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Rapid Sequence Intubation

We read with great interest the article of Mayo et al, presenting a quality improvement project to increase the safety of emergency endotracheal intubation in a medical intensive care unit (ICU). This is a crucial topic: tracheal intubation is the most frequently performed procedure in the ICU that is associated with a significant incidence of morbidity and mortality. In the ICU, intubation is commonly done urgently to treat severe respiratory failure and/or as part of cardiorespiratory resuscitation. Emergency endotracheal intubation in critically ill patients can be fraught with mild-to-severe life-threatening complications related to hemodynamic alterations and difficulty with ventilation and oxygenation. It differs significantly from intubation carried out for routine surgical procedures. And even experienced anesthesiologists may encounter intubation-associated mortality when intubating critically ill patients. The work of Mayo et al, trying to establish better airway management in ICU based on scenario using computerized patient simulator, needs to be encouraged and could potentially reduce risks associated with intubation. But we do not agree with the authors when they stated that choosing propofol as the only induction agent could be more secure than rapid sequence induction (RSI), as far as it simplifies and standardizes the pharmacological strategy Propofol is a usually used induction agent in the operating room and the only hypnotic drug that allows a sufficient muscle relaxation to practice intubation without neuromuscular blocking agents. This last point needs the use of high dose of propofol that can cause profound hypotension, especially in ICU patients. And we were very impressed by the high rate of difficult intubation (20%) found by Mayo et al, contrasting with the relative low rate of severe hypotension (6%). Can the authors specify the dose of propofol used? Moreover, we would like to highlight that RSI could be helpful for intubation and has been previously reported as the commonest method used to secure the airway in ICU. RSI combines the use of hypnotic and neuromuscular blocking agents. Concerning the choice of hypnotic drug, the most distinctive property of etomidate and ketamine as compared with other rapid-acting induction agents (propofol and thiopental) is its minimal effects on cardiovascular parameters. Etomidate has been the drug of choice for patients who are cardiovascularly unstable, permitting to sedate without causing sharp decreases in blood pressure, even in the hypovolemic patients, but its use as been challenged because it can cause a reversible adrenal insufficiency. Even if the effect of such adrenal suppression on patients’ outcome remains debated, several investigators have advised against its use, even as a single bolus. Use of ketamine instead of etomidate was reported to be effective and safe. But intubation conditions depend mostly on the muscle relaxant effects. Suxamethonium is still the most commonly used neuromuscular blocking agent because of its rapid onset and offset. In case of contraindication, rocuronium, a nondepolarizing muscle relaxant with a quick onset of action, is playing an increasing role in RSI as its action can be quickly reversed with Sugammadex (Organon Int., Oss, Netherlands) if it becomes necessary.