Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942004000400015
Brazilian Journal of Anesthesiology
Review Article

Indução anestésica com a técnica de seqüência rápida

Rapid sequence induction of anesthesia

Eduardo Toshiyuki Moro; Norma Sueli Pinheiro Módolo

Downloads: 0
Views: 1016

Resumo

JUSTIFICATIVA E OBJETIVOS: A indução da anestesia por meio da técnica de seqüência rápida é utilizada, principalmente, para proteger as vias aéreas, quando há risco de aspiração do conteúdo gástrico. O objetivo deste artigo é revisar a técnica e os diferentes protocolos que buscam o uso racional dos fármacos disponíveis, visando condições ideais de intubação traqueal, sem aumentar o risco de aspiração do conteúdo gástrico ou de outras complicações. CONTEÚDO: Apresenta uma revisão da técnica da indução com seqüência rápida, enfatizando o uso racional dos hipnóticos, opióides e bloqueadores neuromusculares (BNM), para reduzir o período entre a perda da consciência e o correto posicionamento do tubo traqueal, ou seja, diminuir o período de maior risco para aspiração e ainda manter excelentes condições de intubação traqueal. CONCLUSÕES: A intubação traqueal após indução anestésica por meio da técnica de seqüência rápida está indicada naqueles pacientes, com risco de aspiração gástrica, em que não há suspeita de intubação traqueal difícil. A indicação correta da técnica, sua aplicação criteriosa e a utilização racional das drogas disponíveis podem promover condições excelentes de intubação, com curto período de latência, rápido retorno da consciência e da respiração espontânea, caso haja falha na intubação traqueal.

Palavras-chave

ANALGÉSICOS, BLOQUEADORES NEUROMUSCULARES, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVES: Rapid sequence induction anesthesia is primarily used to protect airways when there is gastric content aspiration risk. This study aimed at reviewing the technique and different protocols looking for the rational use of available drugs, in the search for ideal tracheal intubation conditions without increasing the risk of gastric content aspiration or other complications. CONTENTS: A technical review of rapid sequence induction of anesthesia is presented, emphasizing the rational use of hypnotics, opioids and neuromuscular blockers (NMB) to shorten the period between loss of consciousness and correct tracheal tube positioning, that is, shorten the period of highest risk for aspiration while maintaining excellent intubation conditions. CONCLUSIONS: Tracheal intubation after rapid sequence induction of anesthesia is indicated for patients at risk for gastric content aspiration without suspicion of difficult intubation. The adequate indication of the technique, its judicious application and the rational use of available drugs may promote excellent intubation conditions, with fast onset, early return to consciousness and spontaneous breathing in case of tracheal intubation failure.

Keywords

ANALGESICS, ANESTHETIC TECHNIQUES, ANESTHETIC TECHNIQUES, NEUROMUSCULAR BLOCKERS

References

Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obst Gynecol. 1946;52:191-205.

Sellick BA. Crycoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet. 1961;19:404-406.

Lavazais S, Debaene B. Choice of the hypnotic and the opioid for rapid-sequence induction. Eur J Anaesthesiol. 2001;23:66-70.

Ortenzi AV, D'Ottaviano CR. Jejum Pré-Operatório e o Paciente de Estômago Cheio. Atualização em Anestesiologia. 1996:94-106.

Mallampati SR, Gatt SP, Gugino LD. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434.

Benumof JL. Management of Difficult Airway: The ASA algorithm. Annual Refresher Course Lectures. 1993:01-07.

Lütke C. Abordagem à Via Aérea Difícil. Atualização em Anestesiologia. 2000;11:126-39.

Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with crycoid pressure: a cadaver study. Anaesthesia. 1992;47:732-735.

Salem MR, Joseph NJ, Heyman HJ. Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube. Anesthesiology. 1985;63:443-446.

Alexander NG, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg. 2001;93:494-513.

Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia. 1999;54:376-381.

Salem MR, Wong AY, Sellick BA. Efficacy of cricoid pressure in preventing gastric inflation during bag-mask ventilation in pediatric patients. Anesthesiology. 1974;40:96-98.

Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth. 1987;59:315-318.

Asai T, Barclay K, McBeth C. Cricoid pressure applied after placement of the laryngeal mask prevents gastric insufflation but inhibits ventilation. Br J Anaesth. 1996;76:772-776.

Vanner RG, O'Dwyer JP, Pryle BJ. Upper esophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia. 1992;47:95-100.

Tournadre JP, Chassard D, Berrada KR. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology. 1997;86:7-9.

