Rapid Sequence Induction Practices In The United States And The United Kingdom: A Comparative Survey Study.

摘要

Purpose:We aimed to survey the members of anesthesia departments in two large university hospitals, University of Washington (Seattle, USA) (UW-US) and University of Nottingham (Nottingham, UK) (UN-UK) to compare differences in their current approach to rapid sequence induction (RSI). Methods: The survey was distributed in electronic and paper format in 2009. Overall response rate was 48.6% (146/300). Participants were asked to indicate their practice for a RSI technique for emergency appendectomy in a previously healthy adult. Data were summarized descriptively using frequency distribution. Chi square statistic was used to compare frequency of responses.Results: There were several differences in the practice of RSI: 1. Aspiration prophylaxis was preferred in UW-US (40%) versus UN-UK (12%); 2. Preferred patient position was with a head support in UW-US versus 30o head of the bed elevation in UN-UK; 3. UW-US reported not to use mask ventilation prior to intubation (55%) versus UN-UK (78%); 4. The preferred opioid was fentanyl (93%) for UW-US and alfentanil (74%) for UN-UK; 5. Adjuvant drugs were used by 68% of UW-US versus 8% of UN-UK providers; 6. Commonly used induction agents were propofol in UW-US (94%) and thiopental in UN-UK (51%). Both centers preferred succinylcholine for muscle relaxation to rocuronium (UW-US 80% versus UN-UK 90%). Conclusions: RSI practice differed significantly across continents. Due to disagreement and a lack of scientific evidence regarding the standards of RSI, it appears that traditional RSI practice has already been abolished. Revised evidence based guidance statement is due and has the potential to reduce practice variability. Introduction Pulmonary aspiration is defined as the inhalation of oropharyngeal or gastric contents into the lower respiratory tract. Curtis Mendelson, an obstetrician, was the first physician to study the pathogenesis of the disease (Mendelson’s Syndrome) using both case reports and animal experiments. Following contamination, lung epithelial cells and alveolar macrophages secrete chemical mediators, attracting and activating neutrophils, which in turn release proteases and reactive oxygen species, damaging the alveolar - capillary unit. Pneumonia, chemical pneumonitis and respiratory distress syndrome are possible adverse outcomes associated with significant morbidity and mortality. The overall incidence of pulmonary aspiration of gastric contents during procedures undertaken with general anesthesia is estimated to be 1 in 2,000–3,000 cases. Aspiration is more frequent in emergency (1 in 600–900) than elective (1 in 3,000–4,000) procedures [1].Rapid sequence induction (RSI) is commonly used to secure the airway in patients considered to be at risk of regurgitation and pulmonary aspiration of gastric contents. Stept and Safar originally published the 15-step RSI technique in 1970. The key elements of this technique should include the reduction of gastric volume, the control of acidity and passive movement of gastric content, the minimization of time during which the airway is unprotected, and avoiding hypoxemia during attempts to secure the airways with tracheal intubation. All of these steps would appear to be logical and justifiable precautions. However, there has been debate over the understanding, the evidence base and clinical value of the individual components of this approach [1]. The apparent absence of compelling evidence poses challenges to both the modern practitioner and those responsible for training junior colleagues. It would seem reasonable to adopt and teach what is deemed to be “best practice” at regional, national or international level. Unfortunately a number of published surveys indicate significant variations in practice among anesthesia providers [2]. The purpose of this study was to describe the most utilized strategies to manage RSI and compare practice among university-affiliated hospital providers trained and practicing in different countries.