It would be very interesting to hear comments from our fellow members of the Peds. group regarding this never ending controversy of RSI. Does this simulation study give us the answer?
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Sep
Sep
Controlled RSI in Peds?
2 Responses to “Controlled RSI in Peds?”
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Associate Professor of Anesthesiology at the University of Florida; I did my residency then fellowship in Cardiothoracic anesthesia, completed a Masters In Education at UF in 2012 and have been a UF/VA staff anesthesiologist since 2000. I was also the Director of the Master of Education Fellowship from the C.O.M. until the course was terminated. I am responsible for the Difficult Airway Rotation at the UF and Airway Management Services at the NFSGVHS. My interests include: 1-Airway related topics 2-Education about Airway management 3- Resident training in Airway management 4-Non-Anesthesia providers airway training and education 5-Education in general and specifically technology in education.
Response from Ilan Keidan:
I think this is an extremely important subject. It is not only important to pediatric anesthesiologists as it reasonable to assume that some of our graduating residents practicing general anesthesia will have the privilege to take care of babies with pyloric stenosis. While most pediatric anesthesiologists will use modified (also named controlled Rapid sequence induction, using an IV induction agent like propfol and rocuronium 0.3-0.6 mg/kg ( after suctioning the stomach) , others are still following the unsubstantiated recommendation in Miller (including the new edition) (“Children with pyloric stenosis can be managed with awake endotracheal intubation followed by low-dose rocuronium (0.3 mg/kg) who writes those recommendations ?! or rapid-sequence induction of anesthesia with cricoid pressure after atropine (0.02 mg/kg), propofol (3 mg/kg), and succinylcholine (2 mg/kg)”). Classical RSI includes preoxygenation with 100% oxygen, administration of a predetermined induction dose, cricoid pressure, use of sux to facilitate tracheal intubation and apnea prior to securing the airway with a cuffed tracheal tube, Although these actions seem simple and logical, not one randomized controlled trial has confirmed the benefits of classical RSI . Very often RSI turns into an inappropriate, stressful procedure. In babies different aspects need to be discussed for one preoxygenation is hardly ever possible in an awake baby the second whether, sux with its major side effects should be used at all. It is the only drug that achieves adequate intubation conditions within 1 min (large doses of rocuronium are not reasonable for a relatively short procedure) still magical 1-min apnea is not appropriate for babies and desaturation will occur within <1 min. (limited cooperation during preoxygenation, reduced functional residual capacity and increased oxygen demand. Closing capacity is greater in infants and small children and it leads to increased airway collapse with induction of anesthesia and muscle paralysis). Since maintaining saturation is physiologically impossible most pediatric anesthesiologists use gentle, pressure-limited mask ventilation with 100% oxygen in pediatric RSI after induction of anesthesia to avoid hypoxemia and significant hypercapnia. Bag and mask ventilation with pressure limitation to 10–12 cm H2O while maintaing anesthesia with inhalational agents or repeated doses of intravenous anesthetics are of the outmost importance during this time period. As hypoxemia and hypercapnia are prevented by gentle ventilation the time to obtain ideal intubation conditions is no longer critical
Posted on September 16th, 2009 at 10:51 amLack of rush and establishing ideal respiratory, hemodynamic and anesthetic intubation conditions will also allow anesthesiologists not routinely caring for children to perform tracheal intubation under optimal conditions, we will avoid forceful airway maneuvers, untoward cardiovascular reflexes, coughing and straining or even retching and vomiting It is worthy to remember that pulmonary perioperative aspiration in children is associated primarily with light anesthesia and incomplete muscle paralysis (cricoids pressure does not help ) The study that Dr. Urdaneta was kind enough to bring to our attention is important since it is almost the only one that tried to assess the issue scientifically . however, I think it has major methodological problems
Pediatric patients with a full stomach can be safely anesthetized without getting crushed between hypoxia and traumatic tracheal intubation. Effective induction of deep anesthesia, avoidance of cricoid pressure and confirmation of complete muscle paralysis before intubation attempts are the key featurs of an appropriate pediatric RSI.
Response from Alex Matveevskii:
Personally I let residents do oscillations on bag when they intubate child with pyloric stenosis; cricoid pressure in small children may affect intubating conditions.
Posted on September 16th, 2009 at 10:53 am