Rapid sequence induction: its place in

modern anaesthesia
Matrix reference 1A01,
Claire Wallace MBChB FRCA 1A02,1B02,1C02,2A03

Barry McGuire MBChB FRCA

In 1958, aspiration was credited as the largest with a cuffed tube before removal of the cricoid
Key points
cause of anaesthesia-related death by Snow and pressure. This technique was designed to minim-
Aspiration is the largest Nunn.1 Surprisingly, this remains the case in ize the unprotected airway time and so reduce the
cause of death associated
2011.2 The Royal College of Anaesthetists risk of aspiration during that short period. We
with airway management in
National Audit Project (NAP4) calculated the in- could consider this the traditional RSI. There is
UK anaesthesia.
cidence of fatal aspiration during general anaes- no evidence to show that this practice reduces as-
The risk of aspiration should thesia as one in 340 000, but acknowledging that piration or improves outcome. Despite this, RSI
be assessed in all patients
as a probable underestimate, reported that it may remains a recognized standard of care in the UK
presenting for anaesthesia.
be as common as one in 45 000. The risk of aspir- and many other countries.
Rapid sequence induction ation itself is estimated at one in 2–3000 during
(RSI) remains the technique elective surgery and one in 6–800 during emer-
of choice for minimizing this Recognizing the at-risk patient
gency surgery.3 Potential consequences of aspir-
risk. NAP4 criticized the failure to identify those at
ation include chemical pneumonitis, bacterial
Modification of the aspiration pneumonia, acute respiratory distress risk of aspiration. Many factors influence the
traditional RSI may have syndrome, and death. While recognizing the lack degree of risk (Table 1).
benefits for individual Having recognized risk, it is imperative that
of a clear definition, NAP4 recommended that, in
patients. consideration is given to identify a suitable an-
those patients at risk of regurgitation and subse-
quent aspiration, a rapid sequence induction (RSI) aesthetic technique to minimize this risk. The
with cricoid pressure should be the technique of WHO checklist has a question relating to aspir-
choice to induce anaesthesia. However, RSI as a ation risk. Its presence may help to improve the
practice is not without risk, particularly in the crit- recognition of and therefore subsequent manage-
ically ill population. Risks include hypoxia, failed ment of that particular danger.
intubation, oesophageal trauma, cardiovascular
compromise, and awareness. We will describe Reducing the risk from
how modern practice has deviated from the trad- regurgitation
itional, standardized RSI to an approach where
The volume, pH, and constituents of gastric
management of the patient at increased risk of as-
regurgitant are important in any subsequent
piration involves an assessment of all risks to
pathological process after aspiration.
identify suitable techniques designed to minimize
It is therefore important to ensure adequate
those risks for that individual.
fasting and, if appropriate, it would seem sensible
Claire Wallace MBChB FRCA to make attempts to empty the stomach before an-
Consultant in Anaesthesia aesthesia. While being unable to confirm com-
RSI: the history plete emptying, volume of any gastric contents
NHS Tayside
UK Mendelson first described the deleterious effects can be reduced by the placement and aspiration
Barry McGuire MBChB FRCA of aspiration in 1946. Succinylcholine was intro- of a nasogastric tube.
Consultant in Anaesthesia duced in 1951 and cricoid pressure first described The pH of gastric contents can be reduced by
NHS Tayside by Sellick in 1961. These were collated by Stept pharmacological treatments. These include ant-
UK
and Safar in 1970 to describe a technique they acids, a group of drugs that react with hydrochloric
Department of Anaesthetics called Rapid Sequence Induction and Intubation.4 acid to raise pH, H2 receptor antagonists that com-
Ninewells Hospital It consisted of preoxygenation, induction with a petitively inhibit histamine release from gastric
Dundee DD1 9SY
UK predetermined dose of thiopental followed by parietal cells reducing acid production, and
Tel: þ44 (0)1382 660111 (4007) succinylcholine, application of cricoid pressure at proton pump inhibitors (PPIs) that irreversibly
Fax: þ44 (0)1382 644914 loss of consciousness, avoidance of positive pres- bind to and inactivate the hydrogen-potassium
E-mail: b.mcguire@nhs.net
(for correspondence)
sure ventilation, and finally tracheal intubation ATPase, inhibiting gastric acid secretion. When
doi:10.1093/bjaceaccp/mkt047 Advance Access publication 19 September, 2013
130 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 14 Number 3 2014
& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
 Rapid sequence induction

