Current practice of Rapid Sequence Induction (RSI) in pediatric anesthesia: A survey from India

Abstract

Background and Aims:

Rapid Sequence Induction (RSI) is an established technique to secure the airway in patients who are at risk of aspiration. The practice of RSI in the pediatric population is highly variable due to numerous patient factors. We conducted a survey to find the prevalent practices and adherence of anesthesiologists to the practice of RSI in different pediatric age groups and whether it differs with the experience of the anesthesiologist or the age of the child.

Material and Methods:

The survey was conducted among residents and consultants attending the pediatric national anesthesia conference. The questionnaire consisted of 17 questions on anesthesiologist’s experience, adherence, conduct of pediatric RSI, and the reason for nonadherence.

Results:

The response rate was 75% (192/256). Anesthetists having less than 10 years of experience adhered to RSI more often as compared to respondents with more experience. Succinylcholine was the most commonly used muscle relaxant for induction, with use increasing in higher age groups. The application of cricoid pressure increased with increasing age groups. Anesthetists with >10 years of experience used cricoid pressure more often in age groups of <1 year (P < 0.05). In a scenario of intestinal obstruction, adherence to RSI was low in pediatrics as compared to adults, with 82% of respondents agreeing to this.

Conclusion:

This survey on the practice of RSI in the pediatric population demonstrates wide variation in the practice among individuals and the reasons for nonadherence as compared to adults. It highlights the need felt by almost all the participants for more research and protocol in the practice of pediatric RSI.

Introduction

Rapid sequence induction (RSI) is an established technique to secure the airway in patients who are at risk of aspiration. The sequential steps of “classical RSI” include preoxygenation, induction with thiopentone, application of cricoid pressure, administration of succinylcholine, avoidance of bag-mask ventilation, and rapid tracheal intubation. The practice of RSI in the pediatric population is highly variable due to numerous patient factors. This has led to variation among pediatric anesthetists in the conduct of classical RSI, and modified RSI (MRSI) has taken its place.^[1] Variation occurs in the technique of preoxygenation, administration of drugs, use of cricoid pressure, and ventilation before intubation. These differences stem from differences in the airway anatomy and physiology of the pediatric population in addition to limited evidence-based data of the technique in this age group. Children having low functional residual capacity tend to be uncooperative, making preoxygenation ineffective and leading to short apnea time.^[2] In classical RSI, thiopentone and succinylcholine are used. However, now modifications in drug administration are commonly performed. Administration of opioids, not applying cricoid pressure, and use of propofol and rocuronium instead of succinylcholine are some of the variations being practiced.^[3] Low threshold for desaturation, difficult airway in pediatric patients, and lack of formal training in pediatric anesthesia may result in low adherence to the practice of RSI in children.

In our country, formal training in pediatric anesthesia is limited to a few institutes. Most anesthesiologists giving pediatric anesthesia establish their practice from experience. Protocol-based anesthesia may sometimes not be practiced, resulting in low adherence to this particular life-saving practice or technique. Evidence-based guidelines have not been established to date for pediatric RSI. Previous surveys on pediatric RSI have not studied the adherence and the reasons for not performing this technique.^[3–5]

The aim of the survey is to find the prevalent practices and adherence of anesthesiologists to the practice of RSI in the pediatric age group, whether it differs with the experience of the anesthesiologist or the age of the child, and if more need of protocol-based practice is required. The primary objective was to find out the adherence to RSI and the reasons for not performing it in the pediatric population. The secondary objectives were to evaluate the practice of RSI in terms of drugs used, preoxygenation, use of cricoid pressure, complications faced, and perceived risk factors for aspiration.

