Rapid sequence

[waterbottle10]

We were taught that true rapid sequence is prop sux/1.2roc tube, without anything else. But why does it matter if we push other things in people with full stomachs during induction? If 2mg midaz or 250 fent goes in 1 second before propofol, and then sux, does it matter?

Then there are obvious RSI situations like someone who just ate a burger or someone who is nauseous and vomitted right before, or bowel obstructions or air bleeders. What about people who are getting surgery for a lap chole/appy and vomitted 12 hours prior but has been NPO and not nauseous or vomiting afterwards, do those people need RSI?

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[vector2]

No, it doesn't matter if you push versed or fent two seconds before the prop. It may matter if you give someone 250 of fent 5 minutes before induction and they get nauseated or have a level of consciousness depressed enough where their airway protection is no longer stellar.

I push paralytic immediately after induction agent for 99% of my cases anyway because I think testing ventilation is stupid and that even if you're going to test ventilation it's almost always easier to mask a paralyzed patient. But someone with a hot gallbladder or appy I would still lean towards RSI even if the pt says they're feeling fine. Ongoing abd pathology or peritoneal inflammation in general isn't great for GI motility so I see no reason to take any risks.

 

[anbuitachi]

I also think testing ventilation is stupid and always just push paralytic after induction agent

 

[Wiscoblue]

There are two reasons not to push versed or fentanyl prior to RSI

1. Both are known to reduce GE sphincter tone.

2. If you fail to intubate, presence of other drugs in the system will prolong time to wakefulness in case you’re planning an awake intubation next.

 

[dchz]

I also think testing ventilation is stupid and always just push paralytic after induction agent

+1

What happened 10 seconds later that makes his glottic opening no longer connected to his pharynx?

 

[dchz]

1. Both are known to reduce GE sphincter tone.

I thought opioids tighten GI smooth muscle tone? isn't it a documented side-effect of opioids?

Sphincter of Oddi constriction, etc...

 

[Planktonmd]

2. If you fail to intubate, presence of other drugs in the system will prolong time to wakefulness in case you’re planning an awake intubation next.

Exactly!
If you are anticipating trouble then follow the KISS principle!

 

[Planktonmd]

I thought opioids tighten GI smooth muscle tone? isn't it a documented side-effect of opioids?

Sphincter of Oddi constriction, etc...

Yeah you are right, I am not sure if that applies to the physiological GE sphincter (not a real anatomical one) ... but regardless, if you are doing a rapid sequence for a real indication then just give an induction agent + sux so if you fail you can wake the patient up and do something else.

 

[dchz]

Yeah you are right, I am not sure if that applies to the physiological GE sphincter (not a real anatomical one) ... but regardless, if you are doing a rapid sequence for a real indication then just give an induction agent + sux so if you fail you can wake the patient up and do something else.

Interesting point. To me, the most effective way to attenuate painful injection of propofol is 50mcg of fent 3 mins pre injection. There exists a subset of pts who might be apneic with 50mcg of fentanyl... I guess i have a dilemma if i want 100% of my pt to feel comfortable on propofol injection and don't believe in that lidocaine BS on RSI....

While we are at it, anyone wanna open the cricoid pressure debate?

 

[anbuitachi]

Interesting point. To me, the most effective way to attenuate painful injection of propofol is 50mcg of fent 3 mins pre injection. There exists a subset of pts who might be apneic with 50mcg of fentanyl... I guess i have a dilemma if i want 100% of my pt to feel comfortable on propofol injection and don't believe in that lidocaine BS on RSI....

While we are at it, anyone wanna open the cricoid pressure debate?

what is this lido BS that ive never heard of?

And cricoid pressure isn't really a debate i thought. doesn't do much

 

[dchz]

And cricoid pressure isn't really a debate i thought. doesn't do much

Out of curiosity, anyone say they don't do cricoid pressure on their oral boards?

 

[MirrorTodd]

what is this lido BS that ive never heard of?

And cricoid pressure isn't really a debate i thought. doesn't do much

It has both improved and worsened my view on several occasions.

 

[anbuitachi]

Out of curiosity, anyone say they don't do cricoid pressure on their oral boards?

if i get the question on my boards. im going to say i'll be doing cricoid pressure and applying 30 newtons of force

 

[OB1🤙]

I believe that cricoid pressure is effective in occluding the area of the upper esophageal sphincter when done correctly. There is actually a lot of evidence for this.

