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Modified rapid sequence induction and intubation: a survey of United States current practice.

ABSTRACT: Rapid sequence induction and intubation (RSII) is a technique commonly used to resist regurgitation of gastric contents and protect the airway. A modification of this technique is implemented in certain clinical circumstances. However, there is currently no standard definition for a modified RSII. Therefore, we surveyed clinicians at academic centers across the United States to establish a working definition of a modified RSII as well as the clinical scenarios in which it is being used.A survey was created that queried the use and definition of modified RSII, and validated with test respondents. We then mailed the survey to all 131 anesthesia residency training programs across the United States. Logistic regression models were created to estimate the percentage of affirmative responses among respondents that performed modified RSII procedures and answered survey items in a consistent manner. Similar quantities were calculated by physician status (resident and attending).Four hundred ninety surveys were received from 58 institutions (44% institution response rate); 93% of respondents reported using a modified RSII, and of those 85% consistently completed the survey instrument. A majority of respondents (71%, CI: 63%-77%) reported administering oxygen before anesthesia induction, applying cricoid pressure, and attempting to ventilate the lungs via a facemask before securing the airway. Respondents noted that they would use a modified RSII procedure if the patient were either moderately or morbidly obese (each ?59%, 53%-64%), had a history but no current symptoms of gastroesophageal reflux disease (52%, 46%-57%), had a hiatal hernia (42%, 36%-48%) or were a trauma patient who had been NPO for at least 8 h (39%, 33%-45%). Similar RSII results were obtained when repeating the analysis on the subset that did not enforce the consistency requirements.Based on our survey we have established three defining features of a modified RSII: (1) oxygen administration before induction; (2) the use of cricoid pressure; and (3) an attempt to ventilate the patient's lungs before securing the airway. Although this definition seems intuitively obvious, no previous work has tested whether it is commonly accepted.

SUBMITTER: Ehrenfeld JM

PROVIDER: S-EPMC3270153 | biostudies-literature | 2012 Jul

REPOSITORIES: biostudies-literature

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Modified rapid sequence induction and intubation: a survey of United States current practice.

Ehrenfeld Jesse M JM Cassedy Eva A EA Forbes Victoria E VE Mercaldo Nathaniel D ND Sandberg Warren S WS

Anesthesia and analgesia 20111024 1

<h4>Background</h4>Rapid sequence induction and intubation (RSII) is a technique commonly used to resist regurgitation of gastric contents and protect the airway. A modification of this technique is implemented in certain clinical circumstances. However, there is currently no standard definition for a modified RSII. Therefore, we surveyed clinicians at academic centers across the United States to establish a working definition of a modified RSII as well as the clinical scenarios in which it is b ...[more]

PMID: 22025487

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Project description:BackgroundRapid sequence intubation (RSI) is an advanced airway skill commonly performed in the pre-hospital setting globally. In South Africa, pre-hospital RSI was first approved for non-physician providers by the Health Professions Council of South Africa in 2009 and introduced as part of the scope of practice of degree qualified Emergency Care Practitioners (ECPs) only. The research study aimed to investigate and describe, based on the components of the minimum standards of pre-hospital RSI in South Africa, specific areas of interest related to current pre-hospital RSI practice.MethodsAn online descriptive cross-sectional survey was conducted amongst operational ECPs in the pre-hospital setting of South Africa, using convenience and snowball sampling strategies.ResultsA total of 87 participants agreed to partake. Eleven (12.6%) incomplete survey responses were excluded while 76 (87.4%) were included in the data analysis. The survey response rate could not be calculated. Most participants were operational in Gauteng (n = 27, 35.5%) and the Western Cape (n = 25, 32.9%). Overall participants reported that their education and training were perceived as being of good quality. The majority of participants (n = 69, 90.8%) did not participate in an internship programme before commencing duties as an independent practitioner. Most RSI and post-intubation equipment were reported to be available; however, our results found that introducer stylets and/or bougies and end-tidal carbon dioxide devices are not available to some participants. Only 50 (65.8%) participants reported the existence of a clinical governance system within their organisation. Furthermore, our results indicate a lack of clinical feedback, deficiency of an RSI database, infrequent clinical review meetings and a shortage of formal consultation frameworks.ConclusionThe practice of safe and effective pre-hospital RSI, performed by non-physician providers or ECPs, relies on comprehensive implementation and adherence to all the components of the minimum standards. Although there is largely an apparent alignment with the minimum standards, recurrent revision of practice needs to occur to ensure alignment with recommendations. Additionally, some areas may benefit from further research to improve current practice.

