Systematic Application of Rapid Sequence Intubation With Remifentanil During COVID-19 Pandemic

In this letter, the authors wonder about the need to apply some of the precautions that have been repeatedly suggested during the recent COVID-19 (coronavirus disease 19) pandemic not only to suspected or documented cases of infection but also to all the new cases entering the hospital. In this regard, orotracheal intubation has been universally recognized as a maneuver with a high risk of viral transmission. On the other hand, rapid sequence induction, which represents the gold standard for limiting the risk of transmission for health care professionals, implies side effects that can be potentially harmful for patients with impaired hemodynamics. In this regard, the authors report a particular type of rapid induction that they are performing in a systematic way during the recent pandemic in cardiac surgery patients. This is performed after the patient reaches a deep analgesic plan, thanks to the unique characteristics of the opioid remifentanil. This type of induction, already tested in vasculopathic patients who underwent carotid surgery, is characterized by great hemodynamic stability and is very advantageous, in the writer’s experience, when rapid sequence induction has to be systematically applied to cardiovascular patients, especially if you only want to protect operators.

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Rapid Sequence Intubation with Remifentanil During COVID-19 Pandemic

Anesthesia and Clinical Research ◽

10.31487/j.acr.2021.01.01 ◽

2021 ◽

pp. 1-2

Author(s):

Sergio Bevilacqua ◽

PierLuigi Stefano

Keyword(s):

Low Dose ◽

Rapid Sequence Induction ◽

Rapid Sequence Intubation ◽

Surgical Patient ◽

High Dose ◽

Muscle Paralysis ◽

Intubation Technique ◽

Rapid Induction ◽

Rapid Sequence ◽

Sequence Induction

We greatly appreciate the interest that De Melo MS, et al. showed on the use of remifentanil in a rapid sequence intubation technique that we recently proposed for patients undergoing surgery during the current SARS-CoV-2 pandemic [1, 2]. The authors also reported the response that Tang and Wang wrote to comment on that paper [3]. Given the interest aroused by our article, we think it would be worth making some clarifications. In brief, in order to limit aerosolization, we proposed to systematically perform rapid induction and intubation in the surgical patient after he had reached a state of deep analgesia with a continuous infusion of high-dose remifentanil (0.2-0.3 g/kg/min) [2]. Although in the title of the article this method is labeled as a rapid sequence induction, in the text, we explain how this technique, far from being standard rapid sequence intubation, was a rather longer technique in which the patient, although in a state of profound analgesia and sedation induced by remifentanil, breathed spontaneously and at last on command, until hypnosis, and muscle paralysis was rapidly induced with a low dose of propofol (<0.5 mg/kg) or midazolam (0.05-0.1 mg/kg) and a full dose of rocuronium (1 mg/kg) [2].

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Comparison of Plastic Single-use and Metal Reusable Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia

Anesthesiology ◽

10.1097/00000542-200601000-00011 ◽

2006 ◽

Vol 104 (1) ◽

pp. 60-64 ◽

Cited By ~ 34

Author(s):

Julien Amour ◽

Frédéric Marmion ◽

Aurélie Birenbaum ◽

Armelle Nicolas-Robin ◽

Pierre Coriat ◽

...

Keyword(s):

Rapid Sequence Induction ◽

Orotracheal Intubation ◽

Failed Intubation ◽

Cluster Randomization ◽

Rapid Sequence ◽

Lehane Grade ◽

Sequence Induction ◽

Single Use ◽

S Period ◽

Laryngoscope Blades

Background Plastic single-use laryngoscope blades are inexpensive and carry a lower risk of infection compared with metal reusable blades, but their efficiency during rapid sequence induction remains a matter of debate. The authors therefore compared plastic and metal blades during rapid sequence induction in a prospective randomized trial. Methods Two hundred eighty-four adult patients undergoing general anesthesia requiring rapid sequence induction were randomly assigned on a weekly basis to either plastic single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using metal blade. The primary endpoint of the study was the rate of failed intubations, and the secondary endpoint was the incidence of complications (oxygen desaturation, lung aspiration, and oropharynx trauma). Results Both groups were similar in their main characteristics, including risk factors for difficult intubation. On the first attempt, the rate of failed intubation was significantly increased in plastic blade group (17 vs. 3%; P < 0.01). In metal blade group, 50% of failed intubations were still difficult after the second attempt. In plastic blade group, all initial failed intubations were successfully intubated using metal blade, with an improvement in Cormack and Lehane grade. There was a significant increase in the complication rate in plastic group (15 vs. 6%; P < 0.05). Conclusions In rapid sequence induction of anesthesia, the plastic laryngoscope blade is less efficient than a metal blade and thus should not be recommended for use in this clinical setting.

