Modified rapid sequence induction pdf

Similar associations were observed for applying cricoid pressure and mask ventilation. Modifiable aspects of the rapid sequence induction RSI procedure. A majority of respondents used all three elements. We can also conclude that less than 5 breaths are typically given when attempting to ventilate the lungs via positive-pressure ventilation, and that the majority of respondents who ventilated the lungs did so before administering an NMBD.

Most practicing anesthesiologists in our survey reported using a modified RSII technique for at least some of their cases, with moderate or morbid obesity and gastroesophageal reflux disease being the most common medical reason. While our survey did not explicitly ask what differentiated the classic RSII from a modified RSII or how to choose between the two techniques, we constructed and validated the survey to discern this, because each question explicitly stated that it was asking about a modified RSII.

Our results allow us to highlight one important distinction between a classic RSII and a modified RSII; the attempt to ventilate the lungs using positive-pressure ventilation via a facemask. The avoidance of positive-pressure ventilation is one of the hallmarks of a classic RSII, and so this technique is specifically different from a modified RSII. Our results are consistent with the results of another study by Schleinger and Blanchfield regarding a modified RSII, in which 94 of percent of respondents who used a modified RSII technique reported that it was appropriate to attempt facemask ventilation.

These results are slightly different than the other study regarding a modified RSII, in which half of the respondents who reported facemask ventilation did so both before and after administration of an NMBD. Therefore, it is not surprising to find more variation in practice. The results may therefore reflect training differences or exposure to different case types. Although we did find a clear distinction between a modified RSII and a classic RSII, we were unable to detect differences between the two with respect to the use of oxygen administration, cricoid pressure, and selection of the NMBD.

Consistent with previous literature regarding classic RSII, 2 , 4 oxygen administration is almost always used. We found that a majority of participants applied cricoid pressure during induction of anesthesia, which is consistent with other studies regarding classic RSII and modified RSII.

The majority of respondents reported using succinylcholine most frequently. Succinylcholine remains widely used when performing a classic RSII, 1 — 4 which is consistent with the results of a meta-analysis that reported that succinylcholine leads to better intubating conditions than rocuronium.

One limitation of our survey is a possible voluntary response bias. Because we could not control who, specifically, completed the surveys, it is possible that the data are not representative of all anesthesiologists. For example, a very busy physician who therefore opted out of the survey may have a different perspective than a less busy physician who did take the survey. Additionally, we did not survey any private practice anesthesiologists, making it difficult to generalize our results to all practicing anesthesiologists.

However, we received surveys from nearly half of all residency programs across the country and received almost completed instruments. Therefore, our results should be generalizable among teaching hospitals and recent residency program graduates across the United States. An additional limitation was that we used a paper-based survey and thus respondents may not have followed the instructions as stated, leading to inconsistent responses.

We attempted to rectify this by repeating the analysis on two increasingly restrictive subsets. Finally, we did not examine the frequency with which patients were given premedications, such as opioids or anxiolytics. Although these types of medications were not included in the original description of a classic RSII, their use appears to be increasingly common today. Based on our survey, we have been able to construct a meaningful definition of a modified RSII, which includes the use of oxygen administration, application of cricoid pressure, and an attempt to ventilate the lungs via positive pressure ventilation before securing the airway with a cuffed tracheal tube.

While oxygen administration and cricoid pressure application are also key parts of a classic RSII, positive pressure ventilation is unique to a modified RSII.

Having a standard definition and awareness of this key distinction between a classic and modified RSII will serve as a basis for future research to determine how to safely care for patients under circumstances where a modified RSII is indicated.

Specific modifications of the rapid sequence induction RSI procedure. R: A language and environment for statistical computing.

Ehrenfeld, M. Contribution : This author helped design the study, analyze the data, and write the manuscript. Attestation : This author has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Contribution : This author helped analyze the data and write the manuscript. Attestation : This author has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Contribution : This author performed the statistical analysis. Jesse M.

Eva A. Victoria E. Nathaniel D. Mercaldo, Vanderbilt University Medical Center. Warren S. National Center for Biotechnology Information , U. Anesth Analg. Author manuscript; available in PMC Jul 1. Ehrenfeld , M. Cassedy , B. Forbes , M. Mercaldo , M. Sandberg , M. Author information Copyright and License information Disclaimer. Corresponding Author: Jesse M. Copyright notice. The publisher's final edited version of this article is available at Anesth Analg.

See other articles in PMC that cite the published article. Abstract Background Rapid sequence induction and intubation RSII is a technique commonly used to resist regurgitation of gastric contents and protect the airway.

Methods A survey was created that queried the use and definition of modified RSII, and validated with test respondents. Introduction Rapid sequence induction and intubation RSII is a technique commonly used to protect the airway from aspiration of gastric contents by minimizing the likelihood of regurgitation during induction of anesthesia. Statistical Methods Respondent characteristics, RSII usage and reasons for using the modified RSII procedure were tabulated across the entire data set and by status resident versus attending.

Table 1 Respondent demographics and rapid sequence induction RSI usage by analysis subset. Open in a separate window. Table 2 Rapid sequence induction RSI usage and patient characteristics that warrant the modification of the RSI procedure by physician status. Table 3 Modifiable aspects of the rapid sequence induction RSI procedure.

Before the induction drug 0. Before administration of muscle relaxant 0. Supplementary Material Click here to view. Name: Eva A. Cassedy, B. Name: Victoria E. Forbes, M. Contribution : This author helped conduct the study.

A modification of this technique is implemented in certain clinical circumstances. However, there is currently no standard definition for a modified RSII. Therefore, we surveyed clinicians at academic centers across the United States to establish a working definition of a modified RSII as well as the clinical scenarios in which it is being used.

Methods: A survey was created that queried the use and definition of modified RSII, and validated with test respondents.

We then mailed the survey to all anesthesia residency training programs across the United States. Logistic regression models were created to estimate the percentage of affirmative responses among respondents that performed modified RSII procedures and answered survey items in a consistent manner.

Similar quantities were calculated by physician status resident and attending.