Rescue Reversal

The Myth of Rescue Reversal in "Can't Intubate, Can't Ventilate" Scenarios

BACKGROUND

An unanticipated difficult airway during induction of anesthesia can be a vexing problem. In the setting of can't intubate, can't ventilate (CICV), rapid recovery of spontaneous ventilation is a reasonable goal. The urgency of restoring ventilation is a function of how quickly a patient's hemoglobin oxygen saturation decreases versus how much time is required for the effects of induction drugs to dissipate, namely the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade. It has been suggested that prompt reversal of rocuronium-induced neuromuscular blockade with sugammadex will allow respiratory activity to recover before significant arterial desaturation. Using pharmacologic simulation, we compared the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade in normal, obese, and morbidly obese body sizes in this life-threatening CICV scenario. We hypothesized that although neuromuscular function could be rapidly restored with sugammadex, significant arterial desaturation will occur before the recovery from unresponsiveness and/or central ventilatory depression in obese and morbidly obese body sizes.

METHODS

We used published models to simulate the duration of unresponsiveness and ventilatory depression using a common induction technique with predicted rates of oxygen desaturation in various size patients and explored to what degree rapid reversal of rocuronium-induced neuromuscular blockade with sugammadex might improve the return of spontaneous ventilation in CICV situations.

RESULTS

Our simulations showed that the duration of neuromuscular blockade was longer with 1.0 mg/kg succinylcholine than with 1.2 mg/kg rocuronium followed 3 minutes later by 16 mg/kg sugammadex (10.0 vs 4.5 minutes). Once rocuronium neuromuscular blockade was completely reversed with sugammadex, the duration of hemoglobin oxygen saturation >90%, loss of responsiveness, and intolerable ventilatory depression (a respiratory rate of ≤4 breaths/min) were dependent on the body habitus and duration of oxygen administration. There is a high probability of intolerable ventilatory depression that extends well beyond the time when oxygen saturation decreases <90%, especially in obese and morbidly obese patients. If ventilatory rescue is inadequate, oxygen desaturation will persist in the latter groups, despite full reversal of neuromuscular blockade. Depending on body habitus, the duration of intolerable ventilatory depression after sugammadex reversal may be as long as 15 minutes in 5% of individuals.

CONCLUSIONS

The clinical management of CICV should focus primarily on restoration of airway patency, oxygenation, and ventilation consistent with the American Society of Anesthesiologist's practice guidelines for management of the difficult airway. Pharmacologic intervention cannot be relied upon to rescue patients in a CICV crisis.

Optimal dose of succinylcholine for tracheal intubation in patients during inhalation induction with sevoflurane: a randomized controlled trial

STUDY OBJECTIVE

To determine the dose of succinylcholine during inhalation induction of a patient.

DESIGNED

Prospective, double-blind, randomized study.

SETTING

Operating room of a university hospital.

PATIENTS

180 adult, ASA physical status 1 and 2 patients with a suspected difficult airway, who were scheduled for surgery.

INTERVENTIONS

Nonpremedicated patients were anesthetized with inhalation of 8% sevoflurane, followed by succinylcholine. Group 1 received intravenous (IV) succinylcholine 0.3 mg/kg, Group 2 had IV succinylcholine 0.6 mg/kg, and Group 3 was given IV succinylcholine 1.0 mg/kg. Direct laryngoscopy and tracheal intubation were performed after onset of succinylcholine.

MEASUREMENTS

Intubation conditions were scored as excellent, good, or poor. The recovery time of spontaneous respiration, end-tidal carbon dioxide partial pressure (PETCO2), and pulse oxygen saturation (SpO2) were recorded.

MAIN RESULTS

Acceptable conditions (excellent and good) for intubation were rated in 80% of Group 1 patients (0.3 mg/kg succhinylcholine), 91.7% of Group 2 patients (0.6 mg/kg), and 93.3% of Group 3 patients (1.0 mg/kg), respectively. Intubation scores were similar in Groups 2 and 3, and were significantly higher than in Group 1 patients (0.3 mg; P < 0.01). Time to recovery of spontaneous respiration in Group 3 was significantly prolonged compared with Groups 1 and 2 (238 ± 59 sec vs 132 ± 43 sec, P < 0.001; 238 ± 59 sec vs 151 ± 47 sec, P < 0.001, respectively). SpO2 in Group 3 did not differ significantly from Group 1 and 2 values. However, PETCO2 in Group 3 was significantly higher than in Groups 1 or 2.

CONCLUSIONS

Succinylcholine at a dose of 0.6 mg/kg IV provided intubation conditions similar to succinylcholine at 1.0 mg/kg IV, and recovery of spontaneous respiration following a 0.6 mg/kg dose of succinylcholine was significantly shorter.