Breaking with tradition in paediatric RSI

‘Traditional’ rapid sequence induction of anaesthesia is often described with inclusion of cricoid pressure and the strict omission of any artifical ventilation between paralytic drug administration and insertion of the tracheal tube. These measures are aimed at preventing pulmonary aspiration of gastric contents although there is no convincing evidence base to support that. However it is known that cricoid pressure can worsen laryngoscopic view and can occlude the paediatric airway. We also know that children desaturate quickly after the onset of apnoea, and although apnoeic diffusion oxygenation via nasal cannula can prevent or delay that, in some cases it may be preferable to bag-mask ventilate the patient while awaiting full muscle relaxation for laryngoscopy.
A Swiss study looked at 1001 children undergoing RSI for non-cardiac surgery. They used a ‘controlled rapid sequence induction and intubation (cRSII)’ approach for children assumed to have full stomachs. This procedure resembled RSI the way it is currently done in many modern critical care settings, including the retrieval service I work for:

  • No cricoid pressure
  • Ketamine for induction if haemodynamically unstable
  • A non-depolarising neuromuscular blocker rather than succinylcholine
  • No cricoid pressure
  • Gentle facemask ventilation to maintain oxygenation until intubation conditions achieved
  • Intubation with a cuffed tracheal tube
  • Still no cricoid pressure

The authors comment:
The main finding was that cRSII demonstrated a considerably lower incidence of oxygen desaturation and consecutive hemodynamic adverse events during anesthesia induction than shown by a previous study on classic RSII in children. Furthermore, there was no incidence of pulmonary aspiration during induction, laryngoscopy, and further course of anesthesia.
Looks like more dogma has been lysed, and this study supports the current trajectory away from traditional teaching towards an approach more suitable for critically ill patients.
Controlled rapid sequence induction and intubation – an analysis of 1001 children
Paediatr Anaesth. 2013 Aug;23(8):734-40
[EXPAND Abstract]

BACKGROUND: Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A ‘controlled’ rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort.
METHODS: Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters.
RESULTS: A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as ‘difficult’ in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of ‘silent aspiration’ during cRSII.
CONCLUSION: Controlled RSII with gentle facemask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.


4 thoughts on “Breaking with tradition in paediatric RSI”

  1. Agree with all of your conclusions, Cliff. Would say that it may be better to bag if the sat starts moving from 100%, but not otherwise. As you say apneic ox will usually preserve sats throughout apneic period. If it doesn’t then worth it to give the gentlest of mask ventilations. The reason I shy away from empirical bagging is this recent study: Anesthesiology 2014;120:326.
    Rich Levitan and I used to believe and preach that if the BVM is in the hands of someone who knows what they are doing it is safe to give low volume, low speed, low repetition breaths during apnea–now, I’m a bit more leery.
    Love to know what you think.

    1. Definitely agree Scott – no bagging unless needed for SpO2 maintenance, and NODESAT has changed that game, although I’m sure you’d agree in the very young with acute respiratory presentations they can desaturate pretty quickly. Thanks for pointing out that interesting study

  2. When the paralytic is appropriately dosed, the time between the onset of paralysis and safe, excellent laryngoscopy conditions is 10-20 seconds. In an appropriately preoxygenated/apneic oxygenated patient, the benefit of mask ventilation during that period seems to me clearly exceeded by the harm.
    The notion that laryngoscopy should not commence until paralysis is complete is, in my view, false.
    10-15 seconds after the paralytic is pushed, I begin laryngoscopy. knowing that excellent, safe conditions are another 15 or so seconds away, I use that time to be as explicitly slow and gentle as conceivable; I will often say “1 cm per second.” This deliberate slowness counteracts the surge of adrenaline and frantic feeling that usually accompanies the start of laryngoscopy.
    By the time the epiglottis is in view, airway reflexes are abolished. By the time epiglottis displacement is attempted, paralysis is complete. This “early, leisurely laryngoscopy” technique I believe augments success and downstream decision-making, by operator catecholamine management.
    None of this applies to the patient whose spontaneous respirations are insufficient to allow safe apneic laryngoscopy. In those cases, however, I think you’re better off placing an LMA after the paralytic. And I strongly believe that after a failed laryngoscopy attempt following RSI, if assisted ventilation is required, that ventilation should be via an LMA.

    1. Good points, but not all critically ill patients with hypoxaemia can maintain adequate oxygenation despite preoxygenation and apneic oxygenation measures. My point of posting is to challenge the dogma that you
      mask-ventilate between giving the drugs and intubating.

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