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 II

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 factor, 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.

Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study

BACKGROUND

Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations.

METHODS

A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI).

RESULTS

30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension.

CONCLUSION

Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.

Induction of pre-hospital emergency anaesthesia i-PHEA: a national survey of UK HEMS practice

BACKGROUND

Pre-hospital emergency anaesthesia is a critical intervention undertaken by helicopter emergency medical teams. Previous studies informed current practice for induction regimes, using a standardized approach of fentanyl, ketamine and rocuronium. There may be a trend towards post-induction hypotension attributed to the induction regime used. Several new combinations of fentanyl, ketamine and rocuronium are emerging in clinical practice. There is currently no consensus on what induction regimes should be used.

METHODS

A semi-structured survey was distributed to the medical leads of all UK air ambulance organisations between December 2022 and February 2023. Responses that were returned within the study period were included. Exclusions included missing data, declined participation and failure to return the survey within the data collection period. The survey sought to establish provision of pre-hospital emergency anaesthesia and current induction regimes for stable, unstable and post-cardiac arrest patients. Data was extracted from Microsoft Forms into Excel. Descriptive statistics were used to analyse survey response rate, provision of PHEA and induction regimes. The survey was endorsed by the National HEMS Research and Audit Forum.

RESULTS

19 air ambulance organisations responded (response rate 86%). The majority of organisations provide over 100 pre-hospital emergency anaesthetics per annum (79%, n = 15/19). A standard combination of fentanyl, ketamine and rocuronium is used as a primary induction regime in haemodynamically stable patients by 52% of services (n = 10/19). In haemodynamically compromised patients, fentanyl was omitted or pracititioner choice emphasized by 79% of services (n = 15/19). There was variability in the dose of rocuronium from 1 mg/kg to 2 mg/kg throughout services.

CONCLUSION

There is variability in the approach to pre-hospital emergency anaesthesia. There is a growing dataset that would enable development of a registry to better understand induction regimes and the impact on patient physiology. Organisations are increasingly adopting a patient centered, practitioner choice model towards induction of anaesthesia.

Gastric insufflation and surgical view according to mask ventilation method for laparoscopic cholecystectomy: a randomized controlled study

BACKGROUND

Proper mask ventilation is important to prevent air inflow into the stomach during induction of general anesthesia, and it is difficult to send airflow only through the trachea without gastric inflation. Changes in gastric insufflation according to mask ventilation during anesthesia induction were compared.

METHODS

In this prospective, randomized, single-blind study, 230 patients were analyzed to a facemask-ventilated group (Ventilation group) or no-ventilation group (Apnea group) during anesthesia induction. After loss of consciousness, pressure-controlled ventilation at an inspiratory pressure of 15 cmH2O was performed for two minutes with a two-handed mask-hold technique for Ventilation group. For Apnea group, only the facemask was fitted to the face for one minute with no ventilation. Next, endotracheal intubation was performed. The gastric cross-sectional area (CSA, cm2) was measured using ultrasound before and after induction. After pneumoperitoneum with carbon dioxide, gastric insufflation of the surgical view was graded by the surgeon for each group.

RESULTS

Increase of postinduction antral CSA on ultrasound were not significantly different between Ventilation group and Apnea group (0.04 ± 0.3 and 0.02 ± 0.28, p-value = 0.225). Additionally, there were no significant differences between the two groups in surgical grade according to surgeon's judgement.

CONCLUSIONS

Pressure-controlled ventilation at an inspiratory pressure of 15 cmH2O for two minutes did not increase gastric antral CSA and insufflation of stomach by laparoscopic view.

TRIAL REGISTRATION

http://cris.nih.go.kr (KCT0003620) on 13/3/2019.

Anesthetic management of a patient with achalasia, a disease with a considerable risk for aspiration under anesthesia

BACKGROUND

Achalasia is a rare condition characterized by dysfunction of esophageal motility and impaired relaxation of the lower esophageal sphincter. Anesthetic management of these patients is challenging due to the elevated risk of regurgitation and aspiration.

