Complications during rapid sequence induction of general anesthesia in children: a benchmark study

Objectives: Determine incidence of complications such as difficult or failed intubation, hypoxemia, hypotension, and bradycardia in children undergoing rapid sequence intubation (RSI) in a pediatric anesthesia department in a tertiary care children’s hospital. Aim: To establish a benchmark to be used by other institutions and nonanesthesiologists performing RSI in children. Background: RSI is being increasingly performed in the nonoperating room setting by nonanesthesiologists. No published studies exist to establish a benchmark of intubation success or failure and complications in this patient population. Methods/Materials: Retrospective cohort analysis of children aged 3–12 undergoing RSI from 2001 to 2006. Results: One thousand seventy children underwent RSI from 2001 to 2006. Twenty (1.9%) developed moderate hypoxemia (SpO₂ 80–89%), 18 (1.7%) demonstrated severe hypoxemia (SpO₂ < 80%), 5 (0.5%) developed bradycardia (heart rate <60), and 8 (0.8%) developed hypotension (systolic blood pressure <70 mmHg). One patient had emesis of gastric contents but no evidence of pulmonary aspiration or hypoxemia. Eighteen (1.7%) children were noted to be difficult to intubate and required more than one intubation attempt. All were eventually intubated without significant complications. Patients between 10 and 19 kg had a higher incidence of severe hypoxemia when compared with older children (P < 0.001). There was no association between choice of muscle relaxant and any complication. Conclusions: In our cohort of 1070 children who underwent RSI, difficult intubation was encountered in 1.7% and transient oxyhemoglobin desaturation occurred in 3.6%. Severe hypoxemia was more likely in children <20 kg. There were no children who could not be intubated, and there were no long‐term or permanent complications.     

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts

Pulmonary aspiration of gastric content is a significant cause of anaesthesia-related morbidity and mortality. High-quality prospective randomised evidence to support prevention strategies, such as rapid sequence intubation, is difficult to generate due to well-described practical, ethical and methodological barriers. We aimed to generate an understanding of worldwide practice through surveying clinically practicing anaesthetists and airway experts. Our survey was designed to assess the influence of: departmental standards; patient factors; socio-economic factors; training; and supervision. We surveyed 10,003 anaesthetists who responded to an invitation to participate on LinkedIn. We then surveyed 16 international airway experts on the same content. When asked about a hypothetical patient with intestinal obstruction, respondents expressed preferences for [OR (95%CI)]: the head-up or -down position 4.26 (3.98–4.55), p < 0.001; nasogastric tube insertion 29.5 (26.9–32.3), p < 0.001; and the use of cricoid force 2.80 (2.62–3.00), p < 0.001, as compared with a hypothetical patient without intestinal obstruction also requiring rapid sequence intubation. Respondents from lower income countries were more likely to prefer [OR (95%CI]: the supine position 2.33 (2.00–2.63), p < 0.001; nasogastric tube insertion 1.29 (1.09–1.51), p = 0.002; and cricoid force application 2.54 (2.09–3.09), p < 0.001 as compared with respondents from higher income countries for a hypothetical patient with intestinal obstruction. This survey, which we believe is the largest of its kind, demonstrates that preferences for positioning, nasogastric tube use and cricoid force application during rapid sequence intubation vary substantially. Achieving agreed consensus may yield better training in the principles of rapid sequence intubation.     

Pre-oxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction

Pre-oxygenation using high-flow nasal oxygen can decrease the risk of desaturation during rapid sequence induction in patients undergoing emergency surgery. Previous studies were single-centre and often in limited settings. This randomised, international, multicentre trial compared high-flow nasal oxygen with standard facemask pre-oxygenation for rapid sequence induction in emergency surgery at all hours of the day and night. A total of 350 adult patients from six centres in Sweden and one in Switzerland undergoing emergency surgery where rapid sequence induction was required were included and randomly allocated to pre-oxygenation with 100% oxygen using high-flow nasal oxygen or a standard tight-fitting facemask. The primary outcome was the number of patients developing oxygen saturations <93% from the start of pre-oxygenation until 1 min after tracheal intubation. Data from 349 of 350 patients who entered the study were analysed (174 in the high-flow nasal oxygen group and 175 in the facemask group). No difference was detected in the number of patients desaturating <93%, five (2.9%) vs. six (3.4%) patients in the high-flow nasal oxygen and facemask group, respectively (p = 0.77). The risk of desaturation was not increased during on-call hours. No difference was seen in end-tidal carbon dioxide levels in the first breath after tracheal intubation or in the number of patients with signs of regurgitation between groups. These results confirm that high-flow nasal oxygen maintains adequate oxygen levels during pre-oxygenation for rapid sequence induction.     

