No evidence for decreased incidence of aspiration after rapid sequence induction

Abstract

Purpose:The purpose of this structured, evidence-based, clinical update was to determine if rapid sequence induction is a safe or effective technique to decrease the risk of aspiration or other complications of airway management. Source:In June 2006 a structured search of MEDLINE from 1966 to present using OVID software was undertaken with the assistance of a reference librarian. Medical subject headings and text words describing rapid sequence induction or intubation (RSI), crash induction or intubation, cricoid pressure and emergency airway intubation were employed. OVID's therapy (sensitivity) algorithm was used to maximize the detection of randomized trials while excluding non-randomized research. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search. Principal findings:A total of 184 clinical trials were identified of which 163 were randomized controlled trials (RCTs). Of these clinical trials, 126 evaluated different drug regimens with 114 being RCTs. Only 21 clinical trials evaluated non-pharmacologic aspects of the RSI with 18 RCTs identified. A parallel search found 52 trials evaluating cricoid pressure (outside of the context of an RSI technique) with 44 classified as RCTs. Definitive outcomes such as prevention of aspiration and mortality benefit could not be evaluated from the trials. Likewise, the impact on adverse outcomes of the different components of RSI could not be ascertained. Conclusion:An absence of evidence from RCTs suggests that the decision to use RSI during management can neither be supported nor discouraged on the basis of quality evidence.

A case series of the use of the ProSeal laryngeal mask airway in emergency lower abdominal surgery

“…Peak airway pressure was 16 (SD 3 [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]) cmH 2 O. Airway seal pressure was 34 (SD 4 [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]) cmH 2 O. There were no important changes in measures of ventilation or oxygenation during the procedure.…”

“…In continental Europe, however, RSI is less frequently used than in some other countries. It is notable that a recent systematic review of RSI was unable to find robust evidence for (or against) efficacy in reducing the incidence of aspiration [14]. In our hospital, management of appendicectomy without RSI is routine and our local protocols encourage patients (even those for emergency surgery) who have been starved for more than 6 h to be managed with a PLMA during anaesthesia and surgery.…”

Techniques of rapid sequence induction and intubation at a university teaching hospital

“…The outcomes showed that the prevention of aspiration and mortality could not be evaluated from the trials because the components of rapid sequence induction were uncertained. [9] The rate of aspiration was found to be increased from 1.9% with one attempt to 22% with three or more attempts during intubation. [10] Over the past decades, the practice of rapid sequence induction was evolved with newer drugs and equipments, but the practice was different from country to country and from anesthetist to anesthetist.…”

Is it time to revisit tracheal intubation for Cesarean delivery?

“…However, the value of cricoid pressure as part of the rapid sequence induction technique has been challenged and debated. 21 Does Yao et al's study support a change in practice regarding the choice of airway device in this patient population? The primary end point of the study was the incidence of aspiration.…”

“…Cependant, la contribution de la pression cricoïdienne dans le cadre de la technique d'induction à séquence rapide a été remise en cause et discutée. 21 23 Dans une étude observationnelle incluant un groupe de patients, Pandit a expliqué la distribution de Poisson pour la quantification de l'incidence des complications et a suggéré qu'il était nécessaire d'avoir plus de 5 000 patients pour observer au moins un cas d'inhalation avec une probabilité [ 99 %, en supposant que l'incidence d'inhalation avec une induction à séquence rapide n'est pas supérieure à 1:1000. 24 L'étude de Yao n'a donc pas la puissance suffisante pour ce critère d'évaluation principal.…”