Year : 2014 | Volume
| Issue : 2 | Page : 249-255
Use of modified rapid sequence tracheal intubation in pediatric patients
Claude Abdallah, Raafat Hannallah
Division of Anesthesiology, Children's National Medical Center, NW, Washington D.C. 20010 - 2970, USA
Division of Anesthesiology Children's National Medical Center, 111 Michigan Avenue NW, Washington D.C. 20010 - 2970
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||16-Apr-2014|
Background: Rapid sequence intubation (RSI) has been an established practice, but is not without risks to patient. In different situations, a modification of the standard RSI technique may be more appropriate. The definition of a modified rapid sequence intubation (MRSI) is not well-documented. The purpose of this survey was to determine the working definition of MRSI as well as the modality of its use. Materials and Methods: This descriptive study consisted of a survey of pediatric anesthesiologists and included basic questions related to the anesthesiologist's experience, practice setting and use of MRSI. Responses were compiled and analyzed to identify the working definition, technique, perceived indications/complications as well as hands-on performance of tracheal intubation during use of MRSI in children. Results: The mean ± SD years in practice of the 228 respondents were 14.9 ± 8.16 years, with pediatric patients comprising 77 ± 33% of their practice. 76.8% completed a fellowship in pediatric anesthesia. 60% of the respondents' practice setting was at a Children's Hospital. Different respondents agreed with different techniques of MRSI with the majority (65%) defining a MRSI as equivalent to a RSI, but with mask ventilation. The major indication of use of a MRSI was a concern about apnea time tolerance with traditional RSI (74%). Conclusion: Technique of a MRSI varies among pediatric care providers.
Keywords: Airway, endotracheal, intubation, pediatrics, survey, technique
|How to cite this article:|
Abdallah C, Hannallah R. Use of modified rapid sequence tracheal intubation in pediatric patients. Saudi J Anaesth 2014;8:249-55
| Introduction|| |
Rapid sequence intubation (RSI) and modified rapid sequence intubation (MRSI) are the methods of choice for the majority of pediatric emergency tracheal intubations. Airway manipulations for endotracheal intubation in a pediatric patient are routinely based on the assessment of the patient's airway, the difficulty of tracheal intubation and the potential risk for aspiration. In different situations, a modification of the RSI technique may be more appropriate and may be a common practice in pediatric care. Considerable variation; however, may exist among providers in the use of this technique and different intubation techniques may qualify as a MRSI depending upon the practitioners. Variability may occur in the duration of preoxygenation, the selection, dosage and timing of administration of the induction agent and muscle relaxant, the application of cricoid pressure or other factors. The primary purpose of this survey was to determine the working definition of MRSI as well as modalities of its use in the clinical practice.
| Materials and Methods|| |
After consultation with the Institutional Review Board (IRB), a waiver of IRB approval was granted. This descriptive study consisted of a survey of pediatric anesthesiologists who have completed training and are active members of the Society for Pediatric Anesthesia (SPA). It was submitted to and approved by the SPA research committee and sent via electronic mail to active members. The survey [Appendix 1][Additional file 1] included basic questions related to the anesthesiologist's experience, practice setting and the modalities of use of MRSI. A second electronic mail reminder was sent if the survey was not returned. Responses were compiled and analyzed at the end of the survey to determine the technique, perceived indications and complications of use of MRSI in children.