I believe there aren't very many indications for cricoid, but *elevated gastric pressure* IMO is one of them, SBO being the classic example.

Stomach legit full I think is also, but not the "I had a piece of toast 4 hours ago" kind of "full stomach".

I believe in positioning patients head up, so that gravity works to keep things in the stomach.

I also believe that improperly applied cricoid force decreases LES tone, and makes regurgitation more likely (there's evidence for this too). So if you do it, you gotta do it right, in a way that is occlusive.

Cliff's: there is actually evidence that cricoid force is effective in occluding the esophagus and preventing regurgitation. However, it's probably infrequently indicated, and if done incorrectly, can hurt more than help.

 

[neutro]

if i get the question on my boards. im going to say i'll be doing cricoid pressure and applying 30 newtons of force

lol

 

[OB1🤙]

"Test ventilation" is an antiquated practice that is more likely to cause harm than good.

Roc stings like hell though, worse than propofol, so I make sure they are starting to lose consciousness before I push it.

I use sux almost never outside of "true RSI" situations. Myalgias are awful. Also, now there's sugammadex so routine sux use is just plain mean IMO.

 

[OB1🤙]

I also very rarely mask ventilate anyone these days, to be honest. Push prop and roc, stand around for a few seconds, and DL.

Just don't see the need, usually.

So for the OP: in that case I would do what I almost always do: head up position, propofol chased by roc, no cricoid, don't mask, wait a few seconds, and go straight to DL.

 

[nimbus]

Reviews of cross sectional neck anatomy and cricoid-esophageal alignment. CP is probably effective in about half the cases.

Cricoid Pressure Displaces the Esophagus: An Observational Study Using Magnetic Resonance Imaging | Anesthesiology | ASA Publications

Alignment of cricoid cartilage and esophagus and its potential influence on the effectiveness of Sellick maneuver in children. - PubMed - NCBI

The cricoid cartilage and the esophagus are not aligned in close to half of adult patients. - PubMed - NCBI

 

[OB1🤙]

Actually, that's been refuted since.

Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant.

Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. - PubMed - NCBI

 

[OB1🤙]

There's also this- The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: an experimental and observational... - PubMed - NCBI

 

[pgg]

"Test ventilation" is an antiquated practice that is more likely to cause harm than good.

Roc stings like hell though, worse than propofol, so I make sure they are starting to lose consciousness before I push it.

I use sux almost never outside of "true RSI" situations. Myalgias are awful. Also, now there's sugammadex so routine sux use is just plain mean IMO.

Wish I could like this post twice.

 

[pgg]

Exactly!
If you are anticipating trouble then follow the KISS principle!

Well. If we are anticipating trouble, maybe we shouldn't be inducing and paralyzing in the first place.

Counting on a wakeup & wearoff of propofol & succ to restore spontaneous ventilation and save brain cells is a bad plan.

 

[Planktonmd]

Well. If we are anticipating trouble, maybe we shouldn't be inducing and paralyzing in the first place.

Counting on a wakeup & wearoff of propofol & succ to restore spontaneous ventilation and save brain cells is a bad plan.

Maybe it's a bad plan but you can certainly make it worse by adding sedatives and opiates.
Do you do awake inubations on all patients with questionable airway who need a rapid sequence?

 

[anbuitachi]

Actually, that's been refuted since.

Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant.

Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. - PubMed - NCBI

where are the papers refuting this? or is this now the consensus, cricoid on every full stomach?

 

[pgg]

Maybe it's a bad plan but you can certainly make it worse by adding sedatives and opiates.

I think we're splitting hairs again, as we often do , but a bad plan is a bad plan, and not doing something unnecessary to not make it worse doesn't bootstrap a bad plan into an OK plan. Sure you can make any bad plan worse by adding some extra polypharmacy, but why go there at all?

And for the record I think it's silly, and perhaps foolish, to give sedating drugs to a person who deserves an RSI prior to that RSI. There's no role for fentanyl in an RSI either; if it's hemodynamic blunting you want, esmolol is probably a better choice. So I am absolutely not arguing to add sedatives and opiates to an RSI.

Do you do awake inubations on all patients with questionable airway who need a rapid sequence?

