Eichelsbacher C, Ilper H, Noppens R, Hinkelbein J, Loop T
Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland.
Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt a.M., Deutschland.
Anaesthesist. 2018 Aug;67(8):568-583. doi: 10.1007/s00101-018-0460-3. Epub 2018 Jun 29.
Induction of general anesthesia in patients with risk for aspiration needs special considerations to avoid the incidence and severity of complications. Since no evidence-based guidelines support the challenge for anesthesiologists various practical recommendations exist in clinical practice for rapid sequence induction and intubation (RSI). The aim of this systematic review is, to summarize the evidence and recommend a decision making process.
Multilevel RAND-delphi-method (RAND: Research and Development) combined with systematic literature research, individual assessment and evaluation, consensus conferences and final common sequence.
The consideration of all practical, clinical procedures in patients at risk for aspiration represents an effective prevention of pulmonary aspiration during the induction of anesthesia. These include the optimal drug pre-treatment with antacids (e. g. sodium citrate) for highly aspiration-endangered and proton pump inhibitors or H2 blockers in other patients the evening before. Each patient should be examined and explained prior to RSI according to the recommendations of the National German Society of Anesthesiology for preoperative evaluation. A RSI should be performed in patients with no 2h liquid and no 6h food fasting or acute vomiting, sub-ileus or ileus, or no protective reflexes or a gastrointestinal passenger disorder. In addition, RSI should be performed in pregnant women after the 3rd trimester and during birth. The expertise and competence of the physician before and during rapid sequence induction and intubation about the respective task distribution minimizes the risk of aspiration, as does the adequate equipment, as well as an optimized upper body elevation of the patient. Consistent pre-oxygenation with an FO of 1.0 (FeO-concentration > 0.9) and an oxygen flow > 10 l/min using a completely sealing respiratory mask with capnography should take 3-5 minutes. Fast enough deep anesthesia and muscle relaxation to avoid coughing and choking can be achieved by a combination of opioid, hypnotic and muscle relaxation. In addition, an opioid of choice, propofol, thiopental, etomidate and ketamine can be used as hypnotic and rocuronium with the availability of sugammadex should be used as muscle relaxant. If there are no contraindications, succinylcholine can also be used as a muscle relaxant. In case of an unexpected difficult airway, a 2nd generation extraglottic airway device should be used. During regurgitation or aspiration, intensive medical monitoring and fiber-optic bronchoscopy should be performed, depending on the degree of severity and an X‑ray thorax image or a CT scan should be performed if symptoms arise. Three factors reduce the risk of aspiration: expertise, support from an experienced anesthesiologist and close monitoring of an inexperienced anesthesiologist.
对于有误吸风险的患者，全身麻醉诱导需要特别考虑，以避免并发症的发生和严重程度。由于没有循证指南支持麻醉医生应对此类情况，临床实践中存在各种关于快速顺序诱导插管（RSI）的实用建议。本系统评价的目的是总结证据并推荐一个决策流程。
采用多级兰德 - 德尔菲法（兰德：研究与开发），结合系统文献研究、个人评估与评价、共识会议以及最终的通用流程。
考虑到有误吸风险患者的所有实际临床操作，是预防麻醉诱导期间肺误吸的有效措施。这些措施包括对于误吸高危患者使用抗酸剂（如柠檬酸钠）进行最佳药物预处理，对于其他患者在前一晚使用质子泵抑制剂或H2受体阻滞剂。每位患者在进行RSI前应根据德国麻醉学国家协会关于术前评估的建议进行检查并给予解释。对于未禁食2小时液体、6小时食物或有急性呕吐、亚肠梗阻或肠梗阻、或无保护性反射或胃肠道内容物紊乱的患者，应进行RSI。此外，妊娠晚期及分娩期间的孕妇也应进行RSI。医生在快速顺序诱导插管前后的专业知识和能力以及各自任务的分配可将误吸风险降至最低，适当的设备以及患者上半身的最佳抬高姿势也有同样效果。使用完全密封的呼吸面罩并结合二氧化碳监测仪，以1.0的吸氧浓度（FeO浓度>0.9）和>10升/分钟的氧流量进行持续预充氧应持续3 - 5分钟。通过阿片类药物、催眠药和肌肉松弛剂的联合使用，可实现足够快的深度麻醉和肌肉松弛，以避免咳嗽和呛咳。此外，可选用阿片类药物、丙泊酚、硫喷妥钠、依托咪酯和氯胺酮作为催眠药，可使用罗库溴铵并准备好舒更葡糖钠作为肌肉松弛剂。如果没有禁忌证，琥珀酰胆碱也可作为肌肉松弛剂使用。如果出现意外的困难气道，应使用第二代声门外气道装置。在发生反流或误吸时，应根据严重程度进行强化医学监测并进行纤维支气管镜检查，如果出现症状，应进行胸部X线检查或CT扫描。三个因素可降低误吸风险：专业知识、经验丰富的麻醉医生的支持以及对经验不足的麻醉医生的密切监测。
