Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review

Tran, D.T.T. et al. (2017) Anaesthesia 72(6) pp. 765–777

This systematic review was performed to determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during rapid sequence intubation of the trachea.

Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions (risk ratio (95%CI) 0.86 (0.81 to 0.92), n = 4151) and clinically acceptable intubation conditions (risk ratio (95%CI) 0.97 (0.95–0.99), n = 3992). A high incidence of detection bias amongst the trials coupled with significant heterogeneity means that the quality of evidence was moderate for these conclusions. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: risk ratio (95%CI) 0.81 (0.73–0.88), n = 2302) with or without the use of opioids (risk ratio (95%CI) 0.85 (0.78–0.93), n = 2292 or 0.85 (0.76–0.95), n = 1428).

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Incidence of Connected Consciousness after Tracheal Intubation

Sanders, R.D. et al. (2017) Anesthesiology 2(126) pp. 214-222. 


Background: The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice.


Conclusions: Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.

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Rapid Sequence Intubation With Video Laryngoscopy Common for Difficult Airways in ED

Predicted difficult airways in one emergency department are managed most often using rapid sequence intubation (RSI) and video laryngoscopy (VL), a recent study has found | Anesthesiology News

Although difficult airways occur frequently in emergency medicine, few studies have investigated the incidence, management and outcomes of these patients, according to the investigators.

“We’ve been collecting airway data at our institution for many years, and this past year we decided to focus on the difficult airway,” said John C. Sakles, MD, professor of emergency medicine at the University of Arizona College of Medicine, in Tucson. Dr. Sakles presented the study at the 2016 annual meeting of the Society for Airway Management.

The study examined 348 nonarrest intubations between July 1, 2015, and March 31, 2016, at Banner University Medical Center, in Tucson. Operators performed a difficult airway assessment and classified the airway into one of three categories: routine, challenging or difficult.

Read the full research overview here

Anaesthetists and surgeons reach agreement on front of neck emergency techniques in life-threatening ‘CICO’ situations

Royal College of Anaesthetists | Published online: 19 September 2016

A new research paper, jointly published today by the British Journal of Anaesthesia and Clinical Otolaryngology, recommends the scalpel-bougie cricothyroidotomy technique as the most efficient and reliable method of obtaining emergency front of neck access to the trachea in a situation where the patient’s airway is blocked and routine methods fail.

Without this rescue technique many of these patients would die. The technique, which involves placing a tube into the windpipe using a scalpel and a small guide, is recommended by a working group of anaesthetists and ear, nose and throat surgeons, led by the Royal College of Anaesthetists, which is working to spread this information to clinicians across the country.

Patients who are unconscious, either through illness or during anaesthesia, require a tube to be placed into the trachea to enable oxygen to reach the lungs. Although anaesthetists are able to manage the vast majority of difficult airways, some may rapidly develop into ‘can’t intubate, can’t oxygenate’ (CICO) events, which are one of the most feared emergencies in clinical medicine. These life-threatening situations, occurring  approximately 100 times per year in the UK, often take place after instances of failed airway management and, if not managed correctly will lead to death or brain damage from lack of oxygen.

Anaesthetists and surgeons must work quickly and collaboratively to place a tube in the front of the neck (a front of neck airway, FONA). Good team communication, correct choice of FONA techniques and timing of interventions are all critical to the survival of the patient suffering from life-threatening breathing problems.

Read the original article abstract here

Read the full RCA statement here

Prediction in airway management: what is worthwhile, what is a waste of time and what about the future?

Teoh, W.H. & Kristensen, M.S. British Journal of Anaesthesia (2016) 117 (1): 1-3.