CASE PRESENTATION

A 53-year-old man diagnosed with achalasia was scheduled for renal cancer surgery before esophageal myotomy. Since his severe dysphagia suggested the possibility of vomiting and aspiration under anesthesia, a stomach tube was inserted before induction of general anesthesia. After preoxygenation, rapid sequence induction was performed and an antiemetic was administered to prevent postoperative vomiting. Although anesthetic management was uneventful, the inserted stomach tube coiled up in the dilated esophagus and substantial residue was aspirated via the tube even after a prolonged fasting period.

CONCLUSION

Anesthesiologists should be familiar with achalasia even though it is an uncommon disease, since affected patients are at risk of regurgitation and aspiration under anesthesia.

Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study

BACKGROUND

Post-intubation hypotension (PIH) after prehospital emergency anaesthesia (PHEA) is prevalent and associated with increased mortality in trauma patients. The objective of this study was to compare the differential determinants of PIH in adult trauma patients undergoing PHEA.

METHODS

This multi-centre retrospective observational study was performed across three Helicopter Emergency Medical Services (HEMS) in the UK. Consecutive sampling of trauma patients who underwent PHEA using a fentanyl, ketamine, rocuronium drug regime were included, 2015-2020. Hypotension was defined as a new systolic blood pressure (SBP) < 90 mmHg within 10 min of induction, or > 10% reduction if SBP was < 90 mmHg before induction. A purposeful selection logistic regression model was used to determine pre-PHEA variables associated with PIH.

RESULTS

During the study period 21,848 patients were attended, and 1,583 trauma patients underwent PHEA. The final analysis included 998 patients. 218 (21.8%) patients had one or more episode(s) of hypotension ≤ 10 min of induction. Patients > 55 years old; pre-PHEA tachycardia; multi-system injuries; and intravenous crystalloid administration before arrival of the HEMS team were the variables significantly associated with PIH. Induction drug regimes in which fentanyl was omitted (0:1:1 and 0:0:1 (rocuronium-only)) were the determinants with the largest effect sizes associated with hypotension.

CONCLUSION

The variables significantly associated with PIH only account for a small proportion of the observed outcome. Clinician gestalt and provider intuition is likely to be the strongest predictor of PIH, suggested by the choice of a reduced dose induction and/or the omission of fentanyl during the anaesthetic for patients perceived to be at highest risk.

Pediatric anesthesia and achalasia: 10 years' experience in peroral endoscopy myotomy management

BACKGROUND

Endoscopic treatment for achalasia (POEM) is a recently introduced technique that incorporates the concepts of natural orifice transluminal surgery. Although pediatric achalasia is rare, POEM has been episodically used in children since 2012. Despite this procedure entails many implications for airway management and mechanical ventilation, evidences about anesthesiologic management are very poor. We conducted this retrospective study to pay attention on the clinical challenge for pediatric anesthesiologists. We put special emphasis on the risk in intubation maneuvers and in ventilation settings.

RESULTS

We retrieved data on children 18 years old and younger who underwent POEM in a single tertiary referral endoscopic center between 2012 and 2021. Demographics, clinical history, fasting status, anesthesia induction, airway management, anesthesia maintenance, timing of anesthesia and procedure, PONV, and pain treatment and adverse events were retrieved from the original database. Thirty-one patients (3-18 years) undergoing POEM for achalasia were analyzed. In 30 of the 31 patients, rapid sequence induction was performed. All patients manifested consequences of endoscopic CO₂ insufflation and most of them required a new ventilator approach. No life-threatening adverse events have been detected.

CONCLUSIONS

POEM procedure seems to be characterized by a low-risk profile, but specials precaution must be taken. The inhalation risk is actually due to the high rate of full esophagus patients, even if the Rapid Sequence Induction was effective in preventing ab ingestis pneumonia. Mechanical ventilation may be difficult during the tunnelization step. Future prospective trials will be necessary to individuate the better choices in such a special setting.

