criteria for the study was met by 127 patients. AP OX was used in 72 patients (AP OX group) and was not used in 55 patients (NO AP OX group). The incidence of desaturation was 5/72 (7 %) in the AP OX group and was 16/55 (29 %) in the NO AP OX group. In the multivariate logistic regression analysis the use of AP OX was associated with a reduced odds of desaturation (aOR 0.13; 95 % CI 0.03-0.53). Patients with ICH who received AP OX during RSI in the ED were seven times less likely to have an oxygen saturation of <90 % during the intubation compared to patients who did not receive AP OX. AP OX is a simple intervention that may minimize the risk of oxygen desaturation during the RSI of patients with ICH.

Sugammadex: An Update

The purpose of this update is to provide recent knowledge and debates regarding the use of sugammadex in the fields of anesthesia and critical care. The review is not intended to provide a comprehensive description of sugammadex and its clinical use.

Induced apnea enhances image quality and visualization of cardiopulmonary anatomic during contrastenhanced cardiac computerized tomographic angiography in children

Objective:

The purpose of our study was to determine the effect of induced apnea on quality of cardiopulmonary structures during computerized tomographic (CT) angiography images in children with congenital heart diseases.

Methods:

Pediatric patients with congenital heart defects undergoing cardiac CT angiography at our facility in the past 3 years participated in this study. The earlier patients underwent cardiac CT angiography without induced apnea and while, later, apnea was induced in patients, which was followed by electrocardiogram gated cardiac CT angiography. General anesthesia was induced using sleep dose of intravenous propofol. After the initial check CT, on request by the radiologist, apnea was induced by the anesthesiologist by administering 1 mg/kg of intravenous suxamethonium. Soon after apnea ensued, the contrast was injected, and CT angiogram carried out. CT images in the “apnea group” were compared with those in “nonapnea group.” After the completion of the procedure, the patients were mask ventilated with 100% oxygen till the spontaneous ventilation was restored.

Results:

We studied 46 patients, of whom 36 with apnea and yet another 10 without. The quality of the image, visualization of structures such as cardiac wall, outflow tracts, lung field, aortopulmonary shunts, and coronary arteries were analyzed and subjected to statistical analysis (Mann–Whitney U, Fischer's exact test and Pearson's Chi-square test). In the induced apnea group, overall image quality was considered excellent in 89% (n = 33) of the studies, while in the “no apnea group,” only 30% of studies were excellent. Absent or minimal motion artifacts were seen in a majority of the studies in apnea group (94%). In the nonapnea group, the respiratory and body motion artifacts were severe in 50%, moderate in 30%, and minimal in 20%, but they were significantly lesser in the apnea group. All the studied parameters were statistically significant in the apnea group in contrast to nonapnea group (P < 0.000).

Conclusion:

The image quality of cardiac CT angiography greatly improves, and motion artifact significantly decreases with the use of induced apnea in pediatrics patients being evaluated for congenital heart disease. This technique poses no additional morbidity of significance.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Use of sugammadex after neostigmine incomplete reversal of rocuronium-induced neuromuscular blockade

BACKGROUND AND OBJECTIVES

Neuromuscular blockers (NMB) have been used for more than half of a century in anesthesia and have always been a challenge for anesthesiologists. Until recently, the reversal of nondepolarizing neuromuscular blockers had only one option: the use of anticholinesterase agents. However, in some situations, such as deep neuromuscular blockade after high doses of relaxant, the use of anticholinesterase agents does not allow adequate reversal of neuromuscular blockade. Recently, sugammadex, a gamma-cyclodextrin, proved to be highly effective for reversal of NMB induced by steroidal agents.

CASE REPORT

A female patient who underwent an emergency exploratory laparotomy after rapid sequence intubation with rocuronium 1.2mg.kg(-1). At the end of surgery, the patient received neostigmine reversal of NMB. However, neuromuscular junction monitoring did not show the expected recovery, presenting residual paralysis. Sugammadex 2mg.kg(-1) was used and the patient had complete reversal of NMB in just 2 minutes time.

CONCLUSION

Adequate recovery of residual neuromuscular blockade is required for full control of the pharynx and respiratory functions in order to prevent complications. Adequate recovery can only be obtained by neuromuscular junction monitoring with TOF ratio greater than 0.9. Often, the reversal of NMB with anticholinesterase drugs may not be completely reversed. However, in the absence of objective monitoring this diagnosis is not possible. The case illustrates the diagnosis of residual NMB even after reversal with anticholinesterase agents, resolved with the administration of sugammadex, a safe alternative to reverse the NMB induced by steroidal non-depolarizing agents.