RSI or not?

[dhb]

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Last time on call we get a 40 y/o female with an appy htx of htn 200 lbs. It's 3 pm ate last time the night before looks fine but vomited at noon.
Do you go with a rsi or not (i know the academic answer) we didn't have a cholinesterase level would you use sux?
We went with roc 0.9mg/kg which lasted 90min before we could reverse...

thoughts?

 

[Planktonmd]

Last time on call we get a 40 y/o female with an appy htx of htn 200 lbs. It's 3 pm ate last time the night before looks fine but vomited at noon.
Do you go with a rsi or not (i know the academic answer) we didn't have a cholinesterase level would you use sux?
We went with roc 0.9mg/kg which lasted 90min before we could reverse...

thoughts?

RSI, Propofol, Sux, Tube.
An acute appendicitis is an intra abdominal infection that most likely will cause a certain degree of ileus, and if she vomits on induction and aspirates there will be many volunteers that will love to testify against you if you did not do RSI.
When did we start requiring cholinesterase level to use Sux? are you serious?

 

[militarymd]

so do you guys hold cricoid UNTIL the OG tube is in when you do RSI's???

 

[Trisomy13]

i would say cricoid until the cuff is inflated.

for what it's worth, i'm convinced cricoid is a crock, even if it is standard of care.

if i suggested getting a cholinesterase level, someone would smack me. probably the janitor. try this sometime - tell the ortho resident you're waiting on an IL-6 level to assess the level of soft tissue injury before green-lighting a femur fracture.

 

[proman]

RSI with sux, cricoid until cuff up and placement confirmed.

 

[goodoc]

crichoid,propofol sux, tube,move on.

 

[Noyac]

I'm still waiting to here why you want a cholinesterase level.

 

[DrDre']

I'm still waiting to here why you want a cholinesterase level.

Even those "evil" 🙂 academicians would laugh at this where I am!

Anyone who is belly full, severe pain, opioids or abd pathology is RSI (anything that fills the belly or delays emptying). I think that this goes for me after leaving the confines of academia, too.

 

[militarymd]

for those of you who say cricoid until cuff up.....do you realize that the cuff doesn't prevent aspiration.....ask any intensivist....that's when special ETT with supra cuff aspirators is recommended for patients who will be tubed for a while.


Cuffs may prevent LARGE volume aspiration, but it does NOT prevent liquid acid from seeping into the lungs...

And when was the last time that stuff came streaming up into the pharynx AFTER you release cricoid?

 

[Noyac]

for those of you who say cricoid until cuff up.....do you realize that the cuff doesn't prevent aspiration.....ask any intensivist....that's when special ETT with supra cuff aspirators is recommended for patients who will be tubed for a while.


Cuffs may prevent LARGE volume aspiration, but it does NOT prevent liquid acid from seeping into the lungs...

And when was the last time that stuff came streaming up into the pharynx AFTER you release cricoid?

So how would we know if this was occurring?

 

[dhb]

I'm still waiting to here why you want a cholinesterase level.

I didn't want one the attending did... i suppose that since we use sux very rarely people are more afraid of a cholinesterase deficiency.

Cricoid pressure is bogus, it has been debated before. MRI studies have shown you don't compress the esophagus 50% of the time but displace it laterally.

 

[militarymd]

So how would we know if this was occurring?

There would be stuff in the mouth after you release Cricoid....which you almost never see except in sbo.

If one insists on using cricoid, then I would submit that cricoid pressure needs to be applied until the OG tube is placed.

 

[Planktonmd]

I didn't want one the attending did... i suppose that since we use sux very rarely people are more afraid of a cholinesterase deficiency.

Cricoid pressure is bogus, it has been debated before. MRI studies have shown you don't compress the esophagus 50% of the time but displace it laterally.

Sux remains an irreplaceable drug and training programs should not scare the residents of using it when there is no clear contraindication.
Cricoid pressure might be "bogus" but it is the standard of care and there were several law suits that involved aspiration where cricoid pressure was the main argument.

 

[militarymd]

Sux remains an irreplaceable drug and training programs should not scare the residents of using it when there is no clear contraindication.
Cricoid pressure might be "bogus" but it is the standard of care and there were several law suits that involved aspiration where cricoid pressure was the main argument.

That's because people remain uneducated.