Material and Methods

This cross-sectional survey of anesthesiologists was conducted after obtaining ethical clearance (IRB no. JHIEC/559/20). Initially, a preformed questionnaire with 22 questions on practices of pediatric RSI was prepared by the investigators. It was based on the clinical and sequential practice of RSI. Previous surveys on aspiration prophylaxis in the pediatric age group and adult RSI were explored for questionnaire development.^[5,6] Its comprehensiveness and validity were first determined by circulating the survey among departmental faculty members. Suggestions and changes were incorporated into the questionnaire. It was subsequently validated by four senior anesthesiologists (two from the institute and two independent reviewers from another tertiary care teaching institute) practicing pediatric anesthesia for nearly 20 years and not taking part in the study either as investigators or participants. The relevant questions were retained and modified as per expert recommendations. Finally, the questionnaire consisted of 17 questions on anesthesiologist’s experience, adherence, conduct of pediatric RSI, and the reasons for nonadherence (Appendix).

The survey was conducted among residents and consultants attending a pediatric national anesthesia conference in India from 7^th to 9^th February, 2020. The questionnaire was distributed to all the conference attendees and they were requested to fill and return the same on the registration counter. To maintain respondent anonymity, no personal identifying information was enquired in the survey. Consent was taken from all participants.

Data collection was anonymous, all responses were recorded and transferred to Microsoft Excel in tabulated form. Chi-square test was used for the analysis of categorical data and Fischer’s exact test was applied where Chi-square test was not feasible. P < 0.05% was considered as statistically significant.

Results

A total of 256 questionnaires were distributed out of which we received 205 survey forms back. Thirteen forms were not completely filled and were excluded from the analysis. Therefore, a total of 192 forms were analyzed for the purpose of the survey.

The experience of anesthesiologists was as follows: <5 years (26%), 5–10 years (28%), >10 years (46%). Eighty-eight percent were from teaching institutes, while 12% were from non-teaching institutes. 34% gave anesthesia to pediatric patients on daily basis, 41% did few cases per week, 25% did few cases per month.

The risk factors for pulmonary aspiration described by the respondents are shown in Figure 1, with inadequate nil per oral (NPO) and intestinal obstruction considered by almost all respondents. Tracheoesophageal fistula and congenital diaphragmatic hernia were considered by 4 and 3 respondents, respectively.

Figure 1.

Risk factors for pulmonary aspiration perceived by respondents

The practice of RSI among different age groups is shown in Table 1, with anesthetists having less than 10 years of experience adhering to RSI more often as compared to respondents with more experience (P < 0.05). The adherence to RSI increased with increasing age groups of children; 9% would never insert it and 9% would remove it if present. The practice of preoxygenation has been shown in Figure 2, with most of the respondents practicing the tidal volume breath (TVB) technique.

Table 1.

Adherence to RSI among different pediatric age groups. Values are numeric (%)

Adherence to RSI	All respondents (n=192)	Respondents with >10 years’ experience (n=88)	Respondents with <10 years’ experience (n=104)	P
In <1 year age group
Always	74 (39)	26 (30)	48 (46)	0.005*
Sometimes	70 (36)	31 (35)	39 (38)
Never	48 (25)	31 (35)	17 (16)
In 1-5 year age group
Always	104 (54)	37 (42)	67 (64)	0.0001*
Sometimes	70 (36)	33 (38)	37 (36)
Never	18 (9)	18 (20)	0
In 5-14 years age group
Always	136 (71)	55 (63)	81 (78)	0.0002*
Sometimes	43 (22)	20 (23)	23 (32)
Never	13 (7)	13 (15)	0
Cricoid pressure
In <1 year age group
Always	17 (9)	12 (14)	5 (5)	0.03*
Sometimes	61 (32)	31 (35)	30 (29)
Never	114 (59)	45 (51)	69 (66)
In 1-5 year age group
Always	52 (27)	22 (25)	30 (29)	0.32
Sometimes	72 (38)	38 (43)	34 (33)
Never	68 (35)	28 (32)	40 (38)
In 5-14 years age group
Always	79 (41)	29 (33)	50 (48)	0.079
Sometimes	67 (35)	33 (38)	34 (33)
Never	46 (24)	26 (29)	20 (19)

Figure 2.

The practice of preoxygenation in different pediatric age groups (TVB – tidal volume breathing)

Regarding the use of opioids before induction, in the age group of <1 year, 70% would use opioids while 30% would not. For children aged 1–5 years, 87% would use and 13% would not use, while for children aged 5–14 years, 90% would use and 10% would not give opioids. Thus, with the increasing age of the child, opioid usage increased. All the respondents chose fentanyl as the opioid of choice.