Advanced airway management and drug-assisted intubation skills in an advanced critical care practitioner team

INTRODUCTION

Airway management, including endotracheal intubation, is one of the cornerstones of care of critically ill patients. Internationally, health professionals from varying backgrounds deliver endotracheal intubation as part of their critical care role. This article considers the development of airway management skills within a single advanced critical care practitioner (ACCP) team and uses case series data to analyse the safety profile in performing this aspect of critical care. Skills were acquired during and after the ACCP training pathway. A combination of theoretical teaching, theatre experience, simulation and work-based practice was used. Case series data of all critical care intubations by ACCPs were collected. Audit results: Data collection identified 675 intubations carried out by ACCPs, 589 of those being supervised, non-cardiac arrest intubations requiring drugs. First pass success was achieved in 89.6% of cases. A second intubator was required in 4.3% of cases. Some form of complication was experienced by 42.3% of patients; however, the threshold for complications was set at a low level.

CONCLUSIONS

This ACCP service developed a process to acquire advanced airway management skills including endotracheal intubation. Under medical supervision, ACCPs delivered advanced airway management achieving a first pass success rate of 89.6%, which compares favourably with both international and national success rates. Although complications were experienced in 48.3% of patients, when similar complication cut-offs are compared with published data, ACCPs also matched favourably.

National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments

BACKGROUND

There is paucity of literature on why and how patients are intubated, and by whom, in Irish Emergency Departments (EDs). The aim of this pilot study was to characterise emergency airway management (EAM) of critically unwell patients presenting to Irish EDs.

METHODS

A multisite prospective pilot study was undertaken from February 10 to May 10, 2020. This project was facilitated through the Irish Trainee Emergency Research Network (ITERN). All patients over 16 years of age requiring EAM were included. Eleven EDs participated in the project. Data recorded included patients' demographics, indication for intubation, technique of airway management, medications used to facilitate intubation, level of training and specialty of the intubating clinician, number of attempts, success/complications rates and variation across centres.

RESULTS

Over a 3-month period, 118 patients underwent 131 intubation attempts across 11 EDs. The median age was 57 years (IQR: 40-70). Medical indications were reported in 83% of patients compared to 17% for trauma. Of the 118 patients intubated, Emergency Medicine (EM) doctors performed 54% of initial intubations, while anaesthesiology/intensive care medicine (ICM) doctors performed 46%. The majority (90%) of intubating clinicians were at registrar level. Emergency intubation check lists, video laryngoscopy and bougie were used in 55, 53 and 64% of first attempts, respectively. The first pass success rate was 89%. Intubation complications occurred in 19% of patients. EM doctors undertook a greater proportion of intubations in EDs with > 50,000 attendance (65%) compared to EDs with < 50,000 attendances (16%) (p < 0.000).

CONCLUSION

This is the first study to describe EAM in Irish EDs, and demonstrates comparable first pass success and complication rates to international studies. This study highlights the need for continuous EAM surveillance and could provide a vector for developing national standards for EAM and EAM training in Irish EDs.

Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study

BACKGROUND

Rapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI.

METHODS

In this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals.

RESULTS

From January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58-1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation.

CONCLUSIONS

In this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.

Rapid sequence induction: where did the consensus go?

Background

Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure.

This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment.

Conclusion

The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

Assessment of remifentanil for rapid sequence induction and intubation in patients at risk of pulmonary aspiration of gastric contents compared to rapid-onset paralytic agents: study protocol for a non-inferiority simple blind randomized controlled trial (the REMICRUSH study)

Background

Rapid-onset paralytic agents are recommended to achieve muscle relaxation and facilitate tracheal intubation during rapid sequence induction in patients at risk of pulmonary aspiration of gastric contents. However, opioids are frequently used in this setting. The study’s objective is to demonstrate the non-inferiority of remifentanil compared to rapid-onset paralytic agents, in association with an hypnotic drug, for tracheal intubation in patients undergoing  procedure under general anesthesia and at risk of pulmonary aspiration of gastric contents.

