RSI + dAS 2015 (1).pptx

Rapid Sequence Induction
Hassam Zulfiqar
Anesthesiology
Resident
Moderator
Dr Adnan Mustafa

Pulmonary aspiration of gastric contents
 One of the most feared complications of anaesthesia
 Reason for pulmonary aspiration of gastric contents
in the peri-operative period
 General anaesthesia

 Unconsciousness

 No gag, laryngeal, cough reflexes

 May occur during induction and may occur during
emergence

 Particle-related complications
 Acid-related complications (Mendelson’s syndrome)
 Bacteria-related complications

 Particle-related complications
 Airway obstruction
 Acid-related complications (Mendelson’s syndrome)
 Pneumonitis
 Bronchospasm
 Pulmonary oedema
 Acute respiratory distress syndrome (ARDS)
 Bacteria-related complications
 Pneumonia

Characteristics of aspirate increasing the severity of
aspiration pneumonitis
 Higher volume
 Lower pH
 Particulate matter

Decreasing the severity of aspiration pneumonitis
 Decrease volume of gastric contents
 Increase pH of gastric contents
 Ensure there is no particulate matter in the stomach

 Pre-operative management
 Decrease volume and particulate matter
 Fasting
 NG tube (won’t fully empty stomach)
 Metoclopramide

 Increase pH
 Na citrate 0.3 M 30 ml PO

 Decrease volume and increase pH
 Ranitidine 150 mg nocte and 2 h pre-op. PO
 Proton pump inhibitor, e.g. omeprazole

 Intra-operative management
 Local anaesthesia
or
 General anaesthesia with rapid sequence induction

 Post-operative management
 Extubate the trachea when the patient is fully
awake

Full stomach, risk of regurgitation
 General categories
 Abdominal disease
 Trauma
 Abdominal distension
(pregnancy, obesity, ascites)
 Gastro-oesophageal reflux
(hiatus hernia or reflux symptoms)
Abdominal pain
Bowel obstruction
UGI bleeding

Other situations associated with an increased risk of
regurgitation and aspiration
 Patients who have not been fasting or whose fasting
status is unknown
 e.g.
 Most emergency intubations in the Emergency
Dept., ICU and wards

Pregnancy
 Cause of increased risk of regurgitation and
aspiration
 Decreased LOS pressure
 Effect of progesterone on smooth muscle
 Mechanical effects of enlarging uterus
 Increased intragastric pressure
 Decreased gastro-oesophageal angle
 Increased gastric acidity
 Placental gastrin

Pregnancy
 Cause of increased risk of regurgitation and
aspiration
 Gastric emptying
 Not delayed during pregnancy
 Delayed during labour
 Gastric stasis aggravated by:
 Pain
 Anxiety
 Opioids (including subarachnoid and epidural
opioids)

Pregnancy
 Duration of increased risk of regurgitation and
aspiration
 16 weeks gestation to 48 h postpartum
or
 Anytime if symptoms of gastro-oesophageal reflux

Rapid sequence induction
 Classical
 I will describe
 Commonly used for caesarean section under GA
 Less commonly used in other specialties
 Modified
 Commonly used

Key elements of rapid sequence induction
 Fast-acting IV induction agent and succinylcholine
 No other drugs
 Pre-calculated doses without titration
 Cricoid pressure
 No ventilation with face mask before tracheal
intubation

Drugs given before tracheal intubation
 Fast-acting IV induction agent
(acts in one arm-brain circulation time)
 Propofol
or
 Thiopental (available, now rarely used)
 Succinycholine (suxamethonium) 1.5 mg/kg
 Onset 30-60 s
 Duration 4-6 minutes
 No other drugs

No:
 Premedication
 Benzodiazepines
 e.g. midazolam
 Opiates
 e.g. fentanyl or morphine

Note:
 The IV induction agent and succinylcholine are given
in precalculated doses without titration, i.e. they are
given in “rapid sequence”
 Only these two drugs should be given so that if
intubation is impossible, the patient will resume
spontaneous breathing and wake up before hypoxia
or aspiration occurs

 What’s the problem with giving precalculated doses
of only two drugs and no opiate?

 Too little anaesthesia
 Too much anaesthesia

 What’s the problem with succinylcholine?

 Side effects, esp. allergic reactions
 Very short duration of action

Cricoid pressure
 Mode of action
 The cricoid cartilage is the only cartilaginous part
of the upper airway to be a complete ring
 When cricoid pressure is applied, the hypopharynx
(laryngopharynx) is compressed between the
cricoid cartilage in front and the vertebrae (esp.
C6) and prevertebral muscles behind

Cricoid pressure
 Mode of action
 20 Newtons (2 kg) of cricoid pressure is probably
enough and 30 Newtons (3 kg) is more than
enough to prevent regurgitation into the pharynx

Cricoid pressure
 Procedure
 Locate the cricoid cartilage - the first cartilage
below the thyroid cartilage (Adam’s apple)
 Using the dominant hand, place the index finger
and thumb on either side of the cricoid cartilage
(some use three fingers)
 Normally, the assistant applies cricoid pressure
with his/her dominant hand, as this can be
maintained more accurately and for longer (3-5
min.)

Cricoid pressure
 Procedure
 Apply counter pressure to the back of the neck if
there is a suspected cervical spine injury. This will
reduce movement of the cervical spine.

 When should you apply cricoid pressure?