Depends how questionable. I'm pretty confident that I can intubate, or at least ventilate (particularly with an LMA), just about all comers. So the pertinent question is more one of aspiration risk than hypoxic brain injury risk.

In any case, I'm never, ever confident that any induction drug I give in an RSI sized dose will wear off in time to save me from a can't intubate / can't ventilate situation.

The key words in your post were "anticipating trouble" ... if I am indeed "anticipating trouble" then yes, I do awake intubation.

 

[Globulinus]

Great question OP...
Observing residents and CRNA shows that there are a lot misconceptions...
RSI - is a fastest way to secure airway.
Hence:
1. Pre O2
2. Head up position
3. Induction agent of choice + sux or roc1.5mg/kg => ETT

NO Fent/Versed - pushing it during induction achieve nothing. Giving it 3-5 min before induction increase chances of regurgitation.
If blunting DL response would be a goal, Lido 1-2 min before induction, possibly will do it...I would choose rather Esmolol if blunting is such paramount importance.

Cricoid Pressure is dangerous maneuver that should be eliminated from practice completely. Never do it.
You can "simulate" it (i.e. place hand on neck, but not apply pressure) and chart, just for medico-legal reasons...
Hopefully it will go away soon. fcking bloodsucking lawyers is the only reason it is still in practice (

BURP maneuver is a different thing though.

 

[Globulinus]

There's also this- The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: an experimental and observational... - PubMed - NCBI

The best PRO/CON debate I ever heard on this topic is here



This SMACC debate made Hinds a legend...

 

[vector2]

Cricoid is dumb and I'm not convinced it does anything. Half the time I have to let off the cp anyway cause it's making the DL view worse.

 

[deleted697535]

What about a bit of alfentil or suf or remi anyone?

fentanyl is a neither here nor there drug that doesnt make a huge amount of sense.

If i was rsi'ing an eclamptic id defintely give suf

 

[narcusprince]

What about a bit of alfentil or suf or remi anyone?

fentanyl is a neither here nor there drug that doesnt make a huge amount of sense.

If i was rsi'ing an eclamptic id defintely give suf

Is that stuff ready to go in L and D? Give me esmolol and fentanyl. No need to get elegant. Having sufenta on L and D is a psr waiting to happen.

 

[Planktonmd]

The key words in your post were "anticipating trouble" ... if I am indeed "anticipating trouble" then yes, I do awake intubation.

It depends on how certain you are in your anticipation, I mean you could be anticipating with certainty and then you do awake intubation, but what if your anticipation lacks certainty or is a hesitant type of anticipation, wouldn't you consider just doing RSI and see what happens? I don't see why you would ... I mean I don't see why you wouldn't !

 

[vector2]

It depends on how certain you are in your anticipation, I mean you could be anticipating with certainty and then you do awake intubation, but what if your anticipation lacks certainty or is a hesitant type of anticipation, wouldn't you consider just doing RSI and see what happens? I don't see why you would ... I mean I don't see why you wouldn't !

Outside of laryngeal/pharyngeal/mediastinal masses, severe facial trauma, trismus, and radiation (clear awake FOI indications etc) I put everyone to sleep. Morbidly obese shortchin bullnecks are a dime a dozen in my neck of the woods, and I can remember just one instance in the last 5 years where a FOI + glidescope was needed because they were crazy anterior.

I'm pretty convinced that 99.9999% of the 'does not clearly need awake FOI' population can be intubated with a glidescope 3/4 or cmac d-blade +- quality moldable eschmann prn.

 

[T-burglar]

Outside of laryngeal/pharyngeal/mediastinal masses, severe facial trauma, trismus, and radiation (clear awake FOI indications etc) I put everyone to sleep. Morbidly obese shortchin bullnecks are a dime a dozen in my neck of the woods, and I can remember just one instance in the last 5 years where a FOI + glidescope was needed because they were crazy anterior.

I'm pretty convinced that 99.9999% of the 'does not clearly need awake FOI' population can be intubated with a glidescope 3/4 or cmac d-blade +- quality moldable eschmann prn.

I’ll do you one further and say that 99.9 % of the population requires nothing more than a mil 2 and a bougie. I put everyone to sleep that I believe I can mask ventilate, which is just about everyone. I’m in a community private practice which still sees SOME complicated ENT but probably not as much as the university. I don’t miss that patient population to be honest - I’d rather do cardiac structural thoracic and vascular all day. Let the nightmare airways all go to a place with 24hr in house thoracic ENT ECMO coverage.

