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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
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I have no COI to disclose
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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
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PreoxygenationHypnotic + myorelaxant
Apnea 30 sec to 1 min
Trachealintubation
Cricoid pressure
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Rapid sequence induction=
a single equation with several factors to consider
Preoxygenation-OxygenationCricoid PressurePulmonary aspiration
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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
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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
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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)
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Cricoid pressure: A ritual ? or an effective measure in children ?
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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
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Walker RW et al. Br J Anaesth 2010; 104, 71-74
Cricoid pressure leads to significant compression/distortion of the airways in children
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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
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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
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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
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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.
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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
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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)
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Birenbaum A et al. JAMA Surg 2019; 154: 9-17
IRIS – RCT – non inferiority study
Primary outcome:
Pulmonary aspiration
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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
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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.
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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
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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
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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
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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
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Controlled RSI:an effective measure in children
Decrease risks of hypoxemia, hemodynamic complications and difficult intubation
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Major physiological phenomenon at induction
!Airway collapsibility
!Decrease in FRC and airway closure
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Main goal of controlled RSI
!Opening the Airways
!Restoring FRC
Main target for maintaining adequate gas exchange
and oxygen reserve
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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.
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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
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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
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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.
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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:
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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)
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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
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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
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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.
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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
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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
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Set NIBPper min
PIP max 10 cmH2O
Start TOF-watchAPL valve < 10 cmH2O
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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
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Continuous oscillations (only 2 cmH2O seems enough for CO2 clearence...)
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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
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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
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Effective induction of deep anesthesia Effective muscle paralysisCareful mask ventilation
Optimal oxygenationGentle tracheal intubation
Controlled RSI in children
Optimisation of anesthesia management
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9TH INTERNATIONAL SYMPOSIUM ON THE PEDIATRIC AIRWAY
June 12-14 2019CAMPUS BIOTECH GENEVA SWITZERLAND