| Results|| |
The mean ± SD years in practice of the 228 respondents (estimated at 11% of available surveyed) was 14.9 ± 8.2 years with pediatric patients representing 77 ± 33% of their practice. , 76.8% completed a fellowship in pediatric anesthesia. The median number of years after fellowship completion was 13.4 ± 8.1 years. 60% of the respondent's practice setting was at a Children's Hospital [Table 1]. The majority of respondents (65.4%) defined modified RSI as equivalent to a RSI, but with mask ventilation, 34.7% as equivalent to a RSI, but with the use of rocuronium instead of succinylcholine, 17.1% as equivalent to a regular intravenous (IV) induction, but with cricoid pressure application, 7.9% as a regular mask induction with cricoid pressure application, 6.6% as a RSI with pre or co-administration of narcotics or benzodiazepines, 3.1% as a regular induction without assisted ventilation/oxygenation from time of apnea to laryngoscopy, 2.2% as a RSI without preoxygenation, 2.6% all the above and 16.7% as other [Figure 1] (respondents were allowed to choose multiple answers). The reported frequency of use of a MRSI is documented in [Figure 2], with 6.1% of respondents' stated always using and 4.8% never using a MRSI technique. Indications of use of a MRSI were a concern about apnea time tolerance with traditional RSI, concern about muscular pathology if succinylcholine is used and concern about airway difficulty in 73.7%, 70%, and 44.2% of respondents, respectively [Figure 3]. The muscle relaxant of choice for a RSI in a pediatric patient was succinylcholine (62.2%), followed by rocuronium in 22.1% of respondents. The muscle relaxant of choice was rocuronium (62.7%), followed by succinylcholine in 12.4% of respondents who used the MRSI technique [Figure 4]. The age of patient was considered as a factor in choosing the muscle relaxant (i.e., concern about an undiagnosed neuromuscular pathology) in 35% of respondents using the MRSI technique. The minimum age of patients when succinylcholine is used is shown in [Figure 5].
Of the respondents, 40.6% would wait until the O 2 saturation is less than 95% to modify the RSI and 50% would wait until the O 2 saturation is less than 90% to modify the RSI technique [Figure 4]. Complications upon using a MRSI were reported as none, desaturation, aspiration, difficulty in intubation associated with the induction technique and other in 48.8, 40.6, 12.4, 12 and 3.2% of respondents, respectively [Figure 6]. Most respondents somewhat agree that they consider that a RSI and a modified RSI offered a lower incidence of complications when compared with regular IV induction, in a pediatric patient at risk of aspiration [Figure 7]. 62.7% of respondents think that a cuffed tube should be used in a RSI or MRSI. In case of a high-risk for aspiration or a difficult airway, 32.7% of the respondents would consider an awake intubation in neonates only, 11% in both neonates and infants and 25.8% in all neonates, infants and children, 22.6% would never consider it. Cricoid pressure was more frequently applied by the anesthesiologist during the day shifts and by the operating room nurse during the night shifts [Figure 8].
|Figure 6: Observed complications after modifi ed rapid sequence intubation|
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|Figure 7: Perception of a lower incidence of complications with rapid sequence intubation and modifi ed rapid sequence intubation versus regular intravenous induction in a pediatric patient at risk for aspiration|
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| Discussion|| |
RSI as originally described, includes preoxygenation with 100% oxygen, administration of an IV induction agent, succinylcholine and cricoid pressure to facilitate tracheal intubation and apnea prior to securing the airway with an endotracheal tube (ETT).  RSI has been referred to as the standard of practice in prevention of aspiration; however, in pediatric practice, different considerations such as to the age and status of the patient and different agents administered may favor the use of a MRSI in place of the classic RSI.
In this survey, 65.4% of respondents perceived MRSI as identical to a RSI, but with mask ventilation. More variations to the RSI may be applied as shown in [Figure 1]. The majority of respondents included using the mask ventilation in their definition of MRSI. More recently, an editorial has described a "controlled rapid sequence induction" in pediatric patients with a consensus of its use in Europe.  The authors state that mask ventilation with pressures not exceeding 10-12 cm H 2 O allows oxygenation, limits hypercarbia and keeps the small airways open without the risk of gastric inflation and related morbidity. , This argument was based on applying this induction technique over many years at the authors' and different institutions.
A total of 74% of respondents to the survey considered applying MRSI if they were concerned about apnea time tolerance with traditional RSI. A reduced tolerance to apnea, which may result from different factors such as increased oxygen demand, reduced functional residual capacity and increased closing capacity and very limited cooperation during the preoxygenation are related to age. Neonates and infants may develop hypoxemia (SpO 2 < 90%) before full neuromuscular blockade is accomplished ,, and rapid desaturation may be more dramatic in severely ill-children.
The threshold to modify RSI technique was with oxygen saturation values less than 95% and less than 90% in 41% and 50% of respondents, respectively [Figure 4]. Since severe oxygen desaturation may occur rapidly past these values, stress and haste have been described as important factors with classic RSI in the pediatric population, triggering further complications such as forced mask ventilation and problems with intubation. 
