Systematic Application of Rapid Sequence Intubation With Remifentanil During COVID-19 Pandemic

Abstract

In this letter, the authors wonder about the need to apply some of the precautions that have been repeatedly suggested during the recent COVID-19 (coronavirus disease 19) pandemic not only to suspected or documented cases of infection but also to all the new cases entering the hospital. In this regard, orotracheal intubation has been universally recognized as a maneuver with a high risk of viral transmission. On the other hand, rapid sequence induction, which represents the gold standard for limiting the risk of transmission for health care professionals, implies side effects that can be potentially harmful for patients with impaired hemodynamics. In this regard, the authors report a particular type of rapid induction that they are performing in a systematic way during the recent pandemic in cardiac surgery patients. This is performed after the patient reaches a deep analgesic plan, thanks to the unique characteristics of the opioid remifentanil. This type of induction, already tested in vasculopathic patients who underwent carotid surgery, is characterized by great hemodynamic stability and is very advantageous, in the writer’s experience, when rapid sequence induction has to be systematically applied to cardiovascular patients, especially if you only want to protect operators.

The Invisible Part of the Iceberg in Covid-19 Pandemic: Asymptomatic Cases and Anesthesiologists Protective Approaches-Knowledge Levels

“…In order to prevent leakage between the mask and the face during ventilation, the two-handed mask, namely V-E ventilation, has been found to be safer than the one-handed C-E ventilation. The rapid sequence intubation and the extubation under deep anesthesia, which minimizes cough at the end of the operation, is recommended 23,24 . According to our results, while the safer two-handed mask ventilation technique and the extubation under deep anesthesia were less preferred, the rapid sequence intubation was applied at a rate of 65%.…”

A great tool that resurfaced during the pandemic: Remifentanil

“…Therefore, it is recommended to administer profound analgesia with remifentanil to perform rapid intubation to avoid viral transmission. [50][51][52][53]…”

Review of Anaesthesia and Analgesia in Patients with COVID-19 in Brazil

“…Bevilacqua et al suggest a high dose of remifentanil alone, which is then combined with small doses of midazolam or propofol during the rapid intubation sequence, based on an anaesthetic technique for carotid surgery, in which a venous infusion of remifentanil of 0.2 to 0.3 μg/kg/min until the patient had a profound state of analgesia and sedation, but still reacting to some verbal stimuli and responding to respiratory commands [24]. Tang and Wang responded to the letter from Bevilacqua et al agreeing with the possibility of using remifentanil for intubation in positive COVID-19 patients, but noting that the method is not classified as a rapid sequence of intubation but as a deep induction, in addition to highlighting possible complications such as higher risks of aspiration because it requires more time and hemodynamic risk [24,25].…”