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Rapid sequence induction/intubation controversies

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907920910835 ◽

2020 ◽

pp. 102490792091083

Author(s):

Prihatma Kriswidyatomo ◽

Maharani Pradnya Paramitha

Keyword(s):

Positive Pressure Ventilation ◽

Cricoid Pressure ◽

Rapid Sequence Induction ◽

Blocking Agent ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agent ◽

Rapid Sequence Intubation ◽

Positive Pressure ◽

Rapid Sequence ◽

Sequence Induction

Backgrounds: Since its first definition and publication on 1970, Rapid Sequence Induction / Intubation (RSI) technique has been accepted globally as the “standard” for doing rapid intubation after induction of anesthesia for patients with high risk of aspiration, especially in emergency situation. However, this technique is not so much a “standard” as there are numerous variations on its practice based on national surveys. Anesthesia providers have their own opinions on the practice of RSI components which need to be discussed to assess their advantages and disadvantages, while there has been no review article which discussed these controversies in the last ten years. Objectives: To review the technique differences within RSI protocols. Methods: Online databases were searched, including MEDLINE and COCHRANE for each step in the original RSI protocol using keywords such as: “rapid sequence induction” or “rapid sequence intubation” or “RSI” and “controversies” or “head position” or “cricoid pressure” or “neuromuscular blocking agent” or “NMBA” or positive pressure ventilation” or “PPV”; and so on. Articles were then sorted out based on relevancy. Results and conclusion: Supported by new evidence, RSI practices may differ in: the positioning of patient, choices of induction agent, application of cricoid pressure, choices of neuromuscular blocking agent, and the use of positive pressure ventilation. A more updated and standardized guideline should be established by referring and evaluating to these controversies.

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Rapid-Sequence Induction Technique for Orotracheal Intubation of Adult Nontrauma Patients in a Community Hospital Setting

Annals of Emergency Medicine ◽

10.1016/s0196-0644(95)70310-1 ◽

1995 ◽

Vol 25 (3) ◽

pp. 432-433 ◽

Cited By ~ 9

Keyword(s):

Community Hospital ◽

Rapid Sequence Induction ◽

Hospital Setting ◽

Orotracheal Intubation ◽

Rapid Sequence ◽

Induction Technique ◽

Sequence Induction

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Comparison of Single-Use and Reusable Metal Laryngoscope Blades for Orotracheal Intubation During Rapid Sequence Induction of Anesthesia

Survey of Anesthesiology ◽

10.1097/sa.0b013e3181dcb89c ◽

2010 ◽

Vol 54 (3) ◽

pp. 110

Author(s):

&NA;

Keyword(s):

Rapid Sequence Induction ◽

Orotracheal Intubation ◽

Rapid Sequence ◽

Sequence Induction ◽

Single Use ◽

Laryngoscope Blades

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Faculty Opinions recommendation of Comparison of plastic single-use and metal reusable laryngoscope blades for orotracheal intubation during rapid sequence induction of anesthesia.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.9256.466736 ◽

2006 ◽

Author(s):

Patrick Ray

Keyword(s):

Rapid Sequence Induction ◽

Orotracheal Intubation ◽

Rapid Sequence ◽

Sequence Induction ◽

Single Use ◽

Laryngoscope Blades

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Rapid sequence induction with rocuronium - a challenge to the gold standard

Critical Care ◽

10.1186/cc10418 ◽

2011 ◽

Vol 15 (5) ◽

pp. 190 ◽

Cited By ~ 6

Author(s):

Gerard F Curley

Keyword(s):

Gold Standard ◽

Rapid Sequence Induction ◽

Rapid Sequence ◽

Sequence Induction

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Comparison of Single-use and Reusable Metal Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia

Anesthesiology ◽

10.1097/aln.0b013e3181c92111 ◽

2010 ◽

Vol 112 (2) ◽

pp. 325-332 ◽

Cited By ~ 14

Author(s):

Julien Amour ◽

Yannick Le Manach ◽

Marie Borel ◽

François Lenfant ◽

Armelle Nicolas-Robin ◽

...

Keyword(s):

Statistical Significance ◽

Rapid Sequence Induction ◽

Cluster Randomized Trial ◽

Orotracheal Intubation ◽

Failed Intubation ◽

Rapid Sequence ◽

Sequence Induction ◽

Single Use ◽

Laryngoscope Blades ◽

Cluster Randomized

Background Single-use metal laryngoscope blades are cheaper and carry a lower risk of infection than reusable metal blades. The authors compared single-use and reusable metal blades during rapid sequence induction of anesthesia in a multicenter cluster randomized trial. Methods One thousand seventy-two adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using the opposite type of blade. The primary endpoint was the rate of failed intubation, and the secondary endpoints were the incidence of complications (oxygen desaturation, lung aspiration, and/or oropharynx trauma) and the Cormack and Lehane score. Results Both groups were similar in their main characteristics, including the risk factors for difficult intubation. The rate of failed intubation was significantly decreased with single-use metal blades at the first attempt compared with reusable blades (2.8 vs. 5.4%, P < 0.05). In addition, the proportion of grades III and IV in Cormack and Lehane score were also significantly decreased with single-use metal blades (6 vs. 10%, P < 0.05). The global complication rate did not reach statistical significance, although the same trend was noted (6.8% vs. 11.5%, P = not significant). An investigator survey and a measure of illumination pointed that illumination might have been responsible for this result. Conclusions The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia.

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