The choice of induction agents in different age groups is shown in Figure 3, with propofol being the most commonly used drug. The use of sevoflurane was higher in the <1-year age group, with experienced anesthesiologists (>10 years of experience) more likely to use it (19 vs. 6, P = 0.001). In a scenario where intravenous (I.V.) access was not available before induction, few respondents would induce with sevoflurane as follows: <1 year – 7%; 1–5 years – 6%; 5–14 years – 6%. The rest of the respondents would take an I.V. access and proceed with induction. The choice of muscle relaxants among different age groups and on the basis of the anesthetist’s experience has been tabulated in Table 2. Pre-intubation oxygenation was most commonly practiced by routine gentle bag-mask ventilation (BMV) or only if required [Table 2]. The application of cricoid pressure increased with increasing age groups. Anesthetists with >10 years of experience used cricoid pressure more often in age groups of <1 year (P < 0.05) [Table 1]. In age <1 year, 48% of respondents used cuffed tubes and 52% uncuffed endotracheal tubes. For the 1–5-years age group, 88% used cuffed and 12% uncuffed tubes. While for the 5–14 age group, 96% used cuffed tubes while only 4% used uncuffed tubes. The practice was similar among all anesthesiologists. Regarding placement of nasogastric (NG) tube, 52% of respondents would place an NG tube and perform suction before conducting RSI while 74% would let the NG be in situ if already there.

Figure 3.

Use of induction agents in different pediatric age groups

Table 2.

Practice of relaxant used and pre-intubation oxygenation in different pediatric age groups. Values are numeric (%)

Relaxant used	All respondents (n=192)	Respondents with >10 years experience (n=88)	Respondents with <10 years experience (n=104)	P
In <1 year age group
Succinylcholine	96 (50)	41 (47)	55 (53)	0.38
Rocuronium	53 (28)	24 (27)	29 (28)
Atracurim/Cisatracurium	23 (12)	11 (12)	12 (12)
None	20 (10)	12 (14)	8 (8)
In 1-5-year age group
Succinylcholine	119 (62)	50 (57)	69 (66)	0.43
Rocuronium	55 (29)	28 (32)	27 (26)
Atracurim/Cisatracurium	14 (7)	7 (8)	7 (7)
None	4 (2)	3 (3)	1 (1)
In 5-14-year age group
Succinylcholine	126 (66)	53 (60)	73 (70)	0.28
Rocuronium	53 (28)	26 (30)	27 (26)
Atracurim/Cisatracurium	10 (5)	7 (8)	3 (3)
None	3 (2)	2 (2)	1 (1)
Pre-intubation oxygenation
In <1 year age group
None	8 (4)	4 (5)	4 (4)	0.32
Gentle BMV	93 (48)	43 (49)	50 (48)
Only if required	62 (32)	28 (32)	34 (33)
Oxygen insufflation with nasal cannulae	28 (15)	12 (14)	16 (15)
In 1-5-year age group
None	5 (3)	3 (3)	2 (2)	0.92
Gentle BMV	90 (47)	40 (45)	50 (48)
Only if required	71 (37)	33 (38)	38 (37)
Oxygen insufflation with nasal cannula	26 (13)	12 (14)	14 (13)
In 5-14-year age group
None	6 (3)	3 (3)	3 (3)	0.82
Gentle BMV	86 (45)	42 (48)	44 (42)
Only if required	78 (41)	32 (36)	45 (43)
Oxygen insufflation with nasal cannulae	24 (12)	11 (13)	13 (12)

BMV - Bag-mask ventilation

The complications faced by respondents during pediatric RSI have been shown in Figure 4, with desaturation and difficulty in intubation being the commonest (56% and 47%, respectively). Aspiration was rare, with only 8.5% reporting this complication. Further, 24% of respondents also reported that they never faced any complications during this procedure. In a scenario of intestinal obstruction, adherence to RSI was low in pediatrics as compared to adults, with 82% of respondents agreeing to this. The reasons for low adherence are shown in Figure 5. Paucity of evidence regarding effective cricoid pressure and distortion of laryngoscopic view were the main causes. Moreover, 94% of respondents felt that more research and protocol-based practice is required in pediatric RSI.

