Should patients be manually ventilated during rapid sequence induction of anaesthesia?

Clements, Paul; Washington, Stephen; McCluskey, A.

doi:10.12968/hmed.2009.70.7.43138

Cited by 12 publications

(9 citation statements)

References 7 publications

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“…Advocates for this traditional approach claim that gastric insufflation can occur with PPV, thus increasing the likelihood of regurgitation and aspiration before securing the airway. 71 Manual bag-mask ventilation did not result in gastric insufflation when airway pressures were kept Ͻ15 cm H 2 O even in the absence of CP. Whereas some authors clearly stressed that PPV is contraindicated, 37 others found it acceptable.…”

Section: Manual Ventilationmentioning

confidence: 94%

“…71 Advocates of the use of PPV argue that avoiding the risk of hypoxemia at this point outweighs the potential risk of gastric insufflation. Hypoxemia can develop in obese, pregnant, pediatric, and critically ill patients before tracheal intubation is accomplished, or in the true emergent situations in which effective oxygen administration (denitrogenation) cannot be completed satisfactorily.…”

Section: Manual Ventilationmentioning

confidence: 99%

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Rapid Sequence Induction and Intubation

El-Orbany

Connolly

2010

Anesthesia &Amp; Analgesia

213

152

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The changing opinion regarding some of the traditional components of rapid sequence induction and intubation (RSII) creates wide practice variations that impede attempts to establish a standard RSII protocol. There is controversy regarding the choice of induction drug, the dose, and the method of administration. Whereas some prefer the traditional rapid injection of a predetermined dose, others use the titration to loss of consciousness technique. The timing of neuromuscular blocking drug (NMBD) administration is different in both techniques. Whereas the NMBD should immediately follow the induction drug in the traditional technique, it is only given after establishing loss of consciousness in the titration technique. The optimal dose of succinylcholine is controversial with advocates and opponents for both higher and lower doses than the currently recommended 1.0 to 1.5 mg/kg dose. Defasciculation before succinylcholine was traditionally recommended in RSII but is currently controversial. Although the priming technique was advocated to accelerate onset of nondepolarizing NMBDs, its use has decreased because of potential complications and the introduction of rocuronium. Avoidance of manual ventilation before tracheal intubation was traditionally recommended to avoid gastric insufflation, but its use is currently acceptable and even recommended by some to avoid hypoxemia and to "test" the ability to mask ventilate. Cricoid pressure remains the most heated controversy; some believe in its effectiveness in preventing pulmonary aspiration, whereas others believe it should be abandoned because of the lack of scientific evidence of benefit and possible complications. There is still controversy regarding the best position and whether the head-up, head-down, or supine position is the safest during induction of anesthesia in full-stomach patients. These controversial components need to be discussed, studied, and resolved before establishing a standard RSII protocol.

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Section: Manual Ventilationmentioning

confidence: 94%

Section: Manual Ventilationmentioning

confidence: 99%

Rapid Sequence Induction and Intubation

El-Orbany

Connolly

2010

Anesthesia &Amp; Analgesia

213

152

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“…Indications for this technique include patients at risk of rapid development of hypoxaemia (e.g., in those critically ill, morbidly obese or pregnant), in emergency situations where preoxygenation cannot be satisfactorily completed or when a longer time to achieve tracheal intubation is anticipated. Although the effect of positive pressure ventilation with the application of cricoid pressure in terms of gastric insufflation of air is not definitively known, gentle positive pressure ventilation with an inspiratory pressure < 20 cm H 2 O in combination with cricoid pressure may be acceptable in these clinical scenarios [25]. Positive pressure ventilation via a face mask may also be provided before and after administration of a muscle relaxant for patients unable to tolerate the brief period of apnoea associated with RSII.…”

Section: Modified Rapid Sequence Inductionmentioning

confidence: 99%

RSII rapid-sequence induction of anaesthesia and intubation of the trachea

Wołoszczuk-Gębicka

2017

Disaster Emerg Med J

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Rapid sequence induction and intubation (RSII) is the preferred method of tracheal intubation in emergency situations for patients presenting with a full stomach. The aim of RSII is to intubate the trachea within 60 seconds, without having to use bag-valve-mask ventilation to avoid air insufflation into the stomach. After preoxygenation and while cricoid pressure is applied, an induction dose of intravenous anaesthetic agent is administered and rapidly followed by a fast-acting muscle relaxant, and after 60 seconds tracheal intubation is performed. Preoxygention increases apnoea tolerance. This is particularly important for infants and young children, and in patients who are in critical condition, obese or pregnant. Cricoid pressure (the Sellick manouver) is recommended to prevent regurgitation of the gastric contents to the throat. Propofol or thiopental are routinely used for induction. Ketamine or etomidate may be used if propofol or thiopental administration is contraindicated. Succinylcholine or rocuronium are used to facilitate tracheal intubation. Poor jaw relaxation, patient resistance to a laryngoscope, closed or closing vocal cords, vigorous limb movements or sustained coughing after tube insertion are not clinically acceptable. Modified rapid sequence induction, used in patients at risk of rapid development of hypoxaemia, allows gentle positive pressure ventilation after administration of the induction agent and muscle relaxant, but before the tracheal intubation. If the attempt of intubation fails, sugammadex, 16 mg/kg body weight is recommended for the immediate reversal of the neuromuscular block produced by rocuronium, but not for other muscle relaxants.

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“…This, combined with gentle manual ventilation of of the lungs for all patients soon after induction, would reduce the likelihood of early desaturation. The theoretical risk of stomach inflation caused by gentle manual ventilation is, in our opinion, outweighed by the certain benefit of maintaining adequate oxygenation . Furthermore, inadequate inflation of the chest whilst attempting gentle bag‐mask ventilation could indicate airway maintenance problems at an early stage, and allow senior help to be sought more promptly.…”

mentioning

confidence: 99%

“…Reluctance to use manual ventilation during ‘traditional’ rapid sequence induction leaves the patient at the point of rapid desaturation during the first intubation attempt, compounding an already stressful situation. Anxiety about maternal or fetal hypoxia can tempt anaesthetists to intubate before optimal paralysis has been achieved, increasing the likelihood of intubation difficulties .…”

mentioning

confidence: 99%