Controlled Rapid Sequence Induction and Intubation in Children

Walid Habre, MD, PhDAnesthesiological Investigations Unit

& Pediatric Anesthesia Unit Geneva University Children’s Hospital

www.walidhabre.org

I have no COI to disclose

What is the problem?

The Goal of RSI is to quickly and effectively perform laryngoscopy andtracheal intubation in order to protect the airways in children with alterationin airway reflexes, delayed gastric emptying with presumably full stomach

Minimize the risk of aspiration

PreoxygenationHypnotic + myorelaxant

Apnea 30 sec to 1 min

Trachealintubation

Cricoid pressure

Rapid sequence induction=

a single equation with several factors to consider

Preoxygenation-OxygenationCricoid PressurePulmonary aspiration

Limitations of classical rapid sequence induction in children:

! Limited cooperation during pre-oxygenation! Reduced respiratory oxygen reserves! Increased oxygen demand ! Tendency for airway collapse

Hypoxemia

Hardman, J. G. et al. Br. J. Anaesth. 2006 97:564-570

Time to hemoglobin desaturation is depending on FRC

Hypoxia will occur much quicker in neonates and infants

Age No preO2 1 min preO2 3 min preO2Early Late Total Early Late Total Early Late Total

Closed airway1 month 0.25 1.40 1.65 1.58 1.64 3.22 1.90 1.69 3.591 yr 0.36 1.48 1.84 2.26 1.63 3.89 2.85 1.60 4.458 yr 0.47 1.47 1.94 3.14 1.51 4.65 3.91 1.52 5.4318 yr 0.74 1.72 2.46 5.11 1.62 6.73 6.54 1.56 8.1

Open airway1 month 0.30 1.68 1.98 1.97 2.07 4.04 2.45 2.32 4.771 yr 0.40 1.69 2.09 2.78 2.08 4.86 3.75 2.31 6.068 yr 0.51 1.65 2.16 3.93 1.98 5.91 5.39 2.01 7.418 yr 0.82 1.91 2.73 6.32 2.09 8.41 8.4 2.20 10.6

Hardman, J. G. et al. Br. J. Anaesth. 2006 97:564-570

Minutes from start of apnea to 90% (early), from 90 to 40% (late) and from start of apnea to 40% (total)

Cricoid pressure: A ritual ? or an effective measure in children ?

Limitations of cricoid pressure in children

ANATOMICALSmaller size of the cricoid cartilageBackward inclination of the posterior lamina,Higher position in the neck

Ineffective exerted pressure

Appropriate force for the application of cricoid pressureInterference with smooth induction: bucking and strainingInterference with laryngoscope insertion

MECHANICAL

Distortion and occlusion of the airway

Difficult mask ventilation, laryngoscopy and tracheal intubation

Walker RW et al. Br J Anaesth 2010; 104, 71-74

Cricoid pressure leads to significant compression/distortion of the airways in children

2Rice, M et al. Anesth Analg 2009; 109:1546-1552

Cricoid Pressure Results in Compression of the Postcricoid HypopharynxThe Esophageal Position Is Irrelevant

Postcricoid hypopharynx compression lateral to the vertebral body with cricoid pressure

Imaging at 2 cm inferior to the cricoid ring distinctly showing the cervical esophagus

Postcricoid hypopharynx

Smith KJ et al. Anesthes. 2003;99(1):60-64.

Cricoid Pressure Displaces the Esophagus

MRI without CP Displacement of the airwaysrelative to the midline of the vertebral bodyin 33.3% of subjects without CP 66% of subjects with CP.

MRI with CP in samesubject

Anesthesiology 2017;126(4):738-752modified from Salem MR et al. Anesthesiology 2008; 109:806–10

Cricoid pressure leads to decrease in lower esophageal sphincter pressure

There is currently no information available from published RCTs on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI in the context of endotracheal intubation. On the basis of the findings of non-RCTliterature, however, cricoid pressure may not be necessary to undertake RSI safely, and therefore well-designed and conducted RCTs should nonetheless be encouraged to properly assess the safety and effectiveness of cricoid pressure.

Cochrane Database Syst Rev. 2015 Nov 18;(11):CD011656.

Inclusion criteria:- Patients 18 years and older with a full stomach (<6 hours fasting) - or the presence of at least 1 risk factor for pulmonary aspiration:

- emergency conditions- body mass index >30 - previous gastric surgery [sleeve, bypass, or gastrectomy]- ileus, - early [<48 hours] postpartum,- diabetic gastroparesia, - gastroesophageal reflux, - hiatus hernia, - preoperative nausea/vomiting- pain

Birenbaum A et al. JAMA Surg 2019; 154: 9-17

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: IRIS

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: IRIS

Birenbaum A et al. JAMA Surg 2019; 154: 9-17

Preoxygenation (FEO2 >90%)

Induction of anesthesia (propofol or thiopental or etomidate or ketamine)

succinylcholine (1 mg/kg)