Figure 4.

Complications faced by respondents during RSI

Figure 5.

Causes of low adherence to rapid sequence induction

Subgroup analysis was performed comparing respondents working in teaching hospitals to non-teaching hospitals. There was no difference in adherence to RSI in <1 year (P = 0.94), 1–5 year (P = 1.0), and 5–15 year age group (P = 1.0). The use of succinylcholine was similar in all age groups (P = 0.79, 0.52, and 0.27 for age groups <1 year, 1–5, and 5-14 years, respectively). Rocuronium was also utilized without significant difference among both groups. The practice of applying cricoid pressure did not vary with the type of institute (P = 0.68, 0.11, and 0.57 for age groups <1 year, 1–5, and 5–14 years, respectively).

Discussion

Our survey showed a difference in the practice of RSI in different age groups of children and also with the experience of the anesthesiologist. Those with less than 10 years of experience were more likely to adhere to the practice of RSI. This is perhaps because more experienced anesthesiologists modified their practice on the basis of their experience in absence of guidelines in the pediatric population. However, the Difficult Airway Society guideline for adults recommends that classical RSI should be practiced.^[7] In our survey, experienced anesthesiologists tended to use succinylcholine less often in all age groups compared to less experienced anesthesiologists, though not statistically significant. The commonly perceived risk factors included inadequate NPO and intestinal obstruction by 98% and 94% of respondents, respectively. However, other conditions such as GERD, bleeding tonsils, sepsis, and trauma were not perceived consistently as high-risk factors. These conditions are known to result in aspiration^[8,9] or delay gastric emptying time;^[10] thus, creating more awareness about these clinical scenarios with risk of aspiration in children might be warranted.

Preoxygenation is an important component of RSI. Different methods such as tidal volume breaths (TVB) with 100% oxygen for 3 minutes, vital capacity breaths for 1 minute, and titrating to end-tidal oxygen (ETO2) exist.^[11] In our survey, the TVB technique was the preferred technique in all age groups. End-tidal oxygenation was practiced less in this survey compared to adult RSI in a survey by Sajayan et al.^[6] This may be attributed to decreased availability of oxygen sensors in a developing country, while TVB is considered the gold standard for preoxygenation. Vital capacity breath technique is as effective as TVB^[12] but difficult in children due to non-compliance. As preoxygenation is difficult in children and can be insufficient leading to desaturation during apnea time, most respondents preferred routine gentle bag-mask ventilation after induction, thus deviating from the practice of classical RSI. Some respondents perform bag-mask ventilation when saturation drops, while only a few people do not ventilate. For reducing the risk of aspiration, most respondents chose to keep the nasogastric tube and 52% of people would insert it prior to performing RSI. Evidence suggests that nasogastric tubes should be kept in situ and should be inserted in high-risk cases.^[13] A recent survey indicates that practitioners prefer inserting a nasogastric tube in cases with a high risk of aspiration.^[14]

Although opioids are not a part of classical RSI, in our survey, the majority of the respondents used opioids. Opioid use was lesser in infants (70%) as compared to older children (90%) and fentanyl was the most commonly used drug. Propofol as the induction agent for RSI is being increasingly used as compared to thiopentone as described in classical RSI. Although propofol has greater cardiovascular depression and thiopentone has quicker onset, familiarity with the use of propofol has made it the choice of induction agent.^[5,6] In our study, few respondents preferred sevoflurane for induction despite intravenous access. A study has shown similar intubating conditions compared to propofol in RSI,^[15] but sevoflurane induction is not commonly practiced. Succinylcholine has been shown to produce superior intubating conditions than rocuronium^[16] and was the preferred agent in our survey corroborating with other surveys.^[5,7] Rocuronium was also used by around 30% of respondents and might be because 47% of respondents had concerns regarding the use of succinylcholine in children with undiagnosed muscular dystrophy. In a survey by Abdallah et al., 35% of anesthetists had similar concerns.^[3]