Skinner HJ, Bedforth NM, Girling KJ. Effect of cricoid pressure on gastro-oesophageal reflux in awake subjects. Anaesthesia. 1999;54:798-800.

MacG Palmer JH, Ball DR. The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetised patients. Anaesthesia. 2000;55:263-268.

Vanner RG, Clarke P, Moore WJ. The effect of cricoid pressure and neck support on the view at laringoscopy. Anaesthesia. 1997;52:896-900.

Asai T, Barclay K, Power I. Cricoid pressure impedes placement of laryngeal mask airway. Br J Anaesth. 1995;74:521-525.

Aoyama K, Takenaka I, Sata T. Cricoid pressure impedes positioning and ventilation through the laryngeal mask airway. Can J Anaesth. 1996;43:1035-1040.

Meek T, Vincent A, Duggan JE. Cricoid pressure: can protective force be sustained?. Br J Anaesth. 1998;80:672-674.

Lewis CB. Endotracheal intubation under thiopental. Anaesthesia. 1948;3:113-115.

McKeating K, Bali IM, Dundee JW. The effects of thiopental and propofol on upper airway integrity. Anaesthesia. 1988;43:638-640.

Morris J, Cook TM. Rapid sequence induction: a national survey of practice. Anaesthesia. 2001;56:1090-1097.

Saarnivaara L, Klemola UM. Injection pain, intubation conditions and cardiovascular changes following induction of anaesthesia with propofol alone or in combination with alfentanil. Acta Anaesthesiol Scand. 1991;35:19-23.

Davidson JA, Gillespsie JA. Tracheal intubation after induction of anaesthesia with propofol, alfentanil and IV lignocaine. Br J Anaesth. 1993;70:163-166.

Hovorka J, Honkavaara P, Korttila K. Tracheal intubation after induction of anesthesia with thiopentone or propofol without muscle relaxants. Acta Anaesthesiol Scand. 1991;35:326-328.

Harsten A, Gillberg L. Intubations conditions provided by propofol and alfentanil-acceptable, but not ideal. Acta Anaesthesiol Scand. 1997;41:985-987.

Purcell-Jones G, Yates A, Baker JR. Comparison of the induction characteristics of thiopentone and propofol in children. Br J Anaesth. 1987;59:1431-1436.

Hogue Jr CW, Bowdle TA, O`Leary C. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery. Anesth Analg. 1996;83:279-285.

Vuyk J, Engbers FH, Burm AG. Pharmacodynamic interaction between propofol and alfentanil when given for induction of anesthesia. Anesthesiology. 1996;84:288-299.

Scheller MS, Zornow MH, Saidman LJ. Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil. Anesth Analg. 1992;75:788-793.

Short TG, Chui PT. Propofol and midazolam act synergistically in combination. Br J Anaesth. 1991;67:539-545.

Tighe KE, Warner JA. The effect of co-induction with midazolam upon recovery from propofol infusion anaesthesia. Anaesthesia. 1997;52:1000-1004.

Conway DH, Hasan SK, Simpson ME. Target-controlled propofol requirements at induction of anaesthesia: effect of remifentanil and midazolam. Eur J Anaesthesiol. 2002;19:580-584.

Gamlin F, Vucevic M, Winslow L. The haemodynamic effects of propofol in combination with ephedrine. Anaesthesia. 1996;51:488-491.

Bland BA, Lawes EG, Duncan PW. Comparison of midazolam and thiopental for rapid sequence anesthetic induction for elective cesarean section. Anesth Analg. 1987;66:1165-1168.

Baraka AS, Sayyid SS, Assaf BA. Thiopental-rocuronium versus ketamine-rocuronium for rapid-sequence intubation in parturients undergoing cesarean section. Anesth Analg. 1997;84:1104-1107.

Morgan GE, Mikhail MS, Murray MJ. Non-Volatile Anesthetic Agents. Clinical Anesthesiology. 2002:172.

Egan TD. The clinical pharmacology of the new fentanyl congeners. Anesth Analg. 1997;84:(Suppl):31-38.

Bailey PL, Egan TD, Stanley TH. Intravenous Opioid Anesthesia. Anesthesia. 2000:273-376.

Egan TD. Remifentanil pharmacokinetics and pharmacodynamics: A preliminary appraisal. Clin Pharmacokinet. 1995;29:80-94.

Johnson KB, Swenson JD, Egan TD. Midazolam and remifentanil by bolus injection for intensely stimulating procedures of brief duration: experience with awake laryngoscopy. Anesth Analg. 2002;94:1241-1243.

