It should be obvious by now, after 20 years of the use of VL, that RSI should only be attempted with video laryngoscopy (VL)! So, optimising the first-pass success chance is mandatory every time RSI is chosen it includes not only VL but VL with the head well above the stomach level (steep reverse Trendelenburg or at least 30-degree dorsum elevation). Let’s go to polemic number 1: If a patient’s life depends on the first attempt success, why try a method that is less reliable for first-pass success (direct laryngoscopy)? If the anaesthesiologist chose RSI there is an implicit commitment to achieve first-pass success. The key factor in the safety of RSI is fast success at the first attempt of intubation! Supposing that this rationale is true, this patient could be saved from the aspiration only to “safely die” from hypoxia in the case the anesthesiologist is not able to intubate. Take into consideration that the rationale for RSI is that a paralysed patient with the head elevated to a level superior to the stomach is not able to either vomit or regurgitate, so this paralyzed patient is “safe” from the aspiration risk. Traditional practice advocates that no mask ventilation should be performed in patients who are not fastened (aspiration risk), due to the presumed risk of gastric insufflation and facilitated regurgitation. If you are uncomfortable with the fact that such an important decision is made based on a very fallible (unreliable) evaluation, it gets worse! The worst possible scenario is to have a difficult intubation patient apneic and unconscious, with a tangible aspiration risk with low and falling saturation. Up to this point in the text, there is no polemic question.
If you suspect that the intubation could be difficult you are compelled to choose ATI, for the sake of patient safety if there is no reason to suspect that the intubation is difficult you are allowed to proceed with the so-called RSI. The decision between RSI and ATI will be based on the perceived difficulty you could find in intubation. The second choice is to intubate first and induce later (ATI – awake tracheal intubation). The most common answer is to proceed with the so-called Rapid Sequence Intubation (RSI). There are two different approaches to deal with the aspiration risk. How many of the predictors of difficult ventilation (or which ones in particular) do I need to decide whether to intubate someone before or after induction? For now, we do not know the answer to this question. With all that said, I conclude that it is too preposterous of us to guide our conduct based on something that resembles “guessing”. Literature has repeatedly shown that the clinical evaluation of predictors for both difficult intubation and mask ventilation is NOT reliable, and yet we keep believing in our fictional ability to predict in which patient we are going to face difficulties.
RAPID SEQUENCE INTUBATION CASE SCENARIOS HOW TO
In rougher environments, even the old-fashioned direct laryngoscope may do the trick, but with a much higher discomfort for the patient.Īll this is based on a fictional presumption that we have the slightest idea how to identify which one among all the patients is difficult to ventilate or intubate. The recommended management of patients in whom a difficult airway is predicted is to perform “awake” intubation (ATI), which is accomplished using either a flexible intubation scope or (more recently), a video laryngoscope.
RAPID SEQUENCE INTUBATION CASE SCENARIOS PLUS
We propose and believe that whenever there is uncertainty or doubt about the ability to VENTILATE, the most prudent approach is to proceed with topical anaesthesia (with or exceptionally without) plus sedation (or exceptionally without) and perform the so-called “awake intubation” (ATI). The basis of all the algorithms (and our beliefs) is that once we have defined that we can with “certainty and security” guarantee the ventilation (and/or maybe intubation), we can induce. Marcelo Ramos, most important decision in anaesthesia is whether to intubate BEFORE or AFTER induction. We expect comments and opinions from our readers.
Chief Editor note : This clinical paper raises an important dilemma for the practitioner.
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