Cricoid pressure in RSI has always been a controversial issue with no proven benefits in preventing aspiration.^[17] Paucity of evidence with concerns of distorting the laryngoscopic view dissuades anesthetists from performing this maneuver, with 63% of people in our survey having these concerns. A survey done by Engelhardt et al. showed that only 50% of anesthetists used cricoid pressure in children aged 1–14 years and 40% in infants who were at high risk of aspiration.^[4] Whereas in a survey performed by Sajayan et al. in the United Kingdom, RSI was commonly used in adults and 92% of anesthetists used cricoid pressure.^[6] A similar difference in cricoid pressure between adults and children was also seen in a recent survey.^[18] In our survey, 41% of anesthetists would apply cricoid pressure in infants and 65% in the age group of 1–5 years, correlating with the survey by Engelhardt et al.^[4] Majority of respondents would not apply cricoid pressure in infants, with experienced anesthetists more likely to perform it. Because of lack of evidence, technical difficulty, and a potential application of extensive force leading to airway obstruction, cricoid pressure is not advocated by some experts in the pediatric population.^[19] However, this necessitates that more research should be done and the technical difficulties be overcome by proper training rather than just abandoning this potential aspiration-preventing maneuver in the pediatric population.^[20]

Risk of aspiration is two to four times higher in children.^[21,22] Despite this, a large proportion of respondents (82%) agreed that they are less likely to practice RSI in the pediatric age group than adults for a given scenario of intestinal obstruction. Several reasons were cited by respondents for this. The common grounds were difficulty in preoxygenation, concerns regarding cricoid pressure, and the use of succinylcholine in undiagnosed muscular dystrophy. The incidence of muscular dystrophy is just 0.02%,^[23] and this concern needs justification to avoid succinylcholine. Some practitioners did not practice RSI as aspiration causes lower morbidity and mortality in children;^[22] 16% of people cited unfamiliarity with the practice as their reason for nonadherence, showing an increased need for training. Interestingly, despite being an age-old practice, a significant percentage of respondents (94%) felt that more research and protocol are required for performing pediatric RSI. This suggests that an evidence-based protocol is established for practice of RSI while keeping the abovementioned reasons in mind. This will alleviate the concerns of practitioners, establish a uniform practice, and may prevent aspiration in high-risk cases. The most common complications faced by respondents were desaturation and difficulty in intubation, and there was no difference in these complications with experience of the anesthetist (P = 0.34). In a cohort analysis, these were the most common problems encountered.^[24] This shows that practice of RSI should be modified to minimize these complications.

The significant difference in practice between more experienced and less experienced anesthetists in our survey was adherence to RSI and application of cricoid pressure. Newly trained anesthetists tend to practice RSI more often as it is a standard of care taught to them to be followed in high-risk cases, while cricoid pressure is followed by more experienced anesthetists as it requires more expertise to correctly apply it. This survey highlighted the reasons for nonadherence and complications faced by respondents in pediatric RSI, which have not been enquired in previous surveys. This is the first comprehensive survey in India on this important topic and underscores the felt lacunae in literature and standardized practice by anesthesiologists. A large number of respondents (94%) felt that more research and guideline formation in pediatric RSI is needed, which emphasizes the need for protocol-based practice establishment.

There were certain limitations to our survey. The sample size was less with only 192 respondents. Though we conducted the survey on attendees at a national conference, the sample may not be reflective of practice of RSI at the country level. We did not ask about aspiration-preventing techniques such as head-up position and the use of newer modalities such as gastric ultrasound. Lastly, the questions asked were close-ended and they might give limited insight into a particular situation.