Methods

The REMICRUSH (Remifentanil for Rapid Sequence Induction of Anaesthesia) study is a multicenter, single-blinded, non-inferiority randomized controlled trial comparing remifentanil (3 to 4 μg/kg) with rapid-onset paralytic agents (succinylcholine or rocuronium 1 mg/kg) for rapid sequence induction in 1150 adult surgical patients requiring tracheal intubation during general anesthesia. Enrolment started in October 2019 in 15 French anesthesia units. The expected date of the final follow-up is October 2021. The primary outcome is the proportion of successful tracheal intubation without major complications. A non-inferiority margin of 7% was chosen. Analyses of the intent-to-treat and per-protocol populations are planned.

Discussion

The REMICRUSH trial protocol has been approved by the ethics committee of The Comité de Protection des Personnes Sud-Ouest et Outre-Mer II and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentations at scientific conferences and publications in peer-reviewed journals. The REMICRUSH trial is the first randomized controlled trial powered to investigate whether remifentanil with hypnotics is non-inferior to rapid-onset paralytic agents with hypnotic in rapid sequence induction of anesthesia for full stomach patients considering successful tracheal intubation without major complication.

Trial registration

ClinicalTrials.gov NCT03960801. Registered on May 23, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05192-x.

Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children

BACKGROUND

The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).

METHODS

In this prospective observational study, arterial desaturation < 95% SaO₂ before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year).

RESULTS

Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01).

CONCLUSIONS

Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.

Prolonged onset and duration of action of rocuronium after accidental subcutaneous injection in a patient with chronic renal failure-a case report

Background

Drugs administered subcutaneously have delayed onset and prolonged duration of action versus those given intravenously. Since the duration of action of rocuronium is prolonged in patients with renal dysfunction, subcutaneous administration of rocuronium to such patients might significantly prolong its effect.

Case presentation

A 51-year-old female with chronic renal failure was accidentally administered 1.04 mg/kg rocuronium subcutaneously. Marked prolongation of onset and duration of action of rocuronium were detected on acceleromyography. Slow development of the neuromuscular block was still observed at 100 min after injection. Administration of 4.5 mg/kg sugammadex at 140 min after rocuronium injection facilitated recovery from a train-of-four (TOF) count of 2 to a TOF ratio of 100% within 5 min. No symptoms of postoperative recurarization and upper airway obstruction were observed.

Conclusion

Neuromuscular monitoring is necessary to evaluate the progress and depth of neuromuscular block, particularly when rocuronium is inadvertently administered subcutaneously.

Ultrasound guided paralaryngeal pressure versus cricoid pressure on the occlusion of esophagus: a crossover study

The primary objective of this study is to compare the effectiveness of cricoid pressure (CP) and paralaryngeal pressure (PLP) on occlusion of eccentric esophagus in patients under general anesthesia (GA). Secondary objectives include the prevalence of patients with central or eccentric esophagus both before and after GA, and the success rate of CP in occluding centrally located esophagus in patients post GA. Fifty-one ASA physical status I and II patients, undergoing GA for elective surgery were enrolled in this study. Ultrasonography imaging were performed to determine the position of the esophagus relative to the trachea: (i) before induction of GA, (ii) after GA before external CP maneuver, (iii) after GA with CP, and (iv) after GA with PLP. CP was applied to all patients whilst PLP via fingertip technique was only applied to patients with an eccentric esophagus. Among a total of 51 patients, 28 of them (55%) had eccentric esophagus pre GA, while this number increase to 33 (65%) after induction of GA. CP success rate was 100% in 18 patients with central esophagus post GA versus 27% in 33 patients with eccentric esophagus post GA (P<0.00001). Overall success rate for CP was 53%. In 33 patients with eccentric esophagus anatomy post GA, PLP success rate was 30% compared with 27% with CP (P=1.000). Ultrasound guided PLP fingertips technique was not effective in patients with an eccentrically located esophagus post GA. Ultrasound guided CP achieved 100% success rate in patients with a centrally located esophagus post GA.

Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey)

Background

Maintaining effective oxygenation throughout the process of Pre-Hospital Emergency Anaesthesia (PHEA) is critical. There are multiple strategies available to clinicians to oxygenate patients both prior to and during PHEA. The optimal pre-oxygenation technique remains unclear, and it is unknown what techniques are being used by United Kingdom Helicopter Emergency Medical Services (HEMS). This study aimed to determine the current pre- and peri-PHEA oxygenation strategies used by UK HEMS services.

Methods

An electronic questionnaire survey was delivered to all UK HEMS services between 05 July and 26 December 2019. Questions investigated service standard operating procedures (SOPs) and individual clinician practice regarding oxygenation strategies prior to airway instrumentation (pre-oxygenation) and oxygenation strategies during airway instrumentation (apnoeic oxygenation). Service SOPs were obtained to corroborate questionnaire replies.

Results

Replies were received from all UK HEMS services (n = 21) and 40 individual clinicians. All services specified oxygenation strategies within their PHEA/RSI SOP and most referred to pre-oxygenation as mandatory (81%), whilst apnoeic oxygenation was mandatory in eight (38%) SOPs. The most commonly identified pre-oxygenation strategies were bag-valve-mask without PEEP (95%), non-rebreathable face mask (81%), and nasal cannula at high flow (81%). Seven (33%) services used Mapleson C circuits, whilst there were eight services (38%) that did not carry bag-valve-masks with PEEP valve nor Mapleson C circuits. All clinicians frequently used pre-oxygenation, however there was variability in clinician use of apnoeic oxygenation by nasal cannula. Nearly all clinicians (95%) reported manually ventilating patients during the apnoeic phase, with over half (58%) stating this was their routine practice. Differences in clinician pre-hospital and in-hospital practice related to availability of humidified high flow nasal oxygenation and Mapleson C circuits.

Conclusions

Pre-oxygenation is universal amongst UK HEMS services and is most frequently delivered by bag-valve-mask without PEEP or non-rebreathable face masks, whereas apnoeic oxygenation by nasal cannula is highly variable. Multiple services carry Mapleson C circuits, however many services are unable to deliver PEEP due to the equipment they carry. Clinicians are regularly manually ventilating patients during the apnoeic phase of PHEA. The identified variability in clinical practice may indicate uncertainty and further research is warranted to assess the impact of different strategies on clinical outcomes.

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.

Neuromuscular monitoring during modified rapid sequence induction: A comparison of TOF-Cuff® and TOF-Scan®

BACKGROUND

Acceleromyometry is the clinical standard for quantitative neuromuscular monitoring, mostly using the stimulation pattern train-of-four (TOF). TOF-Cuff®, a recently introduced neuromuscular monitor with stimulating electrodes integrated within a blood pressure cuff, assesses the muscular response in the upper arm.

METHODS

The time from administration of a neuromuscular blocking agent to TOF-ratio 0% during modified rapid sequence induction was compared between TOF-Cuff® and acceleromyometry (TOF-Scan®). Included were 26 adults with body mass index <35 kg/m². TOF-Scan® and TOF-Cuff® were simultaneously fitted on patients' opposite arms. The mean difference to TOF-ratio 0% was compared using the one sample t-test (p < 0.05) and Bland-Altman plots.