Table 1 Risk factors for regurgitation and aspiration cricoid application. It has been suggested that this may relate to
Increased risk of Obesity lateral displacement of the oesophagus during (appropriately
regurgitation Incompetent lower Hiatus hernia applied) cricoid pressure. Research has demonstrated that cricoid
oesophageal sphincter Pregnancy pressure is often poorly performed; that it may hinder bag-valve
Full stomach Inadequate fasting
Delayed gastric Stress mask ventilation, LMA insertion, and view at laryngoscopy; but that
emptying Pain, including it does reduce gastric inflation during mask ventilation. Critically, it
labour has also been shown to potentially obstruct the upper airway and
Opiates
Acute abdomen reduce time to desaturation.6 Taking all this into consideration, some
Gastric outlet or European countries no longer consider cricoid pressure to be an es-
bowel obstruction sential component of RSI. The NAP4 guidelines, however, continue
Gastric paresis, e.g.
DM to support its use as part of an RSI and as such, it is still considered a
Positioning Lithotomy standard of care in the UK. This should be supported by adequate
Trendelenburg training and practice in its use. There should be a low threshold for
Increased risk of Impaired laryngeal Reduced conscious Coma
aspiration reflexes level Anaesthesia reducing or removing cricoid pressure if intubation or mask ventila-
Neuromuscular Inadequate reversal tion proves difficult and to facilitate LMA insertion or cricothyro-
weakness Bulbar palsy tomy rescue techniques.

Tracheal tube choice

given before an operation in single oral doses, H2 antagonists are more
effective than PPIs in increasing the pH. However, when given i.v. or A cuffed tracheal tube represents the gold standard in airway protec-
over two oral doses, there does not appear to be any difference tion and should be used in RSI. Cuffed tracheal tubes with the cap-
between the two. Non-particulate antacids, such as sodium citrate, ability of allowing supraglottic suction reduce the risk of aspiration
have the advantage of immediate onset. Prokinetics, such as metoclo- further. After a failed RSI intubation, where mask ventilation is diffi-
pramide, improve gastric emptying, thus reducing volume. However, cult or impossible, the use of a supraglottic airway device (SAD) is
none of these interventions has been shown to improve outcome after recommended. The use of a second-generation SAD in this situation,
aspiration and they have no effect on the acidity of small bowel con- with its superior seal pressure to facilitate assisted ventilation and
tents, which also have the potential to regurgitate.5 the presence of a channel to direct gastric contents away from the
larynx, makes particular sense. Similarly, in a ‘Can’t intubate, can’t
ventilate’ scenario requiring cricothyrotomy, there is a strong argu-
Reducing the risk of aspiration
ment for performing a surgical airway and inserting a cuffed tracheal
Alternative approach tube that will provide both oxygenation and airway protection.
In certain situations, consideration should be given to the use of a re-
gional technique to avoid general anaesthesia. During difficult Reducing the risk of the anaesthetic
airway management, where the time to intubation is increased, the technique
aspiration risk is also greater. If such difficulty is predicted, consid- Preoxygenation
eration may be given to securing the airway using awake fibreoptic
intubation. Preoxygenation is an attempt to maximize oxygen stores in the body
before a period of pharmacologically induced apnoea. The majority
of these stores are contained within the lungs as part of the function-
Cricoid pressure al residual capacity (FRC). Increasing the oxygen content and the
Cricoid pressure describes the backward displacement of the com- volume of FRC can protect patients from hypoxia during attempts at
plete cartilaginous cricoid ring against the cervical vertebrae to intubation. Critically ill patients with high metabolic rates, low
occlude the hypopharynx. The technique usually involves the appli- cardiac outputs, and respiratory pathology and patients with a
cation of a 10 N force before induction; increasing this force to 30 N reduced FRC, such as the obese and the parturient, have a lower
on loss of consciousness. Thirty Newtons are considered enough to oxygen storage capacity and will desaturate more rapidly. A variety
maintain a barrier pressure, but minimize airway obstruction or dis- of techniques have been described to maximize oxygenation.
tortion. It should be removed immediately if active vomiting occurs
as there is a risk of oesophageal rupture. Much of the conflicting evi- Increased F IO2
dence supporting and refuting this technique comes from cadaveric Evidence shows that 3–5 min tidal ventilation or 8 vital capacity
and radiological studies. There have been no prospective rando- breaths with 100% oxygen, ensuring a tight mask fit and high gas
mized clinical studies performed to prove the clinical hypothesis flows, will maximize denitrogenation. However, to allow for indi-
and the level of evidence to support the use of cricoid pressure is vidual variation, it is preferable to measure F E0O2 as a surrogate for
poor (level 5). Aspiration has occurred in clinical practice despite alveolar partial pressure, aiming for a value of 0.9. Concerns about

Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014 131
Rapid sequence induction

denitrogenation atelectasis are more than balanced by the increased difficulty is the key clinical issue in a specific patient undergoing
safety provided by improving the time to desaturation. Application RSI. Predetermined dosing may be appropriate in those at high risk
of continuous positive airway pressure (CPAP) during preoxygena- of aspiration in order to minimize the time spent with reduced pro-
tion can overcome these effects and minimize atelectasis. tective laryngeal reflexes. This does, however, increase the risk of
both under-dosing with potential awareness and also overdosing
Positive pressure with the risk of cardiovascular collapse. In certain patients, the risks
PEEP/CPAP has been shown to reduce absorption atelectasis, posed by haemodynamic instability will clearly outweigh the risks
improve PaO2 ; and increase time to desaturation in all patient of aspiration. If there is significant risk of hypotension, then drug
groups. If a patient is already receiving non-invasive ventilation choice should reflect this and administration should be titrated to
(NIV) or has a degree of respiratory compromise, the evidence sug- effect. A survey of current practice in Wales stated that the adminis-
gests that continuing or commencing NIV for a short period while tration of induction drug varies, with some anaesthetists always
setting up for intubation is better protection against desaturation using predetermined doses, some never doing so, and 65% varying
than standard preoxygenation. their practice based on the clinical situation.8
NIV in obese surgical patients specifically has been shown to
improve preoxygenation.7 Concerns about increasing aspiration by Neuromuscular blocking agent
gastric distension can be balanced by adopting upright positioning Succinylcholine is the depolarizing neuromuscular blocking agent
to reduce the risk of passive regurgitation and by limiting airway that has traditionally been used in RSI because of its fast onset and
pressures. Gastric distension and regurgitation risk are low if pres- offset; with the presumption being that, in the event of failure to
sures are kept below 25 cm H2O. intubate, ventilate, or both, recovery of spontaneous ventilation
would reliably rescue the situation. However, due to its relatively
Apnoeic oxygenation rapid onset and immediate reversibility, the non-depolarizing neuro-
As a result of differences in solubility of O2 and CO2, once the muscular blocking agent rocuronium is increasingly used as an
patient is apnoeic, more O2 leaves the alveoli and enters the blood- alternative.
stream than CO2 or N2 enter them, creating a slightly negative pres- The key issues regarding neuromuscular block (NMB) and RSI
sure (increasing atelectasis). This negative pressure can be used to are as follows:
an advantage by maintaining a patent airway and continuing admin- (i) Time to complete paralysis and the quality of those intubation
istration of oxygen that then reaches the alveoli by bulk flow. The conditions.
application of nasal prongs (with flows increased once the patient is (ii) Potential reversal (spontaneous or otherwise) of this effect.
unaware), in addition to face mask oxygen, allows this process to (iii) Duration of action.
continue during laryngoscopy and has been shown to increase (iv) Side-effects and contra-indication profile.
time to desaturation after apnoea in both normal and obese surgical
populations.7 In all trials performed, succinylcholine results in faster paralysis and
a quicker time to intubation when compared with rocuronium. In
Positioning for preoxygenation patients at the highest risk of aspiration, minimizing the time to
FRC is lower in the supine position. Evidence in normal, obese, achieving a protected airway may be clinically significant. A large
and pregnant populations suggests that adopting a head-up position meta-analysis performed by the Cochrane Collaboration reported
(20–358) increases FRC and thereby improves preoxygenation. This that succinylcholine was superior to rocuronium (0.6–1.2 mg kg21)
has been shown to be clinically significant by increasing the time in providing both ‘excellent’ and clinically ‘acceptable’ intubating
from apnoea to desaturation. conditions, but there was no statistical difference when making com-
parisons with the recommended rocuronium dose for RSI of 1.2 mg
kg21.9 Timing of NMB administration also varies. In one survey,
Drug choice
just over half of all anaesthetists stated that they routinely wait for
Induction drug unconsciousness before administering; 10% never wait and immedi-
When Stept and Safar described the traditional RSI in 1970 using a ately administer after induction dose; while the remainder vary their
predetermined dose of thiopental, many of the i.v. induction agents practice.8 Theoretically, immediate injection shortens the time to
currently available were not fully established in clinical practice. establishing a protected airway, but there is no evidence that this is
Even now, the ideal i.v. induction agent does not exist, with individ- clinically important.
ual drugs harbouring benefits and disadvantages (Table 2). National Succinylcholine shows considerable variation in its duration of
surveys of clinical practice reveal that all induction agents are used action due to genetic and acquired deficiencies in plasma cholin-
across various clinical scenarios. The choice of i.v. induction agent esterase, the enzyme responsible for its inactivation. The average re-
should be guided by informed clinical reasoning and not by dogma. covery from succinylcholine 1 mg kg21 is 8.5 min. Even healthy
Propofol, for example, will provide the best intubation conditions volunteers will desaturate before the return of spontaneous respira-
and hence may be used when it is deemed that potential airway tory effort without receiving assisted ventilation.10 Furthermore,

132 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014
 Rapid sequence induction

Table 2 Induction agent considerations

Induction agent Advantages Disadvantages Suggested use

Sodium thiopental 3–7 mg kg21 Clear endpoint; rapid one arm brain Postoperative nausea and vomiting Traditional choice for RSI in obstetric practice
(traditionally used) circulation time Potential harm from extravasation
Antanalgesic
Propofol 2– 4 mg kg21 Greater suppression of laryngeal reflexes CVS depression When intubating conditions are a concern
(use increasing) Familiarity
Etomidate 0.3 mg kg21 CVS stability Adrenal suppression CVS instability; caution/avoid in sepsis and, if
(use decreasing) used, early hydrocortisone is recommended
Ketamine 1–2 mg kg21 Bronchodilation Increases ICP Asthma
CVS stimulant; maintains cerebral perfusion Shocked states
pressure in hypotensive situations Avoid in patients with IHD or with non-traumatic
CNS pathology
Midazolam Not routinely used as an induction agent Longer to take effect and long duration Probably no role as a single agent
in the UK of action
Opiate Not routinely used as an induction agent Unreliable amnesic. Not recommended Probably no role as a single agent
in the UK as a general anaesthetic

with a return in spontaneous respiration, the upper airway may ‘wake up’ after a failed RSI intubation. Opioids reduce intraocular,
remain completely obstructed in an unconscious patient. intracranial, and cardiovascular adverse effects associated with
Rocuronium followed by sugammadex results in a comparatively laryngoscopy and should be considered in situations where these
faster return to spontaneous ventilation. However, it is unclear if this effects could be potentially harmful. They also reduce the dose of
would be replicated in actual clinical practice.11 To facilitate this, it hypnotic agent required. The majority of anaesthetists now include
is suggested that, when using rocuronium in an RSI, the rescue opioids as part of their preferred technique. For example, remifenta-
dose of sugammadex 16 mg kg21 should be pre-calculated and im- nil, alfentanil, fentanyl, and morphine are used in up to 92% of UK
mediately available for an assistant to draw up and administer on anaesthetists’ practice.8 Alfentanil has the potential advantage of
instruction. bolus delivery and a more rapid onset and shorter recovery than fen-
The more prolonged action of a non-depolarizing agent such as tanyl or morphine.
rocuronium may be advantageous. First, it is well recognized that
considerable difficulties with airway management can arise when Non-opioids
the succinylcholine paralysis is wearing off and airway conditions Many drugs have been used in an attempt to reduce the presser re-
become suboptimal. Secondly, in certain RSIs, ‘wake up’ is not a sponse to laryngoscopy, including b-blockade. Evidence for the use
feasible option and the reversibility of the induction technique not of lidocaine and magnesium in this setting is at best equivocal.
an issue, for example, the patient with the ruptured abdominal aortic
aneurysm or the critically ill patient with respiratory failure. In these
Ventilation
scenarios, use of a drug that provides the best airway management
conditions for more than a few minutes would seem the most effect- Ventilation after apnoea and before intubation is traditionally
ive strategy. avoided in RSI owing to the assumption that such practice increases
Succinylcholine is a drug with a number of potentially life- gastric distension and the risk of regurgitation. However, there is
threatening side-effects. Potassium efflux occurs at depolarization; no good evidence for this as long as inflation pressures used are
this is increased significantly in conditions that result in ,15 –20 cm H2O. Fit, healthy patients who have normal airway
up-regulation of nicotinic receptors, such as burns, crush injuries, anatomy and are simple to intubate are unlikely to desaturate, but
and chronic neurological conditions, including spinal cord injury, patients who have increased metabolic demands, reduced FRC, pre-
stroke, and critical illness polyneuropathy. It causes malignant existing hypoxia, respiratory pathology, or are not readily intubata-
hyperthermia in susceptible individuals. Rocuronium is a relatively ble may desaturate before intubation despite adequate preoxygena-
cleaner drug; the only absolute contraindication being allergy. There tion. These patients are likely to benefit from gentle ventilation with
is increasing evidence that the incidence of rocuronium allergy is cricoid pressure applied before laryngoscopy. This has been referred
higher than that of other non-depolarizing neuromuscular blocking to as controlled RSI.
agents.12
Management of failure
Opioids Airway management should not be commenced without formulating
Traditionally, opioids were not used as part of an RSI—the belief a patient-specific strategy, with particular emphasis on management
being that they could contribute to an increase in the time to recov- plans in the event of failure. The Difficult Airway Society (DAS)
ery of spontaneous ventilation and consciousness in the event of a guidelines13 for the management of failed intubation and ventilation

Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014 133
Rapid sequence induction