 

[narcusprince]

Ths glidescope and fiber can intubate 99.99999% of patients barring structural collapsing masses. Why hasnt someone invented a flexible bougie for the glidescope that you can manuver like a foi scope without the foi cables?

 

[Psai]

Ths glidescope and fiber can intubate 99.99999% of patients barring structural collapsing masses. Why hasnt someone invented a flexible bougie for the glidescope that you can manuver like a foi scope without the foi cables?

Be the change you want to see in the world

 

[propadope]

Ths glidescope and fiber can intubate 99.99999% of patients barring structural collapsing masses. Why hasnt someone invented a flexible bougie for the glidescope that you can manuver like a foi scope without the foi cables?

Parker Medical | Parker Intubating Stylets

Something like this?

 

[fakin' the funk]

There are two reasons not to push versed or fentanyl prior to RSI

1. Both are known to reduce GE sphincter tone.

2. If you fail to intubate, presence of other drugs in the system will prolong time to wakefulness in case you’re planning an awake intubation next.

If you think an awake intubation night be necessary, you shouldn't RSI.

 

[fakin' the funk]

"Test ventilation" is an antiquated practice that is more likely to cause harm than good.

Can't agree more.

I see people test ventilating full stomachs, and test ventilating known easy DLs from *LIKE LAST WEEK*. Never heard anyone offer a cogent defense of test ventilation, yet most (still) do it.

 

[fakin' the funk]

Why hasnt someone invented a flexible bougie for the glidescope that you can manuver like a foi scope without the foi cables?

The normal bougie doesn't hold shape THAT well, just well enough to bend it for a Glidescope and I have used it to bail out a few airways that way

 

[Wiscoblue]

If you think an awake intubation night be necessary, you shouldn't RSI.

What if thought you could and now you can’t?

 

[fakin' the funk]

What if thought you could and now you can’t?

Then your thinking on the matter was quite misguided, wasn't it?

I'm only being somewhat obtuse. *IMPOSSIBLE* intubation with DL, Glidescope, Bougie (the 3 pretty-damn-quick options) is EXCEEDINGLY rare, absent OBVIOUS anatomic airway abnormalities. If such abnormalities are present, AFOI. If they're not, RSI. This isn't that hard.

That said, I usually DON'T give midazolam or fentanyl to RSI type patients because I don't want them medium-sedated, and at risk for passive regurgitation while we're positioning and preoxygenating etc, for minimal benefit. There are better ways to control hemodynamics than fentanyl, and anxiolysis/amnesia is usually unnecessary.

 

[DrZzZz]

Had an NPO patient who was nauseous in preop, refused pretreatment other than zofran. Sure enough, right before I pushed any meds to induce, patient puked all over. After cleaning up, inducing, and tubing, I asked the nurse in the room..."yea I gave her versed and fentanyl on the way back." We had already discussed her nausea and the RSI plan earlier. As a new attending, lesson learned that I need to be a little more explicit with my instructions (ie no premed).

 

[Twiggidy]

Had an NPO patient who was nauseous in preop, refused pretreatment other than zofran. Sure enough, right before I pushed any meds to induce, patient puked all over. After cleaning up, inducing, and tubing, I asked the nurse in the room..."yea I gave her versed and fentanyl on the way back." We had already discussed her nausea and the RSI plan earlier. As a new attending, lesson learned that I need to be a little more explicit with my instructions (ie no premed).

Yes, with nurses you have to be 1000% clear because most are just creatures of habit

 

[pgg]

I've been to an M&M where a patient aspirated after being induced (essentially) with 1 mg of midazolam in holding.

Sick and old people don't need benzos. They just don't. I think midazolam is by far the most overused drug in our realm.

 

[anbuitachi]

Had an NPO patient who was nauseous in preop, refused pretreatment other than zofran. Sure enough, right before I pushed any meds to induce, patient puked all over. After cleaning up, inducing, and tubing, I asked the nurse in the room..."yea I gave her versed and fentanyl on the way back." We had already discussed her nausea and the RSI plan earlier. As a new attending, lesson learned that I need to be a little more explicit with my instructions (ie no premed).

man i wouldve lost my ****. how does the nurse not know what RSI means. giving versed and fentanyl on way to OR is the opposite of RSI