RESULTS

After anesthesia induction, atracurium 0.9 mg/kg (±0.08) i.v. was administered. The mean time to TOF ratio 0% for TOF-Scan® was 140.4 s (±34.3), and 132.7 s (±32.5) for TOF-Cuff®, with a mean difference of 5.4 (95% CI: -9.9 to 20.7, p = 0.472). The maximum difference between the two modalities was 135 s when the TOF-Cuff® was faster and 60 s when the TOF-Scan® was faster.

CONCLUSIONS

No statistically significant systematic difference was found between TOF-Scan® and TOF-Cuff®. However, there was high variability and wide limits of agreement. The two devices cannot be used interchangeably.

A survey of cricoid pressure application in a single institution in Ethiopia

Objective

The aim of this survey is to determine the standard of practice of cricoid pressure application on rapid sequence induction in Ayder comprehensive specialized hospital from April 3 to May 3, 2019.

Results

A total of 30 anesthetists were involved in the study with a response rate of 87%. Ninety percent of the respondents do not mask ventilate during rapid sequence induction and they do aspirate the naso-gastric tube if present. Almost half of the respondents have witnessed regurgitation during application of cricoid pressure and 93% do not remove the naso-gastric tube before rapid sequence induction. Seventy percent had experienced difficulty of endotracheal intubation during application of cricoid pressure. All of the respondents had less than 10 years of working experience as anesthetist.

The influence of different patient positions during rapid induction with severe regurgitation on the volume of aspirate and time to intubation: a prospective randomised manikin simulation study

BACKGROUND

Aspiration is a main contributor to morbidity and mortality in anaesthesia. The ideal patient positioning for rapid sequence induction remains controversial. A head-down tilt and full cervical spine extension (Sellick) might prevent aspiration but at the same time compromise airway management. We aimed to determine the influence of three different positions during induction of general anaesthesia on the volume of aspirate and on participants' airway management.

METHODS

Eighty-four anaesthetic trainees and consultants participated in a prospective randomised simulation study. Anaesthesia was induced in reverse Trendelenburg position (+ 15°) in a manikin capable of dynamic fluid regurgitation. Participants were randomised to change to Trendelenburg position (- 15°) a) as soon as regurgitation was noticed, b) as soon as 'patient' had been anaesthetised, and c) as soon as 'patient' had been anaesthetised and with full cervical spine extension (Sellick). Primary endpoints were the aspirated volume and the time to intubation. Secondary endpoints were ratings of the laryngoscopic view and the intubation situation (0-100 mm).

RESULTS

Combining head-down tilt with Sellick position significantly reduced aspiration (p < 0.005). Median time to intubate was longer in Sellick position (15 s [8-30]) as compared with the head in sniffing position (10 s [8-12.5]; p < 0.05). Participants found laryngoscopy more difficult in Sellick position (39.3 ± 27.9 mm) as compared with the sniffing position (23.1 ± 22.1 mm; p < 0.05). Both head-down tilt intubation situations were considered equally difficult: 34.8 ± 24.6 mm (Sniffing) vs. 44.2 ± 23.1 mm (Sellick; p = n.s).

CONCLUSIONS

In a simulated setting, using a manikin-based simulator capable of fluid regurgitation, a - 15° head-down tilt with Sellick position reduced the amount of aspirated fluid but increased the difficulty in visualising the vocal cords and prolonged the time taken to intubate. Assessing the airway management in the identical position in healthy patients without risk of aspiration might be a promising next step to take.

Propofol Versus Thiopental for Rapid-Sequence Induction in Isolated Systolic Hypertensive Patients: A Factorial Randomized Double-Blind Clinical Trial

Objective

We investigated the effects of four different anaesthesia induction protocols on the haemodynamic response to laryngoscopy and tracheal intubation during rapid-sequence induction (RSI) in systolic hypertensive patients.