are currently being revised. Knowledge and application of these or thiopental, not to use a pre-determined dose of induction agent, not
similar guidelines, including ensuring availability of and familiar- to use succinylcholine, not to maintain cricoid pressure, or to delib-
ization with airway rescue equipment, and an informed team-based erately assist ventilation before intubation. Future research may
approach may make the difference between patient safety and offer insight to guide the decision-making process and should be
patient catastrophe. Initial attempts at laryngoscopy are commonly encouraged. With the development of new drugs, increasing co-
performed using a Macintosh laryngoscope, but an increasing morbidities, and higher risk profiles of our patients, the traditional
number of anaesthetists are using videolaryngoscopy, if not for their RSI has been modified to provide an optimal balancing of risks. This
initial attempts, as their rescue device, replacing alternative direct can be directed by locally adapted guidelines. A modified RSI as
laryngoscopes such as the McCoy or straight blade. Aids such as in- practiced in modern anaesthesia could be considered to be:
tubating stylets or bougies should be immediately available. There is
(i) Physical and pharmacological reduction in regurgitation and
no evidence to support the use of any one of these devices over
aspiration risk.
another and, in the absence of this, choice will relate to the clinical
(ii) Maximal optimization of oxygen stores. This may involve
situation and professional preference. There should be a third person
assisted ventilation before intubation.
(anaesthetist, assistant, or suitable alternative) present and able to
(iii) Induction of anaesthesia appropriate to clinical conditions,
summon help or retrieve equipment required should unexpected dif-
with paralysis by a rapidly acting agent. Sugammadex should
ficulties arise. The default position in most RSIs where intubation is
be immediately available if rocuronium is used.
unsuccessful will be wake up. This may not be appropriate or pos-
(iv) Application of cricoid pressure is advisable—unless it obscures
sible in all patients and this should be factored in to the planned
the view at laryngoscopy or interferes with manual ventilation
strategy.
or SAD placement.
(v) Tracheal intubation with a cuffed tracheal tube.
Extubation (vi) Implementation of pre-planned strategy in the event of failure
Traditionally, patients who had had an RSI were extubated in the to intubate.
left-lateral head-down position after a full return of protective
airway reflexes. More recently, there has been a trend towards extu-
Declaration of interest
bation in the semi-recumbent position, which is likely to aid upper
airway patency, respiratory function, and access to the airway, par- None declared.
ticularly in the obese patient. There is no good evidence to support
one practice over another. The key issue as regards safe extubation is References
again having a clear strategy, which may be informed by the recently
1. Snow RG, Nunn RF. Induction of anaesthesia in the foot-down position for
published DAS Extubation guidelines.14 patients with a full stomach. Br J Anaesth 1959; 31: 493– 7
2. Cook TM, Woodall N, Frerk C. Fourth National Audit Project of the
Management of process Royal College of Anaesthetists and Difficult Airway Society. Major
Complications of Airway Management in the United Kingdom. Report and