 

[Planktonmd]

That's because people remain uneducated.

Correct!
But uneducated people (the majority) decide what the standard of care should be.

 

[drccw]

Last time on call we get a 40 y/o female with an appy htx of htn 200 lbs. It's 3 pm ate last time the night before looks fine but vomited at noon.
Do you go with a rsi or not (i know the academic answer) we didn't have a cholinesterase level would you use sux?
We went with roc 0.9mg/kg which lasted 90min before we could reverse...

thoughts?

Wait, I am having trouble figuring out the academic answer... if it really is the academic answer to not use sux than do not listen to anything that attending is telling you.......

Does he or she get a halothan-caffeeine test before turning on the sevo?

All acute appys get RSI's... no question... if you arent going to do a RSI then why not slap a LMA in...

 

[Noyac]

There would be stuff in the mouth after you release Cricoid....which you almost never see except in sbo.

If one insists on using cricoid, then I would submit that cricoid pressure needs to be applied until the OG tube is placed.

Obviously my question was rhetorical.

And since we (I) never see any signs or symptoms of this gastric content entering the trachea after intubation why are we talking about holding cricoid for even longer. How many times do you suction at the end of a case and get a fairly large amount of secretions from around the tube and epiglottis? Does this ever cause a problem? Rarely. I know that the cuff does not prevent seepage around the creases but that seepage does not seem to have any adverse effects, or am I wrong? The cases usually are not long enough for this to cause problems. Its the ones that are i the ICU for days that end up with the pulmonary problems.

So, as long as the cuff is up you can release cricoid pressure.

BTW, in my residency we did a lit search on cricoid pressure. It was pretty well shown by the available literature then that cricoid was useless unless applied correctly which not only was placement of the hand but also the amount of pressure used. It was determined that the correct force was approx'ly 20 lbs pressure. Anything less did not occlude the esophagus completely and anything more pushed the esophagus laterally therefore, not occluding as well.

I think that the main reason cricoid is still used is b/c when supervising a resident or crna the attending wants to feel the cuff inflate to assure him/herself that the tube is in the right place.

 

[Noyac]

I didn't want one the attending did... i suppose that since we use sux very rarely people are more afraid of a cholinesterase deficiency.

This is ridiculous! 😱

Have you ever seen it? I've seen a handful only.

Most people know if they have it. Even if they are surgical virgins, their family history gives you a clue. Tell your attending to stop being wasteful/obstructionistic and do his/her job. Or was your attending trying to get out of the case by ordering something that would delay the case enough to get someone else to do it?

And what happens if you give sux to one of these pts? Its not the end of the world. They don't go to the ICU on pressors. Its not like MH. You keep them asleep in the pacu till it wears off. Problem solved.

 

[militarymd]

Obviously my question was rhetorical.

And since we (I) never see any signs or symptoms of this gastric content entering the trachea after intubation why are we talking about holding cricoid for even longer. How many times do you suction at the end of a case and get a fairly large amount of secretions from around the tube and epiglottis? Does this ever cause a problem? Rarely. I know that the cuff does not prevent seepage around the creases but that seepage does not seem to have any adverse effects, or am I wrong? The cases usually are not long enough for this to cause problems. Its the ones that are i the ICU for days that end up with the pulmonary problems.

So, as long as the cuff is up you can release cricoid pressure.

BTW, in my residency we did a lit search on cricoid pressure. It was pretty well shown by the available literature then that cricoid was useless unless applied correctly which not only was placement of the hand but also the amount of pressure used. It was determined that the correct force was approx'ly 20 lbs pressure. Anything less did not occlude the esophagus completely and anything more pushed the esophagus laterally therefore, not occluding as well.

I think that the main reason cricoid is still used is b/c when supervising a resident or crna the attending wants to feel the cuff inflate to assure him/herself that the tube is in the right place.

it is 20 Newtons.

and that's my point....even without Cricoid for the duration of the case, there's nothing coming up...then why are we worrying about the few minutes at most when we are intubating....

My point...If you are REALLY worried about those few minutes, then you should worry a couple of minutes more....until the OG is in.

 

[Noyac]

it is 20 Newtons.

Newtons, YES

I'm just surprised that I remembered "20".

 

[Planktonmd]

it is 20 Newtons.

and that's my point....even without Cricoid for the duration of the case, there's nothing coming up...then why are we worrying about the few minutes at most when we are intubating....