快速顺序诱导气管插管的研究进展

快速顺序诱导气管插管(RSII)是为反流误吸高风险患者气管插管提供的一种保护性措施。经典RSII技术包括：有效的预充氧、快速顺序给予硫喷妥钠和琥珀酰胆碱、环状软骨加压、诱导时避免正压通气、使用带套囊气管导管插管。RSII经历了多次“改良”,但至今临床获益及风险仍未明确。当前技术的发展改变了一些传统观念，如预充氧方式的选择、插管的可视化和正压通气的应用等。本文综述了RSII应用研究进展，旨在为临床RSII实施提供参考。     

探讨头高位联合托下颌改良快顺序诱导插管的效果

目的探讨急诊饱胃患者采用头高位20°～30°联合呼吸暂停期间托下颌开放气道的安全性。方法急诊普外科手术患者197例,男96例,女101例,年龄18～80岁,体重45～75 kg,ASAⅠ—Ⅲ级,随机分为两组:改良快诱导组(M组,n=99)和传统快诱导组(R组,n=98)。充分预给氧后,M组头高位20°～30°行快顺序诱导,呼吸暂停期间托下颌开放气道;R组平卧位下行快顺序诱导,同时行环状软骨压迫,两组均未机械辅助通气。若SpO_292%,手控小潮气量辅助呼吸维持氧合。记录喉镜暴露时间、插管时间、无通气时间、最低SpO_2、SpO_2从100%降至99%所需时间。记录呛咳、反流、误吸、吸入性肺炎等并发症的发生情况。结果两组喉镜暴露时间、插管时间、无通气时间差异无统计学意义。与R组比较,M组SpO_2最低值明显高于R组(P0.01),SpO_2从100%降至99%所需时间明显长于R组(P0.05)。两组呛咳、反流、误吸、吸入性肺炎等并发症发生率差异无统计学意义。结论头高位20°～30°联合呼吸暂停期间托下颌开放气道的改良快顺序诱导气管插管不仅可以有效预防反流误吸,而且可以维持较高的SpO_2,延长无通气安全时间。     

Partial attenuation of hemodynamic responses to rapid sequence induction and intubation with labetalol

The effectiveness of labetalol (a combination nonselective beta and alpha-1-adrenergic receptor antagonist) in modifying hemodynamic responses associated with rapid sequence induction and tracheal intubation was evaluated. In a double-blind study, 24 ASA physical status I or II male patients scheduled for elective surgery were given either IV labetalol, 0.25 mg/kg (n = 8) or 0.75 mg/kg (n = 8), or a saline placebo (n = 8). Five minutes later, patients were given oxygen by mask and IV vecuronium, 0.01 mglkg. Ten minutes after giving labetalol or placebo, cricoid pressure was applied and anesthesia was induced with IV sodium thiopental (4 mg/kg) and succinylcholine (1.5 mg/kg) 1 minute prior to intubation. The mean duration of laryngoscopy was 17 ± 3 seconds. Prior to induction, the 0.25 mg/kg and 0.75 mg/kg) doses of labetalol significantly (p < 0.05) reduced mean arterial pressure by 4.4 ± 1.9 and by 8.6 ± 2.0 mmHg, respectively, but did not significantly alter heart rate or cardiac output. The 0.75 mg/kg) dose of labetalol also significantly (p < 0.05) decreased total peripheral resistance by 10.1 ± 3.0%. Within 30 seconds after intubation, patients in all three groups exhibited increases in heart rate, mean arterial pressure, total peripheral resistance, and rate pressure product and a decrease in stroke volume. However, patients in the 0.25 and 0.75 mg/kg) labetalol groups, compared to those in the placebo group, had significantly lower increases in peak heart rate (33 ± 2 and 27 ± 3 vs. 44 ± 7 beats/minute), peak mean arterial pressure (38 ± 6 and 38 ± 7 vs. 58 ± 7 mmHg), and peak rate pressure product (7,726 ± 260 and 7,215 ± 300 vs. 14,023 ± 250 units). The results show that these doses of labetalol significantly blunt, but do not completely block, autonomic responses to rapid sequence induction and intubation.     

