What is rapid sequence induction?
Technique used to prevent regurgitation of gastric contents during induction of anaesthesia, aiming to prevent aspiration of gastric contents.
Who is at risk of aspiration?
- Unfasted
- Pregnant
- Trauma
- Suffering from shock, hiatus hernia, anxiety, pain, gastric tumour, bowel or oesophageal obstruction,
- Those administered with opiates and/or sedatives
- Obesity
How can the risk of aspiration be reduced?
- Delay surgery
- Use of regional or local anaesthesia
- Follow fasting guidance
- Aspirate nasogastric tube
- Drug therapy to inhibit gastric acid production and to reduce the acidity of stomach contents
What are the fasting guidelines for liquids?
Encourage drinking of clear liquids up until two hours before anaesthesia
What are the fasting guidelines for food?
No solid food or milk at least six hours before anaesthesia
What are the requirements for RSI?
- Airway management plan, discussed and agreed prior to patient arrival
- Sufficient staff
- Tipping trolley
- Range of endotracheal tubes
- Laryngoscope
- Introducer (stylet)
- Bougie
- Syringe for inflation of ETT cuff, already attached to cuff valve
- Yankeur suction - switched on and under patient pillow
- Tie/tapes for ETT
What is the primary goal of RSI?
Insert an ETT and protect the patient from aspiration, even before testing ventilation is possible
What are the chain of events?
Procedure explained to parent >
Ensure there are adequate personnel >
Switch on suction, put below pillow >
Pre-oxygenate patient with 100% oxygen for 3-5 minutes >
Check position of cricoid >
Apply 10 Newtons (N) of pressure to cricoid cartilage >
Intravenous induction agent administered >
Anaesthetist should announce clearly “CRICOID ON” >
Apply 30N of pressure to cricoic cartilage and MAINTAIN this >
Intravenous muscle relaxant administered >
Visualise fasciculations >
Patient intubated >
ETT cuff inflated immediately by anaesthetic practitioner >
ETT position checked
How do you check ETT position?
- Bilateral chest movements
- End tidal CO2
- Misting in the tube
- Breathing sounds at chest auscultation
What are the chain of events once patient is intubated?
- Anaesthetist states “CRICOID OFF”, remove cricoid pressure.
- Do not remove unless told to do so
What drugs are used in RSI?
- Textbook/standard RSIs - thiopentone and suxamethonium
- Modified RSI - propofol and high-dose rocuronium
Why has there been a move away from suxamethonium?
High incidence of adverse events such as potentially fatal hyperkalaemia
What is cricoid pressure?
Compression of the oesophagus between cricoid cartilage and the vertebrae of the spine
Negatives of cricoid pressure?
- Too little pressure ineffective
- Too much pressure can disrupt the anatomy and make view difficult for anaesthetist
- Application too early may cause patient to panic, gag or vomit
- Cricoid pressure must be removed if the patient actively vomits, otherwise there is a risk of oesophageal rupture
When may you need to lessen or remove cricoid pressure?
Failed or difficult Intubation
What are contraindications of cricoid pressure?
- Trauma to neck
- Unstable cervical spine
- Patient actively vomiting
- Difficult intubation
What are the signs and symptoms of aspiration?
- Wheeze (bronchospasm)
- Unexplained rise in airway pressure
- Drop in oxygen saturation
How do you manage aspiration?
- Head down tilt (with left lateral tilt if possible)
- Suction with yankeur sucker then fine-bore catheter
- Increase oxygen
- Laryngoscopy
- Bronchoscopy if severe
- Chest x-ray
- Antibiotics
- Steroids
- Possible ITU admission depending on severity