Methods

One hundred and twenty hypertensive adult patients (systolic pressure >140 mmHg and diastolic pressure <90 mmHg), classified according to the American Association of Anesthesiologists as Class II and III were randomized into four groups. After pre-oxygenation for 3 minutes, induction and tracheal intubation were performed by blinded investigators, who also scored the intubation. Study groups composed of 30 patients each received lidocaine 1 mg kg^-1+thiopental 5 mg kg^-1 or remifentanil 1 μg kg^-1+thiopental 5 mg kg^-1 or lidocaine 1 mg kg^-1+propofol 2 mg kg^-1 or remifentanil 1 μg kg^-1+propofol 2 mg kg^-1. Succinylcholine was the muscle relaxant. Haemodynamic data were obtained before (baseline) and after induction, at intubation, and at 1, 3, 5 and 10 minutes after intubation. A rise or drop in the arterial blood pressure and heart rate >20% were considered to be significant.

Results

Patients receiving remifentanil+propofol had a reduction in the systolic and mean blood pressure >20% when compared to patients receiving remifentanil and thiopental: systolic values were 125±27 mmHg in the remifentanil+propofol group versus 153±35 mmHg in the remifentanil+thiopental group 1 minute after intubation (p<0.01); the mean arterial pressure values were 87±18 mmHg in the remifentanil+propofol group versus 105±25 mmHg in the remifentanil+thiopental group 1 minute after intubation (p<0.05).

Conclusion

Propofol was not superior to thiopental for the attenuation of the response to laryngoscopy and intubation during RSI in systolic hypertensive patients, whereas propofol+remifentanil combination appears to be so in terms of the heart rate stability.

Etomidate as an Induction Agent in Sepsis

Sepsis is a life-threatening response to infection often times requiring endotracheal intubation in critically ill patients. Etomidate is routinely used as an intravenous induction agent to provide sedation and amnesia before placing an endotracheal tube. Although etomidate has many favorable qualities, there is a major concern regarding the predictable adrenal insufficiency that follows its use. Controversy continues to this day as to whether etomidate should be avoided in the setting of sepsis or septic shock.

[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.

A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients

Background

Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures.

Methods

A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation.

Results

Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article.

Conclusions

The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1787-x) contains supplementary material, which is available to authorized users.

[French national survey on difficult intubation in intensive care units]

OBJECTIVES

Assessing the theoretical knowledge, practical experience of French intensivists, and their compliance with French Anesthesiology and Critical Care Society's difficult airway algorithms of the expert's SFAR conference of 2006.

STUDY DESIGN

Prospective and descriptive national survey.

MATERIAL AND METHODS

An anonymous questionnaire with 40 questions was emailed to physicians working in intensive care units in France.

RESULTS

Five hundred and eight intensivists answered the survey. Ninety-seven percent of physicians reported having a portable storage unit for difficult intubation. As for practical experience, 421 physicians (83 %) have set up less than 10 laryngeal mask airway, 257 (51 %) have performed less than 10 intubations under fibroscopy and 269 (53 %) have never performed a cricothyroidotomy on mannequin, and 331 (65 %) on a patient. In case of emergency intubation, 29 % of them do not use a rapid sequence induction. Three hundred physicians (59 %) use capnography as monitoring of the endotracheal position. Two hundred and nine (42 %) consider they have not been trained to difficult intubation and 443 (87 %) would like to participate in high fidelity simulations mannequin.

CONCLUSIONS

National airway management algorithm was insufficiently followed. Alternative techniques do not seem to be mastered by all physicians. French intensivists expect more training on difficult intubation, including high fidelity simulation.

An observational study of paediatric pre-hospital intubation and anaesthesia in 1933 children attended by a physician-led, pre-hospital trauma service

INTRODUCTION

Trauma accounts for 16-44% of childhood deaths. The number of severely injured children who require pre-hospital advanced airway intervention is thought to be small but there is little published data detailing the epidemiology of these interventions. This study was designed to evaluate the children who received pre-hospital intubation (with or without anaesthesia) in a high volume, physician-led, pre-hospital trauma service and the circumstances surrounding the intervention.