Nørskov and colleagues1 randomized Danish anaesthesia departments in two groups, in order to investigate the effect of a structured airway examination on the ability to predict difficult intubation by direct laryngoscopy. The departments either continued with the pre-anaesthetic airway evaluation that they were used to, or applied the structured evaluation that consisted of five parameters (mouth opening, thyromental distance, Mallampati classification, neck movement and ability to prognath) and two questions (weight, previous difficult intubation) that culminated in the calculation of the Simplified Airway Risk Index (SARI).2This study found that clinicians were able to predict between nine and 50% of the patients where intubation with direct laryngoscopy was or would have been difficult. This success-rate in prediction difficulty was NOT different between the departments that continued with business-as-usual, and the departments where the evaluation of the seven predictive parameters was implemented.

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Read the cited Nørskov et al. article abstract here

Intubation performance using different laryngoscopes while wearing chemical protective equipment: a manikin study

Schröder, H et al. BMJ Open 2016;6:e010250

Objectives: This study aimed to compare visualisation of the vocal cords and performance of intubation by anaesthetists using four different laryngoscopes while wearing full chemical protective equipment.

Setting: Medical simulation center of a university hospital, department of anaesthesiology.

Participants: 42 anaesthetists (15 females and 27 males) completed the trial. The participants were grouped according to their professional education as anaesthesiology residents with experience of <2 years or <5 years, or as anaesthesiology specialists with experience of >5 years.

Interventions: In a manikin scenario, participants performed endotracheal intubations with four different direct and indirect laryngoscopes (Macintosh (MAC), Airtraq (ATQ), Glidescope (GLS) and AP Advance (APA)), while wearing chemical protective gear, including a body suit, rubber gloves, a fire helmet and breathing apparatus.

Primary and secondary outcome measures: With respect to the manikin, setting time to complete ‘endotracheal intubation’ was defined as primary end point. Glottis visualisation (according to the Cormack-Lehane score (CLS) and impairments caused by the protective equipment, were defined as secondary outcome measures.

Results: The times to tracheal intubation were calculated using the MAC (31.4 s; 95% CI 26.6 to 36.8), ATQ (37.1 s; 95% CI 28.3 to 45.9), GLS (35.4 s; 95% CI 28.7 to 42.1) and APA (23.6 s; 95% CI 19.1 to 28.1), respectively. Intubation with the APA was significantly faster than with all the other devices examined among the total study population (p<0.05). A significant improvement in visualisation of the vocal cords was reported for the APA compared with the GLS.

Conclusions: Despite the restrictions caused by the equipment, the anaesthetists intubated the manikin successfully within adequate time. The APA outperformed the other devices in the time to intubation, and it has been evaluated as an easily manageable device for anaesthetists with varying degrees of experience (low to high), providing good visualisation in scenarios that require the use of chemical protective equipment.

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Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients

Riad, W. et al. European Journal of Anaesthesiology: April 2016 – Volume 33 – Issue 4 – p 244–249

Image source: Sarah Jordan

Background: There is conflicting evidence as to whether obesity and neck circumference are predictors of difficult intubation in the surgical population. In addition, the cut-off neck circumference related to difficult intubation has not been clearly identified.

Objectives: The primary study objective was to determine whether neck circumference and obesity were predictors of difficult intubation in morbidly obese surgical patients. Secondary outcomes included difficult mask ventilation.

Main Outcome Measures: The primary outcome of the study was difficult tracheal intubation. An Intubation Difficulty Scale (IDS) was derived using seven parameters and difficult intubation was defined as IDS of at least 5. The secondary outcome was difficult mask ventilation; mask ventilation was graded as easy or difficult (inadequate, desaturation, two-handed or impossible).

Results: Univariate analyses showed that difficult intubation was associated with neck circumference, males, BMI more than 50 kg m−2, American Society of Anesthesiologists (ASA) status and waist circumference, and difficult mask ventilation with neck circumference, males, BMI more than 50 kg m−2 and thyromental distance. Multiple logistic regression analysis showed that neck circumference more than 42 cm (P = 0.044) and BMI more than 50 kg m−2 (P = 0.017) were independent predictors of difficult intubation. Male sex (P = 0.004) and BMI more than 50 kg m−2 (P = 0.031) were independent predictors of difficult mask ventilation.

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