My point...If you are REALLY worried about those few minutes, then you should worry a couple of minutes more....until the OG is in.

So if your cricoid is effective (20 Newtons) 🙂 How on earth are you going to pass the OG tube through the presumably compressed esophagus??

 

[militarymd]

So if your cricoid is effective (20 Newtons) 🙂 How on earth are you going to pass the OG tube through the presumably compressed esophagus??

You release pressure as the tube passes

 

[Trisomy13]

20 Newtons is like a Randy Savage flying elbow drop.

"You may feel some pressure on your neck while you drift off to sleep, sir. Snap into a Slim Jim!"

 

[OB1🤙]

20 Newtons is like a Randy Savage flying elbow drop.

"You may feel some pressure on your neck while you drift off to sleep, sir. Snap into a Slim Jim!"

I lol'ed.

 

[Trisomy13]

20 Newtons is like a Randy Savage flying elbow drop.

"You may feel some pressure on your neck while you drift off to sleep, sir. Snap into a Slim Jim!"

or more realistically, it's about the weight of 2kg or 4.4lbs as affected by the earth's gravity, which is still quite a bit more than you will get if you ask a scrub tech to hold cricoid while you intubate. certainly enough to make a person cough if they are not anesthetized enough. try resting a 5 lb bag of sugar on your throat.

 

[Jeff05]

your attending is poorly informed.

an Achase deficiency is exceedingly rare (1/3000 comes to mind). and even if she does have it and you give her sux - is that going to kill her? No. Damage her permanently? No. You will just keep her intubated for 8 hours in the PACU with some fentanyl/versed and extubate when she's strong.

the question isn't RSI or not. It IS RSI. decompression of stomach with NG prior to induction is controversial.

1. IV in holding. Metoclopramide 10mg, Glyco 0.2mg (obese women are juicy), famotidinge 20 mg IV. all about 30 min prior to induction.
2. bicitra within 30 min of induction
3. ramp and slight head up on table.
4. RSI with cricoid (ok so it doesn't work all the time and may even make your view worse, but cricoid...)
5. cuff up - ALL the way, nice and tight until stomach suctioned.
6. OGT to suction. keep head slightly for duration of case.
7. extubate awake.

 

[quaker1996]

Newtons, YES

I'm just surprised that I remembered "20".

I thought it was 44 newtons (8-9 lb pressure)??


[SIZE=-1]bja.oxfordjournals.org/cgi/reprint/58/12/1376.pdf
[/SIZE][SIZE=-1]bja.oxfordjournals.org/cgi/reprint/77/4/468.pdf[/SIZE]

 

[Noyac]

I thought it was 44 newtons (8-9 lb pressure)??


[SIZE=-1]bja.oxfordjournals.org/cgi/reprint/58/12/1376.pdf
[/SIZE][SIZE=-1]bja.oxfordjournals.org/cgi/reprint/77/4/468.pdf[/SIZE]

Awh ****. Now I'm confused again.

 

[dhb]

So what i wanted to get to was: would anyone do a standard induction in this type of patient. What is the rational behind the RSI thing?

I spent a little time searching this and i haven't come up with something conclusive: the idea is that gastric tone is around 25mmHg so to avoid regurgitation you should apply a sufficient counter force on the cricoid... But i don't know of any randomized trial addressing the RSI problem.

If you read these articles you'll see that the incidence of aspiration is pretty low and that morbidity/mortality is very low:
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Cricoid pressure.Brimacombe JR, Berry AM.
Department of Anaesthesia and Intensive Care, University of Queensland, Cairns Base Hospital, Australia.

PURPOSE: Although cricoid pressure (CP) is a superficially simple and appropriate mechanical method to protect the patient from regurgitation and gastric insufflation, in practice it is a complex manoeuvre which is difficult to perform optimally. The purpose of this review is to examine and evaluate studies on the application of (CP). It deals with anatomical and physiological considerations, techniques employed, safety and efficacy issues and the impact of CP on airway management with special mention of the laryngeal mask airway. SOURCE OF MATERIAL: Three medical databases (48 Hours, Medline, and Reference Manager Update) were searched for citations containing key words, subject headings and text entries on CP to October 1996. PRINCIPLE FINDINGS: There have been no studies proving that CP is beneficial, yet there is evidence that it is often ineffective and that it may increase the risk of failed intubation and regurgitation. After evaluation of all available data, potential guidelines are suggested for optimal use of CP in routine and complex situations. CONCLUSIONS: If CP is to remain standard practice during induction of anaesthesia, it must be shown to be safe and effective. Meanwhile, further understanding of its advantages and limitations, improved training in its use, and guidelines on optimal force and method of application should lead to better patient care.



