Jump to comment:

• ED RSI in the UK - the growing evidence base is not inconsistent
  Cliff Reid
  Published on: 29 April 2016
• The who, where, and what of rapid sequence intubation
  Angela J Oglesby
  Published on: 29 April 2016

• Published on: 29 April 2016

  ED RSI in the UK - the growing evidence base is not inconsistent

  • Cliff Reid, consultant in emergency medicine
  • Other Contributors:
    • Louisa Chan

  Dear Editor

  We would like to thank Dr Oglesby and colleagues for their helpful comments [1], and for highlighting their data on complication rates for ED RSI [2] which were published subsequent to the submission of our paper [3].

  We share entirely their reservations regarding propofol as an induction agent in ED patients. It is our observation that it is associated with a greater incidence of hypotens...

  Show More

  Dear Editor

  We would like to thank Dr Oglesby and colleagues for their helpful comments [1], and for highlighting their data on complication rates for ED RSI [2] which were published subsequent to the submission of our paper [3].

  We share entirely their reservations regarding propofol as an induction agent in ED patients. It is our observation that it is associated with a greater incidence of hypotension than other agents in inexperienced hands, and that junior anaesthetic staff consistently demonstrate a remarkable predilection for its use. This is an example of the inappropriateness of directly applying theatre-based anaesthesia practice to the critical care setting, and we continue to hope that our data might contribute to the development of more tailored anaesthesia training for critical care and emergency physicians.

  We note that the larger Scottish study demonstrated a greater proportion of physiologically compromised ED patients than ours. However this does not negate our observation of ‘relative cardiovascular stability and normal respiratory function of ED patients’ compared with patients intubated in the ward and ICU settings. This might also be the case in Scotland if such a comparison between clinical areas were to be made. The point has been made by Dr Oglesby and colleagues in their own paper that ‘the lack of internationally accepted definitions of complications of RSI means that studies of emergency airway management...cannot be compared on an equivalent basis’, and the complication of ‘critical desaturation’ was not defined in their paper. Bearing these limitations and our stricter definition of hypotension in mind, ED complication rates were not in fact markedly dissimilar between our studies, whereas complication rates on the ICU were three times higher than in the ED.

  We applaud the approach of having a senior anaesthetist or intensive care specialist present during ED RSI. Although this may well be achievable in the teaching hospital setting, many district general hospitals may not have an available anaesthetist, let alone a senior one. The challenges of Hospital at Night and European Working Time compliant rostering may further deplete this supply, and only by the development of joint protocols as recommended by Dr Oglesby can this vital patient need be met. In our current practice setting we have pursued a similar course with a joint anaesthesia / emergency medicine Standard Operating Procedure for Rapid Sequence Intubation which we would be happy to share with anyone hoping to develop their ED RSI program.

  References

  (1) Rapid response: The who, where, and what of rapid sequence intubation Angela J Oglesby, Mark J D Dunn, Alasdair J Gray, Diana Beard, Dermot W McKeown, Colin A Graham (10 August 2004)

  (2) Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2003;20:3-5

  (3) Reid C, Chan L, Tweeddale M. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Emerg Med J 2004;21:296-301

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 29 April 2016

  The who, where, and what of rapid sequence intubation

  • Angela J Oglesby, Consultant in Accident & Emergency Medicine
  • Other Contributors:
    • Mark J D Dunn, Alasdair J Gray, Diana Beard, Dermot W McKeown, Colin A Graham

  Dear Editor

  Reid and colleagues have produced an interesting observational study on rapid sequence intubation (RSI) [1].

  The authors comment on the lack of data on complications of RSI in the UK hospital setting. In 2003, we published complication data from a multi-centre prospective observational study of 735 patients undergoing RSI in seven Scottish urban emergency departments (ED) [2].

  The...

  Show More

  Dear Editor

  Reid and colleagues have produced an interesting observational study on rapid sequence intubation (RSI) [1].

  The authors comment on the lack of data on complications of RSI in the UK hospital setting. In 2003, we published complication data from a multi-centre prospective observational study of 735 patients undergoing RSI in seven Scottish urban emergency departments (ED) [2].