Frequency of haemoglobin desaturation with the use of succinylcholine during rapid sequence induction of anaesthesia

BACKGROUND: The perceived safety of the use of succinylcholine is based on the fact that recovery from its effects will occur before oxygen desaturation occurs in case of failure to intubate or ventilate. The purpose of this study was to examine the incidence of oxygen desaturation after the use of succinylcholine prior to resumption of spontaneous ventilation following four different preoxygenation techniques. METHODS: Twenty-five patients each were randomly allocated to preoxygenation with 4 deep breaths of 100% oxygen or by breathing oxygen for 1, 3 or 5 min following which they received a rapid sequence induction of anaesthesia with fentanyl 1 microg kg(-1), a sleep dose of thiopentone and succinylcholine 1 mg kg(-1). Oxygen saturation was monitored continuously using a finger probe. Ventilation was not assisted unless the saturation decreased to 相似文献   

Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury

BACKGROUND: The role of pre-hospital trauma care and the effect of pre-hospital rapid sequence intubation (RSI) on patient outcome are still not clear. This study evaluated the impact of pre-hospital trauma care by emergency physicians (EP) on mortality from severe traumatic brain injury (TBI) and a 180-day Glasgow Outcome Scale (GOS). METHODS: A 48-month parallel non-controlled cohort study compared a group of 64 patients with severe TBI [Glasgow Coma Scale (GCS) < 9; Injury Severity Score (ISS) > 15] who received pre-hospital advanced life support (ALS) with RSI and were transported to the hospital by EPs (EP group), with a group of 60 patients who did not receive pre-hospital ALS with RSI [emergency medical technicians (EMT) group]. RESULTS: There were no significant statistical differences between the groups in age (P= 0.79), mechanism of injury (P= 0.68), gender (P= 0.82), initial GCS (P= 0.63), initial SaO(2) in the field (P= 0.63), initial systolic blood pressure in the field (P= 0.47) and on-scene time (P= 0.41). In the EP group, there was significantly better first hour survival (97% vs. 79%, P= 0.02), first day survival (90% vs. 72%, P= 0.02), better functional outcome (GOS 4-5: 53% vs. 33%, P < 0.01; GOS 2-3: 8% vs. 20%, P < 0.01) and shortened hospitalization time in intensive care unit (ICU) (P= 0.03) and other departments (P= 0.04). In total hospital mortality, we detected no differences between both groups [EP group: 40% (95% CI: 34-45%) vs. EMT group 42% (95% CI: 36-47%, P= 0.76], except in a subgroup of patients with GCS 6-8 where there was significantly lower total hospital mortality in the EP group (24% vs. 78%, P < 0.01). CONCLUSION: After starting the trauma care system with emergency physicians in our region, there was a decrease in the number of deaths on hospital admission, a reduction in hospital mortality in the GCS group 6-8, a change in the temporal distribution of deaths, an improvement in functional neurological outcome and shortened hospitalization time.     

不同剂量阿芬太尼对老年患者快速顺序诱导气管插管心血管反应的影响

目的 比较不同剂量阿芬太尼对老年患者快速顺序诱导气管插管心血管反应的影响。
方法 选择2022年3—9月行气管插管全麻老年患者96例，男47例，女49例，年龄65～80岁，BMI 18～24 kg/m²，ASA Ⅰ或Ⅱ级。采用随机数字表法分为四组：阿芬太尼10 μg/kg组（A组）、阿芬太尼15 μg/kg组（B组）、阿芬太尼20 μg/kg组（C组）和阿芬太尼25 μg/kg组（D组），每组24例。记录麻醉诱导前、气管插管后1、5 min的HR、MAP，同时抽取患者静脉血3 ml，检测血浆中去甲肾上腺素（NE）和皮质醇（Cor）的浓度、超声测量心脏指数（CI）、心脏射血分数（EF）。记录麻醉诱导后至气管插管后5 min高血压、低血压、心动过缓、心动过速的发生情况。
结果 与麻醉诱导前比较，A组和B组在气管插管后1、5 min HR明显增快，MAP、NE和Cor浓度明显升高，CI和EF明显降低（P＜0.05）；C组和D组气管插管后1 min HR明显增快，MAP明显升高，D组插管后5 min HR明显减慢，MAP、血浆NE和Cor浓度、CI和EF明显降低（P＜0.05）。与A组比较，C组和D组气管插管后1、5 min HR明显减慢，血浆NE和Cor浓度明显降低，气管插管后1 min CI和EF明显升高，高血压和心动过速发生率明显降低（P＜0.05）；D组插管后5 min CI和EF明显降低，低血压和心动过缓发生率明显升高（P＜0.05）。
结论 阿芬太尼20 μg/kg用于老年患者快速顺序诱导气管插管，可有效抑制插管引起的剧烈心血管反应，同时避免心血管系统的抑制，血流动力学更平稳。     