Emergent procedures carry a higher risk but how much of it is due to the way the airway are managed: cricoid pressure, attempting to tube the patient to fast with the patient not deep enough...? (+ patient / operator stress).

EBM, outcome...??

 

[Planktonmd]

The issue is: how do you design a study to prove that cricoid pressure is not needed in cases with high aspiration risk?
Think about it:
We take 500 patients with bowel obstruction and apply cricoid pressure to 250 and no cricoid to 250 then see if the aspiration incidence is equal in both groups.
If your mother was included in the no cricoid group would that be OK for you?

Dr. Brian Sellick was a great anesthesiologist and was able to convince the world to adopt his idea more than 50 years ago, he actually demonstrated on X rays with contrast that his cricoid pressure did work if applied correctly.
Here is some history:
http://www.asahq.org/Newsletters/1999/09_99/sellick0999.html

 

[militarymd]

The issue is: how do you design a study to prove that cricoid pressure is not needed in cases with high aspiration risk?
Think about it:
We take 500 patients with bowel obstruction and apply cricoid pressure to 250 and no cricoid to 250 then see if the aspiration incidence is equal in both groups.
If your mother was included in the no cricoid group would that be OK for you?

Dr. Brian Sellick was a great anesthesiologist and was able to convince the world to adopt his idea more than 50 years ago, he actually demonstrated on X rays with contrast that his cricoid pressure did work if applied correctly.
Here is some history:
http://www.asahq.org/Newsletters/1999/09_99/sellick0999.html

50 years ago, people were convinced that it was a good idea to keep colored folks in the back of the bus and have their own schools.

50 years ago, doctors were on TV commercials advertising for tobacco companies.....

ohhh...I could go on and on and on about what other things people where convinced about 50 years ago.

 

[militarymd]

The issue is: how do you design a study to prove that cricoid pressure is not needed in cases with high aspiration risk?
Think about it:
We take 500 patients with bowel obstruction and apply cricoid pressure to 250 and no cricoid to 250 then see if the aspiration incidence is equal in both groups.
If your mother was included in the no cricoid group would that be OK for you?

Dr. Brian Sellick was a great anesthesiologist and was able to convince the world to adopt his idea more than 50 years ago, he actually demonstrated on X rays with contrast that his cricoid pressure did work if applied correctly.
Here is some history:
http://www.asahq.org/Newsletters/1999/09_99/sellick0999.html

You start with an animal model....there is a well described porcine peritoneal sepsis model......

would be EASY to study something like this in an animal model....

 

[militarymd]

The issue is: how do you design a study to prove that cricoid pressure is not needed in cases with high aspiration risk?
Think about it:
We take 500 patients with bowel obstruction and apply cricoid pressure to 250 and no cricoid to 250 then see if the aspiration incidence is equal in both groups.
If your mother was included in the no cricoid group would that be OK for you?

Dr. Brian Sellick was a great anesthesiologist and was able to convince the world to adopt his idea more than 50 years ago, he actually demonstrated on X rays with contrast that his cricoid pressure did work if applied correctly.
Here is some history:
http://www.asahq.org/Newsletters/1999/09_99/sellick0999.html

I thought he used cadavers.

 

[Laryngospasm]

I get an cholineesterase level before every RSI, its standard of care.