  The authors further comment that the underlying patient diagnosis may influence intubating conditions and subsequent complications. Significant complications may also result from operator inexperience together with limited understanding of the pharmacology of induction and other drugs administered during RSI. Propofol was the induction agent used in almost 50% of patients in Reid’s paper. In our study thiopentone and etomidate were the most frequently used induction agents (44% and 33% respectively). In our opinion, propofol should be used with caution during RSI as the pharmacokinetic profile of propofol is not suitable for this role and it has an unacceptably high incidence of hypotension associated with induction [3][4][5].

  Reid also notes that intubation in the ED was associated with a lower immediate complication rate and postulated that this was due to the ‘relative cardiovascular stability and normal respiratory function of ED patients’. This contrasts markedly with our data where 29.5% of patients underwent RSI for hypoventilation and 8.1% for ‘shock’. In our study patients intubated by emergency physicians were more likely to be physiologically compromised (prior to RSI) than those intubated by anaesthetists. This may in part reflect the lower numbers in Reid’s single centre study (208 patients) compared to our larger multi-centre study with 735 adult RSIs.

  We agree that there is evidence that RSI can be safely performed by emergency physicians [6][7][8]. However, further analysis of data from the single largest contributor to our study (the Royal Infirmary of Edinburgh, n=441) showed that there was an increased RSI complication rate for emergency physicians compared to anaesthetists in that centre and this led to the development of a joint RSI protocol.

  This protocol ensures that, wherever possible, a senior anaesthetist or intensive care specialist is present when the emergency physician performs the RSI. This collaborative approach has improved communication and collaboration and reduced the complication rate in the group intubated by emergency physicians [9]. We have also developed an RSI assistant training programme and continue to prospectively audit every intubation attempt in the ED, as part of ongoing quality of care monitoring.

  We agree wholeheartedly with Reid that continuing cooperation and collaboration with our anaesthetic colleagues is vital and that continuous audit and quality assurance are mandatory.

  A J Oglesby, Consultant in Accident & Emergency Medicine, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK

  M J D Dunn, Specialist Registrar in Accident & Emergency Medicine, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK

  A J Gray, Consultant in Accident & Emergency Medicine, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK

  D Beard, Director, Scottish Trauma Audit Group, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK

  D W McKeown, Consultant in Anaesthesia & Intensive Care Medicine, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU, Scotland, UK

  C A Graham, Associate Professor, Accident and Emergency Academic Unit, Chinese University of Hong Kong, Trauma and Emergency Centre, Prince of Wales Hospital, Shatin NT, Hong Kong

  Correspondence to: Dr A J Oglesby, A&E Department, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SU or email: angela.oglesby@luht.scot.nhs.uk

  Competing interests: None declared

  References

  (1) Reid C, Chan L, Tweeddale M. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Emerg Med J 2004;21:296-301

  (2) Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2003;20:3-5

  (3) Harsten A, Gillberg L. Intubating conditions provided by propofol and alfentanil, acceptable but not ideal. Acta Anaesth Scand 1997;41:985-987

  (4) Kazama T, Ikeda K, Morita K et al. Propofol concentration required for endotracheal intubation with a laryngoscope or fiberscope and its interaction with fentanyl. Anesth Analg 1998;86:872-879

  (5) Skinner HJ, Biswas A, Mahajan RP. Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction. Anaesthesia 1998;53:702-710

  (6) Walls RM, Vissers RJ, Sagarin MJ, et al. Emergency Department intubations – final report of the National Emergency Airway Registry Pilot Project. J Accid Emerg Med 1998;15:392 [Abstract]

  (7) Sackle JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one year study of 610 tracheal intubations. Ann Emerg Med 1998;31:325-332

  (8) Tayal VS, Riggs RW, Marx JA, at al. Rapid sequence intubation at an emergency medicine registry: success rate and adverse events during a two year period. Acad Emerg Med 1999;6(1):31-7

  (9) Oglesby AJ, Dunn MJG, Beard D, McKeown DW, Robertson CE. Rapid Sequence Intubation: Collaboration between Emergency Medicine and Anaesthesia. Emerg Med J 2004; 21(2):e4 [Abstract]

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top