Jhaveri R, Joshi P, Batenhorst R. Dose comparison of remifentanil and alfentanil for loss of consciousness. Anesthesiology. 1997;87:253-259.

Streisand JB, Bailey PL, LeMaire L. Fentanyl-induced rigidity and unconsciousness in human volunteers. Incidence. dura;78:629-634.

Grant S, Noble S, Woods A. Assessment of intubating conditions in adults after induction with propofol and varying doses of remifentanil. Br J Anaesth. 1998;81:540-543.

Stevens JB, Wheatley L. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Anesth Analg. 1998;86:45-49.

Durmus M, Ender G, Kadir BA et al. Remifentanil with thiopental for tracheal intubation without muscle relaxants. Anesth Analg. 2003;96:1336-1339.

Fisher MM, Merefield D, Baldo B. Failure to prevent an anaphylactic reaction to a second neuromuscular blocking drug during anaesthesia. Br J Anaesth. 1999;82:770-773.

Almeida MCS. Succinilcolina: 50 anos de soberania. Rev Bras Anestesiol. 2002;52:513-516.

Morgan GE, Mikhail MS, Murray MJ. Neuromuscular Blocking Agents. Clinical Anesthesiology. 2002:183.

Miguel R, Witkowski T, Nagashima H et al. Evaluation of neuromuscular and cardiovascular effects of two doses of rapacuronium (ORG 9487) versus mivacurium and succinylcholine. Anesthesiology. 1999;91:1648-1654.

Donati F. Neuromuscular blocking drugs for the new millennium: current practice, future trends: comparative pharmacology of neuromuscular blocking drugs. Anesth Analg. 2000;90(^s5):S2-S6.

Goudsouzian NG. Rapacuronium and bronchospasm. Anesthesiology. 2001;94:727-728.

Naguib M. How serious is the bronchospasm induced by rapacuronium?. Anesthesiology. 2001;94:924-925.

Engbaek J, Viby-Mogensen J. Can rocuronium replace succinylcholine in a rapid-sequence induction of anesthesia?. Acta Anaesthesiol Scand. 1999;43:1-3.

Dobson AP, McCluskey A, Meakin G et al. Effective time to satisfactory intubation conditions after administration of rocuronium in adults: Comparison of propofol and thiopenthone for rapid sequence induction of anaesthesia. Anaesthesia. 1999;54:172-176.

Vianna PTG, Ganem EM, Takata I. Avaliação comparativa do tempo de latência da succinilcolina e do rocurônio. Rev Bras Anestesiol. 1996;46:147.

Sparr HJ, Mitterschiffthaler G. Are only large doses of rocuronium an alternative to succinylcholine for rapid-sequence induction?. Anesthesiology. 1994;80:1411-1412.

Kirkegaard-Nielsen H, Caldwell JE, Berry PD. Rapid tracheal intubation with rocuronium: a probability approach to determining dose. Anesthesiology. 1999;91:131-136.

Andrews JI, Kumar N, van den Brom RH et al. A large simple randomized trial of rocuronium versus succinylcholine in rapid-sequence induction of anaesthesia along with propofol. Acta Anaesthesiol Scand. 1999;43:4-8.

Heier T, Caldwell JE. Rapid tracheal intubation with large dose rocuronium: a probability-based approach. Anesth Analg. 2000;90:175-179.

Meistelman C, Plaud B, Donati F. Neuromuscular effects of succinylcholine on the vocal cords and adductor pollicis muscles. Anesth Analg. 1991;73:278-282.

Braga AFA, Potério GMB, Braga FSS. Rocurônio: dose preparatória versus injeção única. Rev Bras Anestesiol. 1999;49:379-384.

Foldes FF. Rapid tracheal intubation with non-depolarizing neuromuscular blocking drugs: the priming principle. Br J Anaesth. 1984;56:663.

Glass PS, Wilson W, Mace JA. Is the priming principle both effective and safe?. Anesth Analg. 1989;68:127-134.

Musich J, Walts LF. Pulmonary aspiration after a priming dose of vecuronium. Anesthesiology. 1986;64:517-519.

Van Aken H, Mertes N, Hauss GM. Pretreatment technique for fast intubation with vecuronium: intubation conditions and unwanted effects. Acta Anaesthesiol Belg. 1986;37:199-204.

Engbaek J, Viby-Morgensen J. Pre-curarization: a hazard to the patient?. Acta Anaesthesiol Scand. 1984;28:61-62.

