„Rapid sequence induction and intubation“ beim aspirationsgefährdeten Patienten

Abstract

The consideration of all practical, clinical procedures in patients at risk for aspiration represents an effective prevention of pulmonary aspiration during the induction of anesthesia. These include the optimal drug pre-treatment with antacids (e. g. sodium citrate) for highly aspiration-endangered and proton pump inhibitors or H2 blockers in other patients the evening before. Each patient should be examined and explained prior to RSI according to the recommendations of the National German Society of Anesthesiology for preoperative evaluation. A RSI should be performed in patients with no 2h liquid and no 6h food fasting or acute vomiting, sub-ileus or ileus, or no protective reflexes or a gastrointestinal passenger disorder. In addition, RSI should be performed in pregnant women after the 3rd trimester and during birth. The expertise and competence of the physician before and during rapid sequence induction and intubation about the respective task distribution minimizes the risk of aspiration, as does the adequate equipment, as well as an optimized upper body elevation of the patient. Consistent pre-oxygenation with an FO of 1.0 (FeO-concentration > 0.9) and an oxygen flow > 10 l/min using a completely sealing respiratory mask with capnography should take 3-5 minutes. Fast enough deep anesthesia and muscle relaxation to avoid coughing and choking can be achieved by a combination of opioid, hypnotic and muscle relaxation. In addition, an opioid of choice, propofol, thiopental, etomidate and ketamine can be used as hypnotic and rocuronium with the availability of sugammadex should be used as muscle relaxant. If there are no contraindications, succinylcholine can also be used as a muscle relaxant. In case of an unexpected difficult airway, a 2nd generation extraglottic airway device should be used. During regurgitation or aspiration, intensive medical monitoring and fiber-optic bronchoscopy should be performed, depending on the degree of severity and an X‑ray thorax image or a CT scan should be performed if symptoms arise. Three factors reduce the risk of aspiration: expertise, support from an experienced anesthesiologist and close monitoring of an inexperienced anesthesiologist.

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

“…Patient positioning during induction and intubation in patients with risk of aspiration has been reviewed in several recent publications [15–18]. Although the head-down (Trendelenburg) position has been advocated together with the supine position and the semi-sitting position as one of three preventive methods against aspiration during rapid induction and intubation for more than 50 years [9] there is little data on the feasibility of such a technique.…”

Einleitung des nicht nüchternen Patienten: Welche Techniken sind zu verwenden?

“…das Magenvolumen sonografisch gemessen 200-300 ml übersteigt [13]. Eine nasale Magensonde sollte einer oralen Magensonde vorgezogen werden, sofern hierfür keine Kontraindikationen vorliegen [23].…”

Comparison of the Effectiveness of Transnasal Humidified Rapid Insufflation Ventilator Exchange (THRIVE) with Facemask Pre-Oxygenation in 40 Patients ≥65 Years of Age Undergoing General Anaesthesia During Gastrointestinal Surgery for Intestinal Obstruction

“…Hypoxia during the rapid sequence induction (RSI) of anesthesia is still an important issue that can considerably impact patient outcomes [ 1 ]. Normally, pre-oxygenation with 100% oxygen before intubation is used to denitrogenate, increase the oxygen reserve, and extend safe apnea time [ 2 ]. However, it is common for patients with gastrointestinal obstruction to have increased intra-abdominal pressure, diaphragmatic muscle activity, and decreased abdominal breathing [ 3 ].…”