The percentage of respondents using MRSI if concerned about muscular pathology was 70% [Figure 4] with rocuronium administered as the muscle relaxant of choice for pediatric MRSI (>60% of respondents) [Figure 5]. The use of succinylcholine has been debated in the pediatric literature and practice. , Its favorable use in RSI for aspiration prevention is related to its rapid effect minimizing the time that the airway remains unprotected. The youngest age category for starting administration of succinylcholine by the majority of anesthesiologists was in adolescents (45.2%) followed by neonates (27.4%) with 8.2% never using succinylcholine [Figure 6].
The majority (63%) of respondents replied that a cuffed tube should be used in a RSI or MRSI in a pediatric patient. The youngest age category for use of a cuffed ETT by the majority of respondents was in children. The traditional advantages for young children are that an uncuffed ETT with air leak exerts minimal pressure on the internal surface of the cricoid cartilage and allows insertion of an ETT of larger internal diameter, resulting in less airway resistance while cuffed ETT may offer a reduced number of endotracheal reintubation and decreased leak leading to a greater ease and consistency of delivery of high airway pressures and a theoretical attenuated incidence of aspiration.  In the presence of a high-risk of aspiration and/or difficult airway, 33% of respondents would consider awake intubation in neonates and 23% of respondents would never consider performing an awake intubation. Among different concerns of an awake tracheal intubation are adverse hemodynamic responses and the debatable increased risk of intraventricular hemorrhage in neonates. 
An important described component of aspiration prevention is the application of cricoid pressure. Well-known polemics related to cricoid pressure have been described in the literature. ,, Cricoid pressure may distort the anatomy of the upper airway resulting in a difficult ventilation and tracheal intubation, especially in infants and neonates. , Relaxation of the lower esophageal sphincter is an undesirable side-effect and performing cricoid pressure in a lightly anesthetized patient may result in bucking and coughing.  Pulmonary aspiration in patients during induction of anesthesia or during tracheal intubation despite the application of cricoid pressure has been described.  Esophageal pressures from active vomiting could overcome cricoid pressure, leading to pulmonary aspiration. It is indicated that cricoid pressure should be relieved immediately during active vomiting to avoid spontaneous rupture of the esophagus (Boerhaave's syndrome). On the other hand, the role of cricoid pressure in preventing passive regurgitation has been demonstrated in cadaveric studies.  The results of surveys from the United Kingdom indicated that RSI was modified more frequently for infants.  Cricoid pressure would include hyperextension of the neck with placement of a hard neck rest beneath the cervical curve, which may not be applicable due to the small size of the child. In the literature, several publications refer to a MRSI with the use of inhalation induction , and RSI after pre-loading with narcotics , or without the use of muscle relaxants.  In this survey, 33% of respondents would consider a MRSI without administration of muscle relaxant when concerned about a muscular pathology [Figure 4]. In this survey, cricoid pressure was reported to be applied more frequently by the anesthesiologist during the day shifts and by the operating room nurse during the night shifts [Figure 8]. In children, appropriate force for a specific age group is not well-known. In the literature, different degrees of application and the questionable necessity of application of cricoid pressure have been described in different studies and reports. ,
In this survey, variation of use and observed complications of MRSI [Figure 7] may have been expected along with the variation of MRSI definition. The majority of the responders [Figure 8] agreed that MRSI offers a lower incidence of complications than regular IV induction in pediatric patients at risk for aspiration.
