Findings of two independent surveys on rapid sequence induction

Editor, We read with great interest the article by Klucka et al.1 on rapid sequence induction (RSI) practice. Their results indicate a relatively high variability in some aspects of RSI practice, which is aligned with our recent survey.2 While we targeted anaesthesiologists globally,2 Klucka et al.1 targeted the European Society of Anaesthesiologists members. Nevertheless, both studies, with 10 003 and 1921 respondents, respectively, demonstrated some overlapping results, thus validating each other's findings. One of the similarities between the two surveys is in the frequency of cricoid force use in adult patients. As Klucka et al.1 reported, 37% never use cricoid force during RSI, while in our survey, 19% of responders would not use cricoid force in a hypothetical patient with intestinal obstruction, and 36% would waive its use in any other patient requiring RSI.2 In our sample, cricoid force was more often used in patients with intestinal obstruction than in Klucka et al.'s survey (71 vs. 61%). As Europe has been abandoning strict cricoid force use in several countries,3 this likely reflects the global nature of our survey and strong associations of cricoid force use with decreasing national income.2 Moreover, it becomes notoriously difficult to correctly use cricoid force by an anaesthetic team with less than three members,4 reported as being common practice (64% of our respondents use cricoid force during RSI in a team of two members).2 While the use of cricoid force is certainly one of the more passionately debated manoeuvres in our clinical practice,3 it is not the only ‘technical’ aspect of RSI with great variability in practice. When it comes to patient positioning, 70% of respondents would use the head-up patient position during RSI in patients with intestinal obstruction, compared with 44% for any other patient requiring RSI.2 On the other hand, Klucka et al.1 describe a 60% use of the head-up position with limited details on patient populations. We strongly believe that, for expert performance in RSI, the four basic principles of deliberate practice (having a specific goal, using ‘drills’, providing immediate feedback and perform out of the comfort zone)5 need to be repeatedly followed. Due to the lack of convincing evidence, we recommend these four principles should be practiced regularly and consistently during RSI – regardless of patient type – and disagree with Klucka et al.,1 who recommend to reinforce the head-up position for RSI as standard practice. Even with its obvious limitations, a recent simulation study demonstrated that lung soiling occurs in different patient positions,6 with a –15° head-down tilt, reducing the amount of aspirated fluid. As for gastric tube use, we recommend a more systematic approach, stratified by patient population. It is concerning that more than 35% of respondents would never place a gastric tube for RSI,1 as it is a simple manoeuvre for patients with intestinal obstruction. Regardless of the technique, the depletion of gastric volume by itself reduces the likelihood and extent of subsequent pulmonary aspiration. In addition, while Klucka et al.'s1 data on RSI drug use is informative, we have refrained from making any specific recommendations regarding pharmacologic agents of choice. While we understand the author's concerns that ‘a variation in clinical practice can be dangerous for both patients (safety aspects) and physicians (legal consequences)’, we realise that variation in practice is vast worldwide, including country and regional availability of certain drugs, and most importantly, practitioners should use the techniques that they feel most comfortable with and are well skilled in using,7 as this enhances patient safety by reducing extraneous cognitive load. Finally, while applauding Klucka et al.'s publication and recognising the need for extensive research and consensus on the topic, we would like to add that collaboration in the use of similar questionnaires could positively impact response rates in survey research, tackling survey fatigue and boosting the quality of data. In conclusion, we suggest that the authors thoroughly compare their findings with previous published data and balance their discussion with the best available evidence, while awaiting the publication of the first universal guidelines on airway management (Project for Universal Management of Airways: www.universalairways.org).