光棒在快速诱导经鼻气管内插管中的应用研究

目的探讨快速诱导麻醉下光棒引导经鼻气管内插管临床效果。方法60例全麻患者随机均分为光棒(LW)组和纤维支气管镜(BF)组,比较两组插管时间、置管成功率和导管通过声门顺利率。结果在规定的3min内,LW组插管成功率显著高于BF组(96.7%vs.70.0%,P<0.05);LW组插管时间明显短于BF组[(38.9±16.2)svs.(133.0±37.9)s,P<0.01]。LW组导管通过声门顺利率高于BF组(96.6%vs.66.7%,P<0.05)。结论光棒引导经鼻气管内插管,是口腔颌面部手术全麻快速诱导建立气道安全、有效、快捷的方法之一。     

Haemodynamic responses and prolongation of QT interval of ECG after suxamethonium-facilitated intubation during anaesthetic induction in children: a dose-related attenuation by alfentanil

The haemodynamic response to endotracheal intubation and changes in the QT interval of ECG during anaesthetic induction were studied in 68 healthy children (5.5 years). The children were pretreated double-blindly with either alfentanil 10 micrograms/kg (A10), 25 micrograms/kg (A25), 50 micrograms/kg (A50) or saline (control) (17 children in each group) i.v. 1 min before thiopentone 5 mg/kg. The trachea was intubated after suxamethonium 1.5 mg/kg. Central nervous system excitation was seen in four of 17 and in one of 17 children after alfentanil 50 and 25 micrograms/kg, respectively. After intubation, heart rate increased significantly in the control group, remained at initial levels in the A10 and A25 groups and decreased in the A50 group. A pressor response to intubation was seen in the control and A10 groups. The QT interval was significantly prolonged after suxamethonium in the control and A10 groups, but remained at baseline levels in the A25 and A50 groups. Ventricular ectopic beats were only seen in 2/17 children in the control group. In conclusion, alfentanil 25 microgram/kg is ideal for preventing the haemodynamic response to endotracheal intubation and prolongation of the QT interval, a sign of sympathoadrenal activation, before induction of intravenous anaesthesia in children.     

预注右美托咪定对快速序贯诱导时插管条件的影响

目的观察快速序贯诱导(RSI)前预注右美托咪定对插管条件及血流动力学的影响。方法选择40例择期全麻妇科手术患者,年龄25~50岁,随机分为两组,每组20例。D组诱导前泵注右美托咪定0.6μg/kg(10min泵完),C组泵注等量生理盐水10ml,泵注期间给予面罩高流量吸氧5L/min;泵注完毕后实施RSI。记录插管时间和喉镜暴露分级,以及泵注前及泵注后15min内每分钟的MAP、HR、BIS、SpO2;检测PaO2和PaCO2。结果两组插管时间和喉镜暴露分级差异无统计学意义。插管后14、15min,C组MAP较D组明显下降,HR明显增快(P0.05)。插管期间两组SpO2和PaO2差异无统计学意义。D组呛咳发生率明显低于C组(P0.05)。结论 RSI前预注右美托咪定0.6μg/kg可以在不影响机体氧储备的前提下,减少插管时的血流动力学波动和插管时间。     