Birenbaum A et al. JAMA Surg 2019; 154: 9-17

IRIS – RCT – non inferiority study

Primary outcome:

Pulmonary aspiration

IRIS – RCT: Incidence of pulmonary aspiration

Birenbaum A et al. JAMA Surg 2019; 154: 9-17

Sham procedure was considered noninferior to the cricoid pressure if the incidence of pulmonaryaspiration was not more than 50% higher (relative risk of 1.5)A difference of less than 50%was considered clinically negligible

Differences in intubation time and laryngoscopicexposure suggesting more difficulties in the Sellick group

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children

NEAR4KIDS*

Regurgitation: 35/1’819 (1.9%) with cricoid pressure71/6’006 (1.2%) without cricoid pressure

Unadjusted OR: 1.64; 95% CI, 1.09–2.47

Adjusted

Kojima T et al. Pediatr Crit Care Med 2018;19: 528-537.

Incidence of perioperative pulmonary aspiration2-10/10’000 anesthetics

N patients

APRICOT

31’127

Paris

24’165

L-A

30’695

N-Y

47’272

Mayo

63’180

UK

118’371

Singapore

102’425

% 0.1 0.07 0.02 0.0055 0.04 0.02 0.02

induction % 41.9 86 50 87 50 59

maintenance % 25.850

50 50 13.6

awakening % 25.8 14 13.6

PACU % 6.5 50 13.6

Pulmonary Aspiration: n = 29

!11/29 in emergency or urgent cases= 0.18 % of urgent/emergency cases >< 0.07 elective

!3/29 during rapid sequence induction = 0.22% of RSI cases

!20/29 during surgical cases = 0.09% of surgical cases

!0.09% of IV inductions0.10% of inhalation inductions

9.3/10,000

Risk factors for pulmonary aspiration • Increased risk for regurgitation:

– Increased gastric content– Bowel obstruction– Critically ill children with hemodynamic instability – Esophageal diseases– Neurological diseases– Presence of gastroesophageal reflux– Diabetes with gastric paresis– Preoperative nausea/vomiting– Pain

• Light anesthesia: – bucking, coughing and straining during induction or intubation

Rapid sequence induction: Lessons from APRICOT

Rapid sequence induction 1’372 (4.4%)

Modified with mask ventilation 641 (2.1%)

No mask ventilation 731 (2.3%)

Myorelaxant use (89% of cases) SuxamethoniumRocuroniumAtracuriumCisatracurium/vecuronium

59237911630/15

Without myorelaxant Sevoflurane PropofolSevoflurane + propofol

507130

Controlled RSI:an effective measure in children

Decrease risks of hypoxemia, hemodynamic complications and difficult intubation

Major physiological phenomenon at induction

!Airway collapsibility

!Decrease in FRC and airway closure

Main goal of controlled RSI

!Opening the Airways

!Restoring FRC

Main target for maintaining adequate gas exchange

and oxygen reserve

Suggested SOP for controlled RSI in children I

1. Indications for ‘controlled rapid sequence induction and intubation’1. NPO <6h (<1 h for clear liquids)2. Delay of gastrointestinal passage (e.g., ileus, peritonitis, renal insufficiency, diabetes mellitus, acute trauma,

or pain)2. Preoperative preparation

1. In patients with gastrointestinal obstruction → nasogastric tube with suction2. Intravenous line beforehand/replacement of intravascular deficits

3. Equipment preparation1. Large bore suctioning catheter prepared at the operating table2. Second intubation laryngoscope, intubation stylet3. Appropriately sized cuffed ETT and a 0.5 mm ID smaller size4. Pretesting of operating table function5. Anesthesia respirator with oxygen flow of 8 l and APL valve limited to an airway pressure of 10 cmH2O

Modified from Neuhaus D et al. Ped Anesth 2013; 23(8):734-40.

Gastric tube and controlled RSI

Dadure C. et al. Anaesth Crit Care Pain Med 2019; ; ePub ahead

Bowel obstructionFull stomach

Gastric tube to decrease the intragastric pressure

Leave the gastric tube in place: no effect on efficacy of CP

Proximal end opened to atmosphere: pop-up valve

1. Patient preparation1. Check i.v. line: if child less than 3 months: atropine 20 μg/kg i.v.2. Premedicate intravenously: midazolam 0.05-0.1 mg/kg iv. max 2 mg3. Treat pain with Fentanyl 1 μg/kg i.v.4. If nasogastric tube in place: continuous suctioning5. Monitoring: NIBP, ECG, SpO2, precordial stethoscope, acceleromyograph (TOF!watch apparatus)6. Head-up tilt (Anti!Trendelenburg) position 20° if patient older than 2 years of age7. Preoxygenation by face mask with 80-100% oxygen if possible (use scented pen/face mask)

2. Induction of anesthesia1. Patient in cardiovascular shock: ketamine 2 mg/kg, rocuronium 1.2 mg/kg or atracurium 0.6-0.8 mg/kg2. Hemodynamically stable neonates and infants ≤3 months: thiopental 5 mg·kg−1, atracurium 0.6-0.8 mg/kg3. Hemodynamically stable >3 months: 1-2 μg/kg, Propofol 3–4 mg/kg, rocuronium 1.2 mg/kg or atracurium

0.6-0.8 mg/kg atracurium (diluted and inject slowly over 10 s)4. No cricoid pressure

Modified from Neuhaus D et al. Ped Anesth 2013; 23(8):734-40.

