Induction for rapid sequence induction: a tri‐deanery survey

I read with interest the recent results of a trainee survey of rapid sequence induction by Walker et al. [1], reporting that 97% of respondents used thiopental for obstetric anaesthesia. This correlates well with our recent national survey of consultant obstetric anaesthetists, of whom 93% used thiopental for obstetrics [2]. The risk of drug substitution errors may indeed increase as non-obstetric use of thiopental decreases, especially amongst new trainees. Indeed, the continued occurrence of this problem has been recently highlighted [3]. I agree with the authors that trainees should be encouraged to use thiopental, wherever appropriate, to ensure familiarity with more than one induction agent. I would also like to comment on their recommendation that operating departments consider discarding drawn-up thiopental after seven hours, in line with the manufacturer’s recommendations. This may be excessively cautious, as the chemical stability and sterility of thiopental prepared in sterile conditions has been shown to be retained for up to six days at 22 °C and greater than seven days when stored at 3 °C [4]. Reconstituting thiopental every seven hours would generate significant waste at substantial cost to individual departments, particularly in a time of austerity and in the context of continued concerns over the supply of thiopental. The greater frequency of reconstitution alone would increase the likelihood of a drug error. One possible solution would be to use pre-filled thiopental syringes prepared by aseptic units. This reduces wastage and saves money as they can be provided pre-prepared with a shelf life of up to 90 days [5]. Pre-filled syringes are inherently safer, as their appearance is distinct from that of antibiotic preparations. A review of strategies for preventing drug errors recommended pre-filled syringes in combination with other techniques such as checking the drug with a second person before administration [6]. Whilst the timing issue of antibiotic administration remains, the use of pre-filled syringes may allow more time to consider antibiotics before induction.