 When the patient is unconscious

 When should you release cricoid pressure?

 When the anaesthetist says you can
 This is usually when a cuffed tracheal tube
protects the airway and the anaesthetist confirms
this with capnography

 What’s the problem with cricoid pressure?

Cricoid pressure
 Problems
 Difficult to do it properly
 May be difficult to identify cricoid cartilage
 May be difficult to apply correct force in correct
direction to cricoid cartilage
? Ultrasound

Cricoid pressure
 Problems
 It may make airway management more difficult,
especially if too much force
 Difficult mask ventilation
 Difficult tracheal intubation
 Difficult insertion of supraglottic airway
? Release
? Release
Release

intubation

 What’s the problem with not ventilating with a face
mask before tracheal intubation?

 Increased risk of hypoxia

Preoxygenation
 Rationale
intubation
 Ventilation only after tracheal intubation
 A longer period of apnoea than during routine
induction of anaesthesia
 Adequate pre-oxygenation prevents oxygen
desaturation during this period of apnoea

Preoxygenation
 Procedure
 100% O2
 Gas flow at least 10 L/min.

Preoxygenation
 Procedure
 3-5 min. of tidal volume breathing
 or
 4-8 slow, vital capacity breaths
 or
 Until end-tidal O2 is at least 90%
 The mask must have a seal on the face and the
reservoir bag must distend with each breath

Two anaesthetists, two anaesthetic assistants
 Anaesthetist No. 1 holds face mask
 Anaesthetist No. 2 injects drugs
 Anaesthetic assistant No. 1 applies cricoid pressure
 Anaesthetic assistant No. 2 prepares airway
equipment

One anaesthetist, two anaesthetic assistants
 Anaesthetic assistant No. 1 applies cricoid pressure
 Anaesthetic assistant No. 2 prepares airway
equipment and holds face mask
 Anaesthetist injects drugs
 When the drugs are injected, the anaesthetist holds
face mask

 
 Anaesthetic assistant No. 3 performs manual in-line
stabilisation, if there is a possible cervical spine injury
(remove collar first)

Preparation
 Equipment
 Usual equipment
 Difficult airway trolley

Tracheal Intubation
Position of head and neck
 “Sniffing position”
 “Sniffing the morning air”
 “Drinking a full pint of beer”
 “Win with the chin”
 Best position to win a running race, where the
chin wins the race

Tracheal Intubation
 Flexion of lower cervical spine
 35o neck flexion
 Extension of atlanto-occipital joint
 15o head extension

Tracheal Intubation
 BMI ≥ 30
 Consider head-up position

InternationalAnesthesia Research Society. Published by International Anesthesia Research Society. 8
Figure 7
Head and Neck Position for Direct Laryngoscopy.
El-Orbany,Mohammad;Woehlck, Harvey; Salem, M
Anesthesia & Analgesia. 113(1):103-109, July 2011.
DOI: 10.1213/ANE.0b013e31821c7e9c
Figure 7 . Some commercially available elevation pillows
for positioning obese patients before direct
laryngoscopy.A, Troop Elevation Pillow. B, Oxford Head
Elevating Laryngoscopy Pillow (HELP). C, Rapid Airway
Management Positioner (RAMP).
Inflatable
A Troop Elevation Pillow
B Oxford Head Elevating Laryngoscopy Pillow (HELP)
C Rapid Airway Management Positioner (RAMP)

Tracheal Intubation
 Horizontal alignment of the external auditory meatus
and the sternal notch

Sequence of events
 Check equipment
 Draw up drugs
 Attach monitors
 Ensure good IV access
 Place sucker and bougie under pillow
 Switch on suction
 Aspirate NG tube, if present

Sequence of events
 Start preoxygenation
 The anaesthetist should confirm that the assistant’s
fingers are correctly placed on the cricoid cartilage
and that it is tolerable to the patient
 Give IV induction agent and succinylcholine
 When the patient is unconscious, apply cricoid
pressure (30 N = 3 kg)

Sequence of events
 Leave face mask in situ until the fasciculations have
stopped
 Remove face mask
 Perform laryngoscopy and insert ETT
 Inflate cuff immediately, without titration
 Ventilate via the ETT
 Check capnograph for expired CO2
  Auscultate chest bilaterally in midaxillary line and
over stomach

Sequence of events
 Release cricoid pressure only when instructed to do
so by the anaesthetist
 Check cuff pressure is 20-30 cm H2O
 Start sevoflurane, give non-depolarising muscle
relaxant, e.g. rocuronium
 If not caesarean section, give opiate
 If caesarean section, give opiate after delivery

Modified Rapid Sequence Induction
 Opiate, e.g. fentanyl
 Wait for IV induction agent to work
 Ventilation with face mask
 Rocuronium 1-1.2 mg/kg
 Onset 30-60 s (similar to succinylcholine)
 Duration ≥ 60 min, up to 230 min, variable++
 Rocuronium 0.6 mg/kg
 Onset “1-2 min”, variable++
 Duration 30-45 min, variable++

Modified Rapid Sequence Induction
 …and many other modifications!

Difficult intubation
 ? Release cricoid pressure
 Maintain oxygenation and anaesthesia
Don’t keep trying
Failed intubation
 Insert second generation supraglottic airway, e.g.
i-gel
 Stop and think…
 ? Wake the patient up

Difficult Airway Society
Guidelines 2015

RSI + dAS 2015 (1).pptx

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