Suggested SOP for controlled RSI in children II

Rocuronium 0.6-0.7 mg/kg

Rocuronium 0.9-1 mg/kg

Outcome: Excellent Intubation condition

Rocuronium 1.2 mg/kg

Outcome: Acceptable Intubation condition

Tran DT et al. Cochrane Database Syst Rev. 2015 Oct 29;(10):CD002788.

First Cochrane review in 2003, updated in 2008 and now in 2015

Lysakowski C et al. Acta Anaesthesiol Scand. 2007;51:848-57.

Propofol Propofol ThiopentoneIntubation conditions

better with:

Suxamethonium vs Rocuronium for RSI Faster onset of ! SaO2 during subsequent apnoea

Taha SK et al. Anaesthesia, 2010; 65: 358–361

(L+F+P+S)(L+F+P+R) (P+S)

To avoid coughing, bucking, and strainingTo facilitate airway management

Complete muscle paralysis Cricoid pressure

+anti!Trendelenburg positioning

Patients with bowel obstructionPatients suffering from achalasia, Zenker diverticulumor after colon interposition for esophageal replacement

BOWEL OBSTRUCTIONBLEEDING TONSILS SUXAMETHONIUM

Cricoid pressure can be useful

Pirotte T et al. Paediatr Anaesth. 2013; 23:1225-6

Preventing insufflation of gas into the stomach

! Infants less than 1 year

!Children with decrease lung compliance

Moynihan RJ et al. Anesthesiology 1993; 78:652-6

This implies appropriate cricoid pressure being applied

Sellick statement in 1961:

‘during cricoid pressure the lungs may be ventilated by intermittentpositive pressure ventilation without risk of gastric distention’

Sellick BA et al. Lancet. 1961 Aug 19;2(7199):404-6.

Inspiratory pressure threshold and gastric insufflation

Lagarde S et al. Anesth Analg. 2010;110:1676-9. Age of children with or without gastric insufflation associated with different inspiratory pressure levels

Only children < 1 year experienced gastric insufflation at 10 cm H2O when ventilated 8 ml/kg

Controlled RSI and Facemask ventilationEducated hand ?

Gentle bag facemask ventilation with APL valve that limits PIPmax to 10 cmH2O

Restore FRC up to a mean PIP of 10 cmH2O & apply a high frequency oscillation ventilation

Set NIBPper min

PIP max 10 cmH2O

Start TOF-watchAPL valve < 10 cmH2O

Controlled RSI that mimics a High Frequency Oscillation Ventilation

Physiological basis of HFO:

Employs very small tidal volumes (usually less than anatomic dead space) around a constant mean airway pressure, delivered at a frequency typically between 9 -12 Hz.

High volume strategy: strategy to maintain lung volume

Better alveolar recruitment Mean Airway Pressure controls oxygenation (!PaO2/FiO2) Amplitude controls CO2

Continuous oscillations (only 2 cmH2O seems enough for CO2 clearence...)

At ‘zero single twitch’ and adequate oxygenationBURP if necessary, Inflate ETT cuff immediately after placement Confirm adequate ETCO2 & ETT placement

Modified from Neuhaus D et al. Ped Anesth 2013; 23(8):734-40.

Controlled RSI – Intubation and extubation

Reverse muscle relaxation if necessary Gastric suctioning with large bore NGT

Extubate patient – fully awake

EmergenceIntubation

Engelhardt T. Paediatr Anaesth 2015; 25: 5-8

*"Gencorelli FJ"et"al." Pediatr Anesth 2010;"20:"4216424§ Neuhaus D et al. Pediatr Anesth 2013; 23: 734–740.

Comparison of RSI with and without face mask ventilation prior to tracheal intubation in children

Age (years) SpO280-89%

SpO2< 80%

Heart rate< 60/min

Difficultintubation

Controlled RSI§

(n= 1001)0-22.4 (8.9) 0.5 0.3 0 0.3

Classical RSI* (n= 1071)

3-12 (8.1) 1.9 1.8 0.8 1.7

8 patients in CRSI had mean age of 0.8 years and ASA-PS > 3 with majority compromised condition preoperatively

Effective induction of deep anesthesia Effective muscle paralysisCareful mask ventilation

Optimal oxygenationGentle tracheal intubation

Controlled RSI in children

Optimisation of anesthesia management

9TH INTERNATIONAL SYMPOSIUM ON THE PEDIATRIC AIRWAY

June 12-14 2019CAMPUS BIOTECH GENEVA SWITZERLAND

ispa19@hcuge.ch