Project description:BACKGROUND AND OBJECTIVES:Practicing clinical nephrologists are performing fewer diagnostic kidney biopsies. Requiring biopsy procedural competence for graduating nephrology fellows is controversial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:An anonymous, on-line survey of all Walter Reed training program graduates (n=82; 1985-2017) and all United States nephrology program directors (n=149; August to October of 2017), regarding kidney biopsy practice and training, was undertaken. RESULTS:Walter Reed graduates' response and completion rates were 71% and 98%, respectively. The majority felt adequately trained in native kidney biopsy (83%), transplant biopsy (82%), and tissue interpretation (78%), with no difference for ≤10 versus >10 practice years. Thirty-five percent continued to perform biopsies (13% did ≥10 native biopsies/year); 93% referred at least some biopsies. The most common barriers to performing biopsy were logistics (81%) and time (74%). Program director response and completion rates were 60% and 77%. Seventy-two percent cited ≥1 barrier to fellow competence. The most common barriers were logistics (45%), time (45%), and likelihood that biopsy would not be performed postgraduation (41%). Fifty-one percent indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications. Program directors citing ≥1 barrier or whose fellows did <50 native biopsies/year in total were more likely to think that procedural competence should not be required versus those citing no barriers (P=0.02), or whose fellows performed ≥50 biopsies (P<0.01). CONCLUSIONS:Almost two-thirds of graduate respondents from a single military training program no longer perform biopsy, and 51% of responding nephrology program directors indicated that biopsy procedural competence should not be required. These findings should inform discussion of kidney biopsy curriculum requirements.

Project description:Background:Stereotactic radiosurgery (SRS) has emerged as an important modality for the treatment of intracranial metastases. There are currently few established guidelines delineating indications for SRS use and fewer still regarding plan evaluation in the treatment of multiple brain metastases. Methods:An 18 question electronic survey was distributed to radiation oncologists at National Cancer Institute (NCI) designated cancer centers in the USA (60). Centers without radiation oncologists were excluded. Physicians who indicated that they do not prescribe SRS were excluded from the remaining survey questions. Sign test and Chi-square test were used to determine if responses differed significantly from random distribution. Results:One hundred sixteen of the 697 radiation oncologists surveyed completed the questionnaire, representing 51 institutions. Sixty-two percent reported treating patients with brain metastases using SRS. Radiation oncologists prescribing SRS most commonly treat CNS (66.2%) and lung (49.3%) malignancies. SRS was used more frequently for < 10 brain metastases (73.7%; p < 0.0001) and whole brain radiation therapy (WBRT) for > 10 brain metastases (82.5%; p < 0.0001). The maximum number of lesions physicians were willing to treat with SRS without WBRT was 1-4 (40.4%) and 5-10 (42.4%) (p < 0.0001 compared to 11-15, 16-20 and no limit). The most important criteria for choosing SRS or WBRT were number of lesions (p < 0.0001) and performance status (p = 0.016). The most common margin for SRS was 0 mm (49.1%; p = 0.0021). The most common dose constraints other than critical structure was conformity index (84.2%) and brain V12 (61.4%). The LINAC was the most common treatment modality (54.4%) and mono-isocenter technique for multiple brain metastases was commonly used (43.9%; p = 0.23). Most departments do not have a policy for brain metastases treatment (64.9%; p = 0.024). Conclusions:This is one of the first national surveys assessing the use of SRS for brain metastases in clinical practice. These data highlight some clinical considerations for physicians treating brain metastases with SRS.

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Modified rapid sequence induction and intubation: a survey of United States current practice.

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Modified rapid sequence induction and intubation: a survey of United States current practice.

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