METHODS

We conducted a 12 year retrospective database analysis of paediatric patients attended by a United Kingdom, physician-led, pre-hospital trauma service. All paediatric patients (<16 years of age) that were attended and received pre-hospital advanced airway intervention were included. The total number of pre-hospital intubations and the proportion that received a rapid sequence induction (RSI) were established. To illustrate the context of these interventions the ages, injury mechanisms and intervention success rates were recorded.

RESULTS

Between 1 January 2000 and 31 October 2011 the service attended 1933 children. There were 315 (16.3%) pre-hospital intubations. Of those intubated, 81% received a rapid sequence induction and 19% were intubated without anaesthesia in the setting of near or actual cardiac arrest. Nearly three quarters of the patients were in the age range of 6-15 years with only 3 patients under the age of 1 year. The most common injury mechanisms that required intubation were Road Traffic Crashes (RTC) and 'falls from height'. These accounted for 79% of patients receiving intubation. Intubation success rate was 99.7% with a single failed intubation during the study period.

CONCLUSION

Pre-hospital paediatric intubation is not infrequent in this high-volume trauma service. The majority of patients received a rapid sequence induction. The commonest injury mechanisms were RTCs and 'falls from height'. Pre-hospital paediatric intubation is associated with a high success rate in this physician-led service.

Is the rapid sequence induction possible with 0.6 mg/kg rocuronium in pediatric patient?

Background

We have investigated the possibility of rocuronium 0.6 mg/kg and timing principle application with the same dose for rapid sequence induction (RSI) in 65 children, aged 4-8 yr.

Methods

Sixty five patients were randomly assigned to one of two groups; Group A (n = 31, timing principle application) received rocuronium (0.6 mg/kg) followed by administration of propofol (2.5 mg/kg), and group B (n = 36) received rocuronium (0.6 mg/kg) after administration of propofol. Intubation was assessed at 60 seconds just after administration of last injectants. Intubating conditions (jaw relaxation, vocal cord movement, and response to tracheal intubation) were evaluated as excellent, good, fair and poor.

Results

Excellent intubation conditions were obtained in 87% in group A and 61% in group B. However, clinically acceptable intubation conditions which means excellent and good did not show any significant difference as 100% (group A) and 99% (group B).

Conclusions

In cases of pediatiric patients undergoing elective surgery, RSI was possible irrespective of the use of timing principle.

Effect of mixed administration of propofol and rocuronium on intubating conditions

BACKGROUND

We investigated whether the intubating condition change acoording to the methods of administration of propofol and rocuronium.

METHODS

Ninety adult patients (ASA physical status I or II) undergoing elective surgery were randomly assigned to one of three groups; Group I (n = 30) received rocuronium (0.6 mg/kg) after administration of propofol (2 mg/kg), Group II (n = 30) received propofol and rocuronium simultaneously via different intravenous routes, and Group III (n = 30) received a mixture of propofol and rocuronium via same intravenous route. Intubation was attempted at 60 seconds after administration of rocuronium. Hemodynamic parameters (mean blood pressure, heart rate) were measured before and after propofol administration with 20 seconds interval. Intubating conditions (jaw relaxation, vocal cord movement, and response to tracheal intubation) were evaluated as excellent, good, fair and poor. Train of four counts were recorded at 60 seconds after administration of rocuronium.

RESULTS

Excellent intubating conditions were obtained in 13% in group I, 60% in group II, 77% in group III. Mean train of four counts were 3.7 in group I, 3.4 in group II, and 3.5 in group III. Mean blood pressures were decreased gradually after propofol administration in all groups. However, heart rates were not changed in all groups.

CONCLUSIONS

At induction of anesthesia, simultaneous or mixed administration of propofol and rocuronium provides excellent or good intubating conditions 60 seconds after rocuronium administration. It could be an effective alternative to succinylcholine for rapid sequence induction of anesthesia.