Sevoflurane (12% and 8%) inhalational induction in children

BACKGROUND: Sevoflurane induction of anesthesia is frequently used in children. Rapidly performed inhalational induction may reduce excitation during early anesthesia. Increasing the total anesthetic MAC delivered to patients can be achieved by increasing volatile concentration or adding nitrous oxide. The latter reduces inspired oxygen concentration delivered, which may not be desirable. Even 8% sevoflurane induction is associated with excitation. A system capable of delivering 12% sevoflurane using two tandem vaporizers has been developed. METHODS: A randomized double blind study was undertaken to assess whether 12% sevoflurane offered any advantage over 8% in time and quality of induction. Sixty children aged 5-10 years were recruited and received either 12 or 8% sevoflurane. Time to loss of eyelash reflex, central pupils, incidence of adverse events, induction quality, systolic blood pressure and heart rate were recorded. RESULTS: Twelve percent sevoflurane reduced time to loss of eyelash reflex compared with 8% [mean (sd): 35 (12) and 46 (14) P<0.05], but the reduction was only 10% higher than the error in the measurement (assessment every 10 s). Twelve percent sevoflurane offered significantly better quality of induction (P<0.05). There was no difference in cardiovascular stability between groups, although heart rate rose significantly in both groups. Maintaining sevoflurane at 12% for 4 min caused significant amounts of apnea (69% with 12% and 38% with 8%, P<0.05). CONCLUSION: Twelve percent sevoflurane offers a smoother anesthesia induction than 8% in children of this age with no additional consequences for the cardiovascular system.     

Prevention of pulmonary aspiration

Pulmonary aspiration is a complication associated with anaesthesia. This article aims to enable readers to identify patients at risk of aspiration and then go on to weigh up the risks and benefits of differing techniques that minimize the risk.     

Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children

BACKGROUND: The purpose of our study was to determine whether a smaller dose of rocuronium than previously reported could provide similar intubating conditions to suxamethonium during rapid-sequence induction of anaesthesia in children. METHODS: One hundred and twenty ASA I, unpremedicated children, aged 1-10 years, who were undergoing elective surgery, were randomized into three groups to receive rocuronium 0.6 mg.kg-1, rocuronium 0.9 mg.kg-1 or suxamethonium 1.5 mg.kg-1. The study was double-blinded, anaesthesia and timing of injection was standardized to alfentanil 10 microg.kg-1, thiopentone 5 mg.kg-1 and the study drug. Intubation was attempted at 30 s after injection of neuromuscular relaxant and intubating conditions graded as excellent, good, poor or impossible. RESULTS: All 120 children were successfully intubated within 60 s without need for a second attempt after administration of neuromuscular relaxant. Differences between suxamethonium and rocuronium 0.6 mg.kg-1 and between the two doses of rocuronium were statistically significant (P=0.016 and 0.007, respectively). CONCLUSIONS: Rocuronium 0.9 mg.kg-1 provides similar intubating conditions to suxamethonium 1.5 mg.kg-1 during modified rapid-sequence induction using alfentanil and thiopentone in children (P=0.671). Rocuronium 0.6 mg.kg-1 was inadequate.     

Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia

We determined the effective time to satisfactory intubation conditions after the administration of rocuronium 0.6 mg.kg-1 to 120 unpremedicated adult patients anaesthetised with propofol 2.5 mg.kg-1 or thiopentone 5 mg.kg-1. Intubation conditions were assessed in 10 subgroups of 12 patients at 30, 40, 50, 60 and 70 s. The effective times to satisfactory intubation conditions in 50 and 90% of patients were obtained by the method of maximum likelihood after log time-probit response transformations. Intubation conditions after induction of anaesthesia with propofol were satisfactory in 5/12 patients at 30 s, 7/12 at 40 s, 10/12 at 50 s, 11/12 at 60 s and 11/12 at 70 s compared with 1/12 patients at 30 s, 2/12 at 40 s, 5/12 at 50 s, 7/12 at 60 s and 8/12 at 70 s after induction with thiopentone. The effective times to satisfactory intubation conditions in 50% and 90% (95% confidence intervals) of patients after rocuronium 0.6 mg.kg-1 were 34 (26-40) s and 61 (50-81) s in patients given propofol compared with 57 (48-69) s and 101 (79-167) s in patients given thiopentone. We conclude that rocuronium 0.6 mg.kg-1 may be a suitable alternative to suxamethonium during rapid sequence induction of anaesthesia with propofol in situations where suxamethonium is contraindicated.