| References|| |
|1.||Turner DAB. Emergency Anesthesia. 5 th ed. In: Aitkenhead AR, Smith G, editors. Textbook of Anesthesia. Edinburgh: Churchill Livingstone; 2006. p. 540-6. |
|2.||Weiss M, Gerber AC. Rapid sequence induction in children-it's not a matter of time! Paediatr Anaesth 2008;18:97-9. |
|3.||Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth 1987;59:315-8. |
|4.||Weiler N, Heinrichs W, Dick W. Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. Prehosp Disaster Med 1995;10:101-5. |
|5.||Hardman JG, Wills JS. The development of hypoxaemia during apnoea in children: A computational modelling investigation. Br J Anaesth 2006;97:564-70. |
|6.||Xue FS, Luo LK, Tong SY, Liao X, Deng XM, An G. Study of the safe threshold of apneic period in children during anesthesia induction. J Clin Anesth 1996;8:568-74. |
|7.||Kinouchi K, Fukumitsu K, Tashiro C, Takauchi Y, Ohashi Y, Nishida T. Duration of apnoea in anaesthetized children required for desaturation of haemoglobin to 95%: Comparison of three different breathing gases. Paediatr Anaesth 1995;5:115-9. |
|8.||Eich C, Timmermann A, Russo SG, Cremer S, Nickut A, Strack M, et al. A controlled rapid-sequence induction technique for infants may reduce unsafe actions and stress. Acta Anaesthesiol Scand 2009;53:1167-72. |
|9.||Mazurek AJ, Rae B, Hann S, Kim JI, Castro B, Coté CJ. Rocuronium versus succinylcholine: Are they equally effective during rapid-sequence induction of anesthesia? Anesth Analg 1998;87:1259-62. |
|10.||Cheng CA, Aun CS, Gin T. Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children. Paediatr Anaesth 2002;12:140-5. |
|11.||Kagawa T. Pediatric airway management: Cuffed endotracheal tube and other devices for tracheal intubation. Masui 2007;56:534-41. |
|12.||Cook-Sather SD, Tulloch HV, Cnaan A, Nicolson SC, Cubina ML, Gallagher PR, et al. A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis. Anesth Analg 1998;86:945-51. |
|13.||Brock-Utne JG. Is cricoid pressure necessary? Paediatr Anaesth 2002;12:1-4. |
|14.||Lerman J. Is cricoid pressure necessary? Paediatr Anaesth 2002;12:655; author reply 655. |
|15.||Lerman J. On cricoid pressure: "May the force be with you". Anesth Analg 2009;109:1363-6. |
|16.||Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: An observational study using magnetic resonance imaging. Anesthesiology 2003;99:60-4. |
|17.||MacG Palmer JH, Ball DR. The effect of cricoid pressure on the cricoid cartilage and vocal cords: An endoscopic study in anaesthetised patients. Anesthesia 2000;55:263-8. |
|18.||Tournadre JP, Chassard D, Berrada KR, Boulétreau P. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology 1997;86:7-9. |
|19.||Robinson JS, Thompson JM. Fatal aspiration (Mendelson's) syndrome despite antacids and cricoid pressure. Lancet 1979;2:228-30. |
|20.||Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia. Lancet 1961;2:404-6. |
|21.||Stoddart PA, Brennan L, Hatch DJ, Bingham R. Postal survey of paediatric practice and training among consultant anaesthetists in the UK. Br J Anaesth 1994;73:559-63. |
|22.||Lowry DW, Carroll MT, Mirakhur RK, Hayes A, Hughes D, O'Hare R. Comparison of sevoflurane and propofol with rocuronium for modified rapid-sequence induction of anesthesia. Anesthesia 1999;54:247-52. |
|23.||El-Orbany MI, Wafai Y, Joseph NJ, Salem MR. Tracheal intubation conditions and cardiovascular effects after modified rapid-sequence induction with sevoflurane-rapacuronium versus propofol-rapacuronium. J Clin Anesth 2002;14:115-20. |
|24.||Istvan J, Belliveau M, Donati F. Rapid sequence induction for appendectomies: A retrospective case-review analysis. Can J Anaesth 2010;57:330-6. |
|25.||Cork RC, Weiss JL, Hameroff SR, Bentley J. Fentanyl preloading for rapid-sequence induction of anesthesia. Anesth Analg 1984;63:60-4. |
|26.||Lloréns Herrerías J. Rapid-sequence anesthesia induction. Rev Esp Anestesiol Reanim 2003;50:87-96. |
|27.||Escott ME, Owen H, Strahan AD, Plummer JL. Cricoid pressure training: How useful are descriptions of force? Anaesth Intensive Care 2003;31:388-91. |
|28.||Schmidt A, Akeson J. Practice and knowledge of cricoid pressure in southern Sweden. Acta Anaesthesiol Scand 2001;45:1210-4. |
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