Conclusion

This survey on the practice of RSI in the pediatric population demonstrates wide variation in the practice among individuals and the reasons for nonadherence as compared to adults despite perceived risk factors. This survey highlights the felt need by almost all the participants for more research and protocol-based practice in pediatric RSI. Adequate training should be imparted to trainees in pediatric RSI so that they are able to confidently practice all components of RSI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Survey: Practice of Rapid Sequence Induction (RSI) in Pediatric Anesthesia

1. How many years have you been practicing Anesthesia?

<5yrs _____ 5–10yrs ____ >10yrs _____

2 .Do you work in

Teaching hospital ____ Non-teaching hospital ____

3. How often do you anesthetize children?

Daily ____ Few cases per week ____ Few cases a month ____ Never ____

4. What do you consider as risk factors for gastric aspiration in pediatric anesthesia?

YES NO

1. Emergency surgery with inadequate NPO ___ ___

2. Sepsis ___ ___

3. Intestinal obstruction ___ ___

4. Gastroesophageal reflux disease ___ ___

5. Congenital hypertrophic pyloric stenosis ___ ___

6. Bleeding tonsils ___ ___

7. Difficult intubation ___ ___

8. Trauma within 24 h ___ ___

9. Others (please specify)

5 .Do you generally consider using RSI/Modified RSI in children who are full stomach or at risk of aspiration?

	<1 yr	1-5 yrs	5-14 yrs
Always
Sometimes
Never

6. What steps do you take regarding the Gastric tube if full stomach? (can choose more than one option)

1. Place and suction before induction

2. Never insert

3. Keep in place if already there and suction

4. Remove if already there

7. What is your technique of preoxygenation during pediatric RSI?

	<1 yr	1-5 yrs	5-14 yrs
Normal tidal breathing for 3 mins
Vital capacity breaths for 1 min
To a specific end-tidal oxygen concentration
Do not consider preoxygenation

8. Will you consider giving opioids before induction?

	<1 yr	1-5 yrs	5-14 yrs
Not give
Yes, Fentanyl
Yes, other opioids (specify)

9. Which induction agent do you give during RSI?

	<1 yr	1-5 yrs	5-14 yrs
Thiopentone
Propofol
Ketamine
Sevoflurane
Others
If I.V. line not secured - Sevoflurane
iv access in awake f/b iv induction

10. Which paralyzing agent do you usually give if the child is full stomach?

	<1 yr	1-5 yrs	5-14 yrs
Succinylcholine
Rocuronium
Other non-depolarizing muscle relaxants (specify)
Not give any muscle relaxant before intubation

11. How do you practice pre-intubation oxygenation/ventilation during pediatric RSI?

	<1 yr	1-5 yrs	5-14 yrs
Never do
Routinely with gentle bag-mask ventilation
Only if required (e.g., desaturation)
Oxygen insufflation with nasal cannula/catheter

12. Do you use cricoid pressure in a child who is full stomach or at risk of aspiration?

	<1 yr	1-5 yrs	5-14 yrs
Always
Sometimes
Never

13. What type of endotracheal tube do you use in a child at risk of aspiration?

	<1 yr	1-5 yrs	5-14 yrs
Uncuffed
Cuffed

14. Have you ever experienced any complications while using RSI in pediatric patients? (can choose more than one option)

1. None

2. Desaturation

3. Bradycardia

4. Difficulty in laryngoscopy and intubation

5. Aspiration

6. Others (specify)

15. Do you think you are more likely to adhere to using RSI in an adult patient with intestinal obstruction as compared to an infant or child?

1. Yes

2. No

16. What do you think is the reason for your non/low adherence to the practice of RSI in at-risk pediatric patients? (can choose more than one option)

1. Difficult to preoxygenate due to non-compliance

2. Paucity of evidence regarding the effectiveness of cricoid pressure

3. Distortion of laryngoscopic view due to cricoid pressure

4. Presumption that cricoid pressure might lead to decrease in lower esophageal sphincter tone

5. Unwillingness to use succinylcholine in children with undiagnosed muscular dystrophies

6. Lower prevalence of morbidity and mortality due to aspiration in children

7. Unfamiliarity with practice of RSI in children

8. Others (specify)

17. Do you feel there is a need for further studies, standardization of the technique, and guideline formation for RSI in the pediatric population?

1. Yes

2. No

* (Your opinion and identity will be confidential.)*

*Thank you for completing the survey*