In 1951 Morton and Wylie described the technique of rapid IV administration of a barbiturate and a muscle relaxant almost simultaneously followed by intubation with a cuffed endotracheal tube “to prevent regurgitation or vomiting of gastric contents”. Later in 1971 Stept and Safar reported a fifteen-step technique to prevent “regurgitation, vomiting and aspiration during Induction of anesthesia and resuscitation” and use the term “rapid sequence induction” still in vogue today. A lot has been written on the subject and considerable controversy persists: a)is it effective or not? b)should crycoid pressure be used and if so, how should it be performed? c)Should BMV be withheld or not.?
I expect a lot of controversy and participation (do not make me think this is wishful thinking) .
I’ll be interested to see what Mark Rice offers with regard to Cricoid Pressure. I was trained in the “don’t ventilate” camp…both for aspiration reasons, and b/c in virtually all cases, regardless you’re going to push the Succ (whether or not you can mask ventilate). Maybe more impt if considering Roc. These places where “standard of care” exists and EBM is lacking (not negative, just lacking), pose a problem for medico-legal issues I’d think…perhaps Dr. Kirby has an opinion here?
Posted on June 22nd, 2009 at 2:23 pmUnfortunately I do not know if Mark reads the blog. I am more inclined to “yes” can ventilate provided the pressure is monitored and limited to 20 ccm H20, however, i have seen we get a bit stronger when the chips are down and I have seen occasional high pressures when we ventilate prior to the fasciculations or we wait for the NDA to act. This is a topic that the Society of airway management has not been able to come to an agreement because of what you say: lack of evidence.. but we do have plenty of opinions.
Posted on June 22nd, 2009 at 2:41 pmi am a fan of routine use of modified rsi. the cricoid prevents gastric insufflation and offers osme protection for even the fasted patient who still has something in their stomach. regardless of full stomach concern or not i gently ventilate. this buys time and alerts the operator at earliest possible moment that yes there is a maskable airway which is reassuring or allows early identification that the airway is not perfect and then m,aneuvers can be initiated to establish ventilation long before desaturation begins to make its presence known. i think it really shifts moving to alternate plan for airway mgmt earlier than if modified rsi mask ventilation werent used and is therefore safer. there are plenty of data that properly applied cricoid protects airway during gentle ventilation. perhaps the focus should be on the skill of the person applying the cricoid. if its not a trained colleague you would be surprised at the answers you get when you ask a circulating nurse what their goal is and how firmly the apply pressure and even where they apply the pressure.
Posted on September 23rd, 2009 at 8:27 amI agree with you, and would like to hear what our OB colleagues say.
Posted on September 23rd, 2009 at 9:36 am