Rapid sequence induction

SOAP ME mnemonic for rapid sequence induction/intubation Suction, Oxygen, Airway Equipment (including a... 

Maximum block after suxamethonium develops in 60-90 seconds following a dose of 1 mg-kg-1 (about 3xED95) with a duration of action of 5-10 minutes. This dose provides near ideal intubating conditions in 60-90 seconds. It is because of a rapid onset and a short duration of action that suxamethonium is considered as the ideal agent for facilitating tracheal intubation during rapid sequence induction. 

Fuchs-Buder T, Sparr HJ, Zeigenfu BT. Thiopentone or etomidate for rapid sequence induction with rocuronium Br J Anaesth 1998 80 504-6. 

SOAP ME mnemonic for rapid sequence induction/intubation Suction, Oxygen, Airway Equipment (including a rescue/backup airway device or technique), Pharmacology, Monitoring Equipment SOB short of breath soln solution sp species... 

Adrenocortical function has been assessed in a randomized trial after intravenous etomidate in 30 patients who required rapid-sequence induction and tracheal intubation (402). The controls received midazolam. Etomidate caused adrenocortical dysfunction, which resolved after 12 hours. 

Patients with burns, nerve damage or neuromuscular disease, closed head injury, and other trauma can respond to succinylcholine by an exaggerated release of potassium into the blood, occasionally resulting in cardiac arrest. As a result of the cardiac arrests (presumably caused by hyperkalemia), the Food and Drug Administration recommended in 1993 that succinylcholine no longer be used in children. However, this highly controversial contraindication was subsequently modified to a simple warning because no acceptable alternative to succinylcholine was available for rapid-sequence inductions. 

Paralysis is preceded by muscular fasciculation, and this may be the cause of the muscle pain experienced commonly after its use. The pain may last 1-3 days and can be minimised by preceding the suxamethonium with a small dose of a competitive blocking agent. Suxamethonium is the neuromuscular blocker with the most rapid onset and the shortest duration of action. Tracheal intubation is possible in less than 60 seconds and total paralysis lasts up to 4 min with 50% recovery in about 10 min (t / for effect). It is particularly indicated for rapid sequence induction of anaesthesia in patients who are at risk of aspiration — the ability to secure the airway rapidly with a tracheal tube is of the utmost importance. If intubation proves impossible, recovery from suxamethonium and resumption of spontaneous respiration is relatively rapid. Unfortunately, if it is impossible to ventilate the paralysed patient s lungs, recovery may not be rapid enough to prevent the onset of hypoxia. 

Sparr HJ, Mellinghoff H, Blobner M, Noldge-Schomburg G. Comparison of intubating conditions after rapacuronium (Org 9487) and succinylcholine following rapid sequence induction in adult patients. Br J Anaesth 1999 82(4) 537-41. 

Abouleish El, Abboud TK, Bikhazi G, Kenaan CA, Mroz L, Zhu J, Lee J, Abboud TS. Rapacuronium for modified rapid sequence induction in elective caesarean section neuromuscular blocking effects and safety compared with succinylcholine, and placental transfer. Br J Anaesth 1999 83(6) 862-7. 

The authors postulated that rapid-sequence induction of anesthesia with sevoflurane had blunted sympathetic tone and allowed uncompensated parasympathetic activation by remifentanil. 

A 72-year-old woman with a symptomatic hiatus hernia, osteoarthritis, and Alzheimer s disease was taking fluoxetine 20mg/day, donepezil hydrochloride 10 mg/ day, nimesulide 12.5mg/day, and omeprazole 20 mg/ day (288). There still was no twitch response to peripheral nerve stimulation 20 minutes after rapid-sequence induction of anesthesia with propofol 2.5mg/kg and suxamethonium 1 mg/kg. She then gradually developed a weak twitch response, and 50 minutes after induction of anesthesia four twitches with a fade were elicited by train-of-four stimulation. No additional medication was given and after the end of the procedure 10 minutes later she was extubated uneventfully. She refused further blood testing and so her plasma cholinesterase activity at that time is not known. However, her anesthetic notes from a previous operation did not reveal any problems with prolonged paralysis after suxamethonium. 

Edmondson L, Lindsay SL, Lanigan LP, Woods M, Chew HE. Intra-ocular pressure changes during rapid sequence induction of anaesthesia. A comparison between thiopentone and suxamethonium and thiopentone and atracurium. Anaesthesia 1988 43(12) 1005-10. 

Zimmerman AA, Funk KJ, TidweU JL. Propofol and alfentanU prevent the increase in intraocular pressure caused by succinylchohne and endotracheal intubation during a rapid sequence induction of anesthesia. Anesth Analg 1996 83(4) 814-17. 

Perry J, Lee J, Wells G. Rocuronium versus succinylcho-hne for rapid sequence induction intubation (Cochrane Review). The Cochrane Library. Oxford Update Software, 2003 1. 

Frakes MA Muscle relaxant choices for rapid sequence induction. Air Med J 20(I) 20-2I, 2001. 

Stacey MRW, Barclay K, Asai T, Vaughan R Effects of magnesium sulphate on suxame-thonium-induced complicatic is during rapid-sequence induction of anaesthesia Anaesthesia (1995) 50,933-6. 

Leaking thiopental syringe during rapid sequence induction for emergency Caesarian section - leak in pre-prepared syringe made up in pharmacy department. 

Systematic reviews Because of its fast onset of action, rocuronium is a potential alternative to suxamethonium for rapid-sequence intubation in patients with an increased risk of aspiration. Four relevant studies considering the use of suxamethonium and rocuronium in emergency departments were selected from an evidence search and a structured review performed [11 ]. For the outcomes of clinically acceptable intubation conditions and time to onset, the two agents were not statistically significantly different. Suxamethonium seems to produce conditions that have higher satisfaction scores. The authors concluded that suxamethonium remains the drug of choice for emergency department rapid-sequence induction, unless there is a contraindication. 

Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2008 (2) CD002788. 

Sluga M, Ummenhofer W, StuderW, et al. Rocuronium versus sucdttylcho-line for rapid sequence induction of anesthesia and endotracheal intubation a prospective, randomized trial in emergent cases. Anesth Analg. 2005 101 1356-1361. 

---