 

[dhb]

Dr. Brian Sellick was a great anesthesiologist and was able to convince the world to adopt his idea more than 50 years ago, he actually demonstrated on X rays with contrast that his cricoid pressure did work if applied correctly.
Here is some history:
http://www.asahq.org/Newsletters/1999/09_99/sellick0999.html

more up-to date:
Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT.
Department of Anesthesia, St. Joseph's Healthcare and McMaster University, Hamilton, Ontario, Canada. [email protected]

BACKGROUND: Cricoid pressure (CP) is often used during general anesthesia induction to prevent passive regurgitation of gastric contents. The authors used magnetic resonance imaging to determine the anatomic relationship between the esophagus and the cricoid cartilage ("cricoid") with and without CP. METHODS: Magnetic resonance images of the necks of 22 healthy volunteers were reviewed with and without CP. Esophageal and airway dimensions, distance between the midline of the vertebral body and the midline of the esophagus, and distance between the lateral border of the cricoid or vertebral body and the lateral border of the esophagus were measured. RESULTS: The esophagus was displaced laterally relative to the cricoid in 52.6% of necks without CP and 90.5% with CP. CP shifted the esophagus relative to its initial position to the left in 68.4% of subjects and to the right in 21.1% of subjects. Unopposed esophagus was seen in 47.4% of necks without CP and 71.4% with CP. Lateral laryngeal displacement and airway compression were demonstrated in 66.7% and 81.0% of necks, respectively, as a result of CP. CONCLUSION: In the absence of CP, the esophagus was lateral to the cricoid in more than 50% of the sample. CP further displaced both the esophagus and the larynx laterally.

 

[Planktonmd]

more up-to date:
Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT.
Department of Anesthesia, St. Joseph's Healthcare and McMaster University, Hamilton, Ontario, Canada. [email protected]

BACKGROUND: Cricoid pressure (CP) is often used during general anesthesia induction to prevent passive regurgitation of gastric contents. The authors used magnetic resonance imaging to determine the anatomic relationship between the esophagus and the cricoid cartilage ("cricoid") with and without CP. METHODS: Magnetic resonance images of the necks of 22 healthy volunteers were reviewed with and without CP. Esophageal and airway dimensions, distance between the midline of the vertebral body and the midline of the esophagus, and distance between the lateral border of the cricoid or vertebral body and the lateral border of the esophagus were measured. RESULTS: The esophagus was displaced laterally relative to the cricoid in 52.6% of necks without CP and 90.5% with CP. CP shifted the esophagus relative to its initial position to the left in 68.4% of subjects and to the right in 21.1% of subjects. Unopposed esophagus was seen in 47.4% of necks without CP and 71.4% with CP. Lateral laryngeal displacement and airway compression were demonstrated in 66.7% and 81.0% of necks, respectively, as a result of CP. CONCLUSION: In the absence of CP, the esophagus was lateral to the cricoid in more than 50% of the sample. CP further displaced both the esophagus and the larynx laterally.

You did not answer my hypothetical question though:
Would you want your mother to be included in the study and be one of the patients who does not get cricoid pressure during induction for bowel obstruction?
That question applies to MMD as well.

 

[Planktonmd]

I get an cholineesterase level before every RSI, its standard of care.

Really!
Who's standard of care?
Let's say you get a ruptured AAA patient who collapsed at McDonald's while he was eating his third Big Mac, would you send a cholinesterase level and wait for the results before you put him to sleep?

 

[Intubate]

I get an cholineesterase level before every RSI, its standard of care.

I hope this is a joke.

However, I do get a muscle biopsy before administering volatiles. I also get cardiac caths on kids before doing ear tubes to make sure they don't have CAD.

 

[militarymd]

You did not answer my hypothetical question though:
Would you want your mother to be included in the study and be one of the patients who does not get cricoid pressure during induction for bowel obstruction?
That question applies to MMD as well.

I said that it would be easy to develop an animal model...and if the animal model is supportive, then I would have NO problems including me and any member of my family into the randomization process.....

But, isn't this why we have Medicaid patients, and prisoners for?

 

[Planktonmd]

But, isn't this why we have Medicaid patients, and prisoners for?

😱

 

[DrDre']

Watch, he'll say he meant to have a smiley face there!


Our favorite bigoted, chauvinist brilliant anesthesiologist/MBA

I said that it would be easy to develop an animal model...and if the animal model is supportive, then I would have NO problems including me and any member of my family into the randomization process.....

But, isn't this why we have Medicaid patients, and prisoners for?

 

[militarymd]

Watch, he'll say he meant to have a smiley face there!


Our favorite bigoted, chauvinist brilliant anesthesiologist/MBA

here's your smiley

 

[DrDre']

Well, whether sexist or not, I have to admit that I really liked your smiley this time.

here's your smiley

 

[dhb]

You did not answer my hypothetical question though:
Would you want your mother to be included in the study and be one of the patients who does not get cricoid pressure during induction for bowel obstruction?

