Timothy M. Cook

Summary: Introduction: Pulmonary aspiration of gastric contents remains an important cause of anaesthetic morbidity and mortality, and is important medicolegally. Rapid sequence induction is a multi‐element technique designed to mitigate risk in those patients at increased risk of pulmonary aspiration during induction of general anaesthesia. Methods: We undertook a narrative review to summarise evidence and evidence gaps focusing on controversial aspects of rapid sequence induction. Results: Despite widespread use of rapid sequence induction, many elements of the technique lack robust evidence and consensus. Nasogastric tubes can be used to reduce gastric content, but do not empty the stomach reliably. Correctly applied cricoid force obstructs the hypopharynx and has a limited impact on airway management, but incorrect application can cause clinically significant difficulties. Correct location of cricoid force may require ultrasound localisation of the cricoid cartilage. Applying the correct force, which varies with age and sex, is improved by education, practice and feedback. The use of videolaryngoscopy during rapid sequence induction is supported by evidence. The role of gastric ultrasound in determining anaesthetic technique is uncertain. Cardiovascular complications of rapid sequence induction are common, particularly in the patients who are critically ill, and modifications to the technique may reduce their frequency and severity. Effective use of airway rescue techniques may require removal of cricoid force. Discussion: There is insufficient evidence for many of the elements of rapid sequence induction to determine whether they reduce patient harm or to state confidently that they do not. Controversies and evidence gaps should be acknowledged. Despite this, optimal use of rapid sequence induction requires a thorough knowledge of the subject, including areas of uncertainty to guide individualised risk assessment; clinical decision‐making; and practical conduct of the technique.

Summary: Introduction: Airway management research has historically incorporated heterogeneous outcome selection and definitions. This impedes evidence synthesis and hinders advances in patient care. We aimed to develop a core outcome set to standardise airway management research and improve outcome reporting. Methods: We performed a systematic review of outcomes reported in airway management studies to identify candidate outcomes from a random sample of eligible studies. We used a modified Delphi survey of three key stakeholder groups: patients with experience of airway management; clinicians engaged in airway management; and others (including researchers, device manufacturers and policymakers). Outcomes were classified into five domains: procedural effectiveness; physiological parameters; adverse events; patient‐reported outcomes; and other. Outcomes were presented in random order in two sequential virtual Delphi surveys and rated by each respondent. Candidate outcome measurement instruments were identified through included studies and targeted literature searches. Subsequently, a core outcome set with suggested outcome measurement instruments was discussed and agreed. Results: The systematic review identified 4368 studies, with 68 candidate outcomes longlisted from a random sample of 100 studies. Rounds one and two Delphi surveys were completed by 453 and 155 participants, respectively, from six continents. First and second virtual panels were attended by 62 and 44 participants, respectively. The final agreed core outcome set included 11 outcomes: death; cardiac arrest; serious complications; pulmonary complications; neurological complications; airway trauma; unrecognised oesophageal intubation; hypoxaemia; first attempt success without complications; overall success without complications; and difficult airway. Proposed outcome measurement instruments were agreed for all included outcomes. Discussion: We present the first consensus‐based core outcome set for airway management research, with agreed definitions and measurement instruments. Incorporation of these outcomes into future airway management studies will harmonise evidence synthesis and improve the translatability of findings to improve clinical care.