After the implementation of a 10-point checklist/care bundle for in- Findings. London: Royal College of Anaesthetists, March 2011
tubation in a critical care unit, rates of severe hypoxaemia and cardio- 3. Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment for
vascular collapse significantly decreased.15 NAP4 recommended that aspiration. Best Pract Res Clin Anaesthesiol 2004; 18: 719– 37
an intubation checklist should be developed and used for the tracheal 4. Sept WJ, Safar P. Rapid induction and intubation for prevention of gastric-
intubations of all critically ill patients. They suggested a checklist content aspiration. Anesth Analg 1970; 49: 633– 6
might identify issues regarding preparation of the patient, equipment, 5. Puiga I, Calzadob S, Suárezc D et al. Meta-analysis: comparative efficacy of
H2-receptor antagonists and proton pump inhibitors for reducing aspir-
drugs, and personnel and help clarify the back-up plan. Some units ation risk during anaesthesia depending on the administration route and
have introduced these checklists for critical care and emergency schedule. Pharmacol Res 2012; 65: 480–90
medicine. The use of standard operating procedures may also be bene- 6. Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure.
ficial, such as the instruction on the preparation of sugammadex for Anaesthesia 2000; 55: 208– 11
potential reversal of NMB if rocuronium is to be used during an RSI. 7. Weingart SD, Levitan RM. Preoxygenation and the prevention of desatur-
Local guidelines for RSI practice for junior trainees may also be ad- ation during emergency airway management. Ann Emerg Med 2012; 59:
165–75
vantageous to ensure safe and consistent practice.
8. Koerber JP, Roberts GEW, Whitaker R et al. Variation in rapid sequence in-
duction techniques: current practice in Wales. Anaesthesia 2009; 64: 54–9
Summary 9. Perry JJ, Lee JS, Sillberg VAH et al.. Rocuronium versus succinylcholine for
rapid sequence induction intubation. Cochrane Database Syst Rev 2008,
The available evidence does not allow strict guidance on when and Issue 2. Art. No. CD002788.pub2
when not to perform an RSI, nor does it clarify the precise compo-
10. Heier T, Feiner J, Lin J. Hemoglobin desaturation after succinylcholine-
nents that should constitute this approach, so-called ‘best practice’. induced apnea. A study of the recovery of spontaneous ventilation in
In certain clinical scenarios, an anaesthetist may chose not to use healthy volunteers. Anesthesiology 2001; 94: 754– 9

134 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014
 Rapid sequence induction

11. Bisschops MMA, Holleman C, Huitink JM. Can sugammadex save a 14. Popat M, Mitchell V, Dravid R et al. Difficult Airway Society Guidelines
patient in a simulated ‘cannot intubate, cannot ventilate’ situation? for the management of tracheal Extubation. Anaesthesia 2012; 67:
Anaesthesia 2010; 65: 936 –41 318– 40
12. Sadlier PHM, Clarke RC, Bunning DL et al. Anaphylaxis to neuromuscular 15. Jaber S, Jung B, Corne P et al. An intervention to decrease
blocking drugs: incidence and cross-reactivity in Western Australia from complications related to endotracheal intubation in the intensive care
2002. Br J Anaesth 2013; 110: 981– 7 unit: a prospective, multiple-center study. Intensive Care Med 2010; 36:
13. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society 248– 55
guidelines for management of the unanticipated difficult intubation.
Anaesthesia 2004; 59: 675 –94 Please see multiple choice questions 25–28.

Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014 135