YES

show me some good evidence otherwise, i haven't found any...

 

[Planktonmd]

YES

show me some good evidence otherwise, i havn't found any...

You must be really convinced that cricoid pressure is ineffective that you are willing to bet your mother's life on this belief!
I wish I could feel this strongly about anything in anesthesia.
The literature against cricoid pressure is not outcome based, for example that study you mentioned is about the anatomical changes caused by cricoid pressure seen on MRI, it does not address weather or not cricoid pressure decreases the risk of aspiration.
On the other hand cricoid pressure has been around for 50 years and during that same period we witnessed dramatic decrease of the incidence of aspiration related morbidity and mortality after GA, So we must have been doing something right, could that be RSI? could it be cricoid pressure? could it be both or neither one?
I don't know and I don't think you do.
So until we actually know we probably shouldn't change the way we practice.

 

[dhb]

You must be really convinced that cricoid pressure is ineffective that you are willing to bet your mother's life on this belief!

From the information available yes i'm convinced which doesn't mean i won't change if presented conclusive data. If you look at the mortality rate from the studies it's a pretty safe bet...

The literature against cricoid pressure is not outcome based

Neither is the one in favor

On the other hand cricoid pressure has been around for 50 years and during that same period we witnessed dramatic decrease of the incidence of aspiration related morbidity and mortality after GA, So we must have been doing something right, could that be RSI? could it be cricoid pressure? could it be both or neither one?

Drugs used in anesthesia have changed dramatically in 50y (not to mention antibiotics)

I don't know and I don't think you do.

No i don't

So until we actually know we probably shouldn't change the way we practice.

Or maybe we should 😀

 

[dhb]

I'm surprised no one wants to engage in this debate.

More food for thought:
" Can J Anaesth. 2007 Sep;54(9):748-64. Links
No evidence for decreased incidence of aspiration after rapid sequence induction.Neilipovitz DT, Crosby ET.
Department of Anesthesiology, The Ottawa Hospital and the University of Ottawa, Ontario K1Y 4E9, Canada. [email protected]

PURPOSE: The purpose of this structured, evidence-based, clinical update was to determine if rapid sequence induction is a safe or effective technique to decrease the risk of aspiration or other complications of airway management. SOURCE: In June 2006 a structured search of MEDLINE from 1966 to present using OVID software was undertaken with the assistance of a reference librarian. Medical subject headings and text words describing rapid sequence induction or intubation (RSI), crash induction or intubation, cricoid pressure and emergency airway intubation were employed. OVID's therapy (sensitivity) algorithm was used to maximize the detection of randomized trials while excluding non-randomized research. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search. PRINCIPAL FINDINGS: A total of 184 clinical trials were identified of which 163 were randomized controlled trials (RCTs). Of these clinical trials, 126 evaluated different drug regimens with 114 being RCTs. Only 21 clinical trials evaluated non-pharmacologic aspects of the RSI with 18 RCTs identified. A parallel search found 52 trials evaluating cricoid pressure (outside of the context of an RSI technique) with 44 classified as RCTs. Definitive outcomes such as prevention of aspiration and mortality benefit could not be evaluated from the trials. Likewise, the impact on adverse outcomes of the different components of RSI could not be ascertained. CONCLUSION: An absence of evidence from RCTs suggests that the decision to use RSI during management can neither be supported nor discouraged on the basis of quality evidence."

The more i look into this the more i believe RSI to prevent aspiration is DOGMA and that rushing to shove a tube down someone's throat while apply pressure on their neck is what is causing regurgitation and eventually aspiration.

 

[Planktonmd]

I'm surprised no one wants to engage in this debate.
The more i look into this the more i believe RSI to prevent aspiration is DOGMA and that rushing to shove a tube down someone's throat while apply pressure on their neck is what is causing regurgitation and eventually aspiration.

Good,
I think you should not do RSI and cricoid pressure anymore and that you should make a point of documenting on each anesthesia record that you don't agree with this practice and refuse to do it.
👍

 

[goodoc]

It may be dogma, or in fact it may help, I have not seen any evidence that it hurts the patient so I think I will err on the side of caution and continue to use RSI.

 

[dhb]

Good, you should document that you don't adapt your practice to the clinically relevant literature 👍