Rapid Sequence Intubation with Remifentanil During COVID-19 Pandemic

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

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253220941369 ◽

2020 ◽

pp. 108925322094136 ◽

Cited By ~ 1

Author(s):

Sergio Bevilacqua ◽

Vanessa Bottari ◽

Ilaria Galeotti

Keyword(s):

Health Care Professionals ◽

Gold Standard ◽

Rapid Sequence Induction ◽

Orotracheal Intubation ◽

Rapid Sequence Intubation ◽

Hemodynamic Stability ◽

Rapid Induction ◽

Rapid Sequence ◽

Cardiovascular Patients ◽

Sequence Induction

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 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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Anaesthesia

Oxford Handbook of Clinical Specialties ◽

10.1093/med/9780198827191.003.0011 ◽

2020 ◽

pp. 656-681

Author(s):

Nina Hjelde

Keyword(s):

Rapid Sequence Induction ◽

Postoperative Nausea And Vomiting ◽

Preoperative Assessment ◽

Nerve Blocks ◽

Intubation Technique ◽

Anaesthetic Agents ◽

Inhalational Anaesthetic ◽

Rapid Sequence ◽

Intravenous Anaesthetic ◽

Sequence Induction

This chapter in the Oxford Handbook of Clinical Specialties explores the specialty of anaesthesia. It reviews preoperative assessment, sedation, drugs used to induce anaesthesia, inhalational anaesthetic agents, intravenous anaesthetic agents, and muscle relaxants. It explores the practical conduct of anaesthesia, Difficult Airway Society (DAS) guidelines, maintaining and monitoring, rapid sequence induction aspiration, and intubation technique. It examines some complications of anaesthesia, end of anaesthesia, recovery, pain, and postoperative nausea and vomiting, and describes regional anaesthesia, including peripheral nerve blocks and neuraxial anaesthesia.

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