Rapid sequence induction: where did the consensus go?

Avery, Pascale; Morton, Sarah; Raitt, James; Lossius, Hans Morten; Lockey, David

doi:10.1186/s13049-021-00883-5

Cited by 28 publications

(26 citation statements)

References 77 publications

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“…The avoidance of adverse events during RSI and successful intubation of acutely ill patients on the first attempt can be influenced by operator-related factors, selection of airway equipment, and choice of medications; 18 hence, the choice of induction drug is dictated by hemodynamic considerations. 19 This is the first systematic review and meta-analysis to compare the safety and efficacy of etomidate and ketamine as induction agents for RSI with respect to post-induction hypotension and first-attempt intubation success in prehospital and emergency department settings.…”

Section: Discussionmentioning

confidence: 99%

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

Sharda¹,

Bhatia²

2022

Indian Journal of Critical Care Medicine

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A bstract Aims and objectives The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. Materials and methods For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. Results Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31–0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95–1.36; I 2 = 16%). Conclusion The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. How to cite this article Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108–113.

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Section: Discussionmentioning

confidence: 99%

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

Sharda¹,

Bhatia²

2022

Indian Journal of Critical Care Medicine

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“…Another piece of evidence supporting the use of cricoid pressure is the idea that the pressure applied inhibits air from entering the stomach, which reduces the risk of aspiration 71 . The conundrum is that although more research is needed to ascertain morbidity and mortality as they relate to the application of cricoid pressure, it is unethical to conduct large, prospective, randomized clinical trials with and without cricoid pressure on patients because the enrolled patient population would be patients at risk for regurgitation and aspiration—how would researchers ethically withhold cricoid pressure for patients in the control group? 2,11,34 These studies also would need to involve more than 50,000 patients to reduce the incidence of aspiration by 50%, and numerous variables would have to be standardized 41 …”

Section: Cricoid Pressurementioning

confidence: 99%

Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice

Dunn¹

2022

AORN Journal

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The purpose of applying cricoid pressure is to prevent pulmonary aspiration of regurgitated gastric contents during airway management in mask‐ventilated patients who are at risk of aspiration. Providers may apply cricoid pressure during induction and intubation if they expect a difficult intubation or if the patient has a high risk for regurgitation. Although the application of cricoid pressure has been accepted as a standard practice worldwide, controversy persists because pulmonary aspiration can occur even when cricoid pressure is applied. The perioperative nurse should have thorough knowledge of the anatomy of the upper respiratory and gastrointestinal tracts, be able to demarcate the surface landmarks of the neck, and be skilled in applying cricoid pressure properly and safely. This article discusses cricoid pressure in the context of safe airway management as well as the perioperative nurse’s role as an assistant to the anesthesia professional when applying cricoid pressure.

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“…the airway to be secured rapidly and minimises air entry into the stomach, which can increase the risk of gastric regurgitation and aspiration of stomach contents. 1 RSI in the ED is a high-risk procedure with increased risk of complications such as oxygen desaturation, oesophageal intubation, pneumothorax, hypotension and cardiac arrest. 2 Patients presenting to the ED are often unfasted, which increases the risk of regurgitation and aspiration of gastric contents.…”

Section: Key Findingsmentioning

confidence: 99%

“…[5][6][7] Since its introduction, the use of CP has become controversial. 1 First, the anatomical and physiological basis of the manoeuvre has been challenged. MRI studies have shown that the oesophagus often lies laterally to the cricoid cartilage, leading to concerns that applying CP does not occlude the oesophagus.…”

Section: Key Findingsmentioning

confidence: 99%

“…Rapid sequence induction (RSI) involves the administration of an induction agent and a muscle relaxant in rapid succession to facilitate endotracheal intubation. 1 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.…”

Section: Introductionmentioning

confidence: 99%

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Review article: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review

Tessarolo

Alkhouri

Lelos

et al. 2022

Emerg Medicine Australasia

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The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first‐pass success (FPS) of intubation. This systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation. After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP. The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed.

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Rapid sequence induction: where did the consensus go?

Cited by 28 publications

References 77 publications

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice

Review article: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review

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