Audit on Current Practice of Rapid Sequence Induction and Intubation of Anesthesia in the University of Gondar Hospital, Northwest Ethiopia, 2018

Background In patients who are liable to the risk of pulmonary aspiration, airway control is the primary and first concern for the anesthetists both in emergency and elective surgical procedures. Rapid sequence induction is universally required in any occasion of emergent endotracheal intubation needed for unfasted patients or patients' fasting status is unknown. Methods institutional-based prospective observational study was conducted from December 2017 to January 2018 in all elective and emergency adult or pediatric patients with a risk of pulmonary aspiration who were operated under general anesthesia with rapid sequence induction and intubation during the audit period. Result A total of 35 patients were operated during the study period. Of these, 31 (88.57%) patients were adults and 4 (11.43%) patients were pediatrics. Most of the patients were emergency (29 (82.857%)), and the rest were elective (6 (17.142%)). Conclusion Most anesthetists were good at preparing all available monitoring and drugs, making sure that IV line is well-functioning, preparing suction with a suction machine, preoxygenation, application of cricoid pressure, and checking the position of the ETT after intubation was performed. Preparing difficult airway equipment during planning of rapid sequence induction and intubation, giving roles and told to proceed their assigned role for the team, attempt to ventilate with a small tidal volume, and routine use of bougie or stylet to increase the chance of success of intubation needed improvement.


Introduction
In patients who are liable to the risk of pulmonary aspiration, airway control is the primary and first concern for the anesthetists both in emergency and elective surgical procedures and in any occasion of need of airway protection [1].
Rapid sequence intubation and induction of anesthesia is a very fundamental skill of anesthesia practice during encountering patients who are at risk of pulmonary aspiration. It is commonly used to prevent regurgitation and vomiting of gastric contents at aiming of protecting the airway. To optimize patient outcome and to reduce risk of hypoxia, currently the modified technique of rapid sequence induction/intubation is practiced in certain clinical circumstances [2,3]. e modified technique of rapid sequence induction/ intubation is the use of pharmacological prophylaxis, preoxygenation, application of cricoid pressure, and positive pressure ventilation before securing the patient's airway [3].
Rapid sequence induction is universally required in any occasion of emergent endotracheal intubation needed for unfasted patients or patients' fasting status is unknown like trauma patients, emergency surgery, resuscitation and patients with diminished level of consciousness, patients who are known for gastroesophageal reflux, diabetes, Parkinson's disease, gastric banding surgery, severe pain, recent opioid use, and pregnancy [4].
During rapid sequence induction, patients should be in optimal condition as much as possible, and they must not experience pain and major discomfort and recall to avoid any psychological trauma afterward [5].
Rapid sequence induction is the safest and fastest technique of induction to protect the airway from adverse airway events like pulmonary aspiration. During planning of this technique, there should be skilled assistance for the application of cricoid pressure [6].
Wrong technique of rapid sequence induction by most anesthetists results in high chance of failure to intubate, experiencing of regurgitation, hypoxia, and patient death [7].
Among many clinical skills applied to maintain the airway management both in the operating theater and out of the operating theater, the skill of applying safe and efficient rapid sequence induction is arguably one of the most frequently used and important techniques while encountering clinically indicated patients [8].
Cricoid pressure during the rapid sequence induction technique is the gold standard means of preventing gastric content entering the respiratory tract if it is applied correctly. But incorrect application of cricoid pressure leads to complications and risks to the patient [9].
To reduce adverse events to the patient during rapid sequence induction, it is important developing standards and procedural checklists [10]. In hemodynamically instable patients, using fentanyl, ketamine, and rocuronium produce the best intubating condition comparing the classic technique [11]. e incidence of desaturation during rapid sequence induction in Gondar University Hospital is around 35.9% which is too high clinically. e reason for the incidence is thought to be inadequate preoxygenation and lack of trained assistant [12].
is clinical audit is aiming at evaluating the current practice of RSII in the University of Gondar against the wellestablished standard and giving training for those who do have skill gap to use it.

Audit Design and
Period. An institutional-based prospective observational study was conducted from December 2017 to January 2018.

Audit Area.
is audit was conducted in the GUH obstetrics operation room and the main surgical operation room located in Gondar town, Northwest Ethiopia.

Audit Source Population.
All patients planned for emergency and elective operation.

Audit Population.
All elective and emergency adult or pediatric patients with a risk of pulmonary aspiration who were operated under general anesthesia with rapid sequence induction and intubation during the audit period.

Exclusion Criteria.
Patients with a risk of pulmonary aspiration who are planned to undergo surgery with susceptible cervical spine fracture, patients with anticipated difficult intubation, and patients who are operated under regional anesthesia and sedation.
2.6. Audit Sampling Procedure. All consecutive elective and emergency adult or pediatric patients with a risk of pulmonary aspiration who were operated under general anesthesia with rapid sequence induction and intubation at the University of Gondar Hospital operation theaters who were eligible for the study based on the inclusion-exclusion criteria.

Data Collection
Method. Data were collected by using a standard checklist. e checklist was primarily prepared in English language.

Data Quality Management.
e collected data were checked for the completeness, accuracy, and clarity. en necessary corrections were made accordingly to the standard checklist for the audit.

Sociodemographic Characteristics of Respondents.
A total of 35 patients were operated during the study period. Of these, 31 (88.57%) patients were adults and 4 (11.43%) patients were pediatrics. Most of the patients were emergency (29 (82.857%)), and the rest were elective (6 (17.142%)). Around 97.1% of the anesthetists prepared the necessary airway equipment as per the standard ( Table 2).
All anesthetists preoxygenated their patients during planning of rapid sequence induction, and only 14.3% of the anesthetists used bougie or stylet to maximize the chance of success (Table 3).
Intubation performed after the intubation conditions are obtained after observing fasciculation and the ETT cuff inflated and the correct position of ETT checked by