Mahajan RP, Laverty J. Lung function after vecuronium pretreatment in young, health patients. Br J Anaesth. 1992;69:318-319.

Aziz L, Jahangir SM, Choudhury SN. The effect of priming with vecuronium and rocuronium on young and elderly patients. Anesth Analg. 1997;85:663-666.

Mirakhur RK, Lavery GG, Gibson FM. Intubation conditions after vecuronium and atracurium given in divided doses (the priming technique). Acta Anaesthesiol Scand. 1986;30:347-350.

Stevens JB, Walker SC, Fontenot JP. The clinical neuromuscular pharmacology of cisatracurium versus vecuronium during outpatient anesthesia. Anesth Analg. 1997;85:1278-1283.

Puhringer FK, Scheller A, Kleinsasser A. The effect of different priming doses on the pharmacodynamics of cisatracurium. Anaesthesist. 2000;49:102-105.

Kopman AF, Khan NA. Precurarization and priming: a theoretical analysis of safety and timing. Anesth Analg. 2001;93:1253-1256.

Donati F. The priming saga: where do we stand now?. Can J Anesth. 1988;35:1-4.

Kopman AF, Klewicka MM, Kopman DJ. Molar potency is predictive of the speed of onset of neuromuscular block for agents of intermediate, short, and ultrashort duration. Anesthesiology. 1999;90:425-431.

Naguib M. Different priming techniques, including mivacurium, accelerate the onset of rocuronium. Can J Anesth. 1994;41:902-907.

Foldes FF, Nagashima H, Nguyen HD. The neuromuscular effects of ORG 9426 in patients receiving balanced anesthesia. Anesthesiology. 1991;75:191-196.

Hofmockel R, Benad G. Time-course of action and intubating conditions with rocuronium bromide under propofol-alfentanil anaesthesia. Eur J Anaesthesiol. 1995;11:69-72.

Feldman SA. Rocuronium - onset times and intubating conditions. Eur J Anaesthesiol. 1994;9::49-52.

Hofmockel R, Benad G, Kabott A. Mechanomyographyc and electromyographyc studies of endotracheal intubation with 2 different rocuronium dosages. Anaesthesiol Reanim. 1994;19:144-148.

Redai I, Feldman SA. Priming studies with rocuronium and vecuronium. Eur J Anaesthesiol. 1995;11:11-13.

Tan CH, Onisong MK, Chiu WK. The influence of induction technique on intubating conditions 1 min after rocuronium administration: a comparison of a propofol-ephedrine combination and propofol. Anaesthesia. 2002;57:223-226.

Naguib M. Neuromuscular effects of rocuronium bromide and mivacurium chloride administered alone and in combination. Anesthesiology. 1994;81:388-395.

Fletcher JE, Heard CMB. The optimum rocuronium and mivacurium for maximum synergistic effect. Anesth Analg. 1998;86:(Suppl):442S.

Kim SY, Cho MH. Neuromuscular and cardiovascular advantages of combinations of mivacurium and rocuronium over either drug alone. Anaesthesia. 1996;51:929-931.

England AJ. Rocuronium and the onset-offset paradox. Anaesth Pharmacol Rev. 1995;3:212-217.

England AJ, Feldman SA. The interaction between mivacurium and rocuronium during onset and recovery. Anaesthesia. 1997;52:279-280.

Lien CA. Combining non-depolarizing neuromuscular blocking agents: synergism, addition or antagonism?. Curr Opin Anesthesiol. 1999:467-471.

Moore EW, Hunter JM. The new neuromuscular blocking agents: do they offer any advantages?. Br J Anaesth. 2001;87:912-925.

Gyermek L, Lee C, Cho YM. Neuromuscular pharmacology of TAAC3, a new nondepolarizing muscle relaxant with rapid onset and ultrashort duration of action. Anesth Analg. 2002;94:879-885.

Bom A, Mason R, Hope F. The cyclodextrin derivative ORG 25969, which forms complexes with steroidal neuromuscular blocking agents, causes selective reversal of normal and profound neuromuscular block. Anesthesiology. 2001;95:A1020.

Hope F, Bom A. ORG 25969 reverses rocuronium-induced neuromuscular blockade in the cat without important hemodynamic effects. Eur J Anaesthesiol. 2001;18:(23):9.

Van Egmond J, Van de Pol F, Booji L. Neuromuscular blockade induced by steroidal NMBs can be rapidly reversed by Org 25969 in the anaesthetized monkey. Eur J Anaesthesiol. 2001;18:(23):10.

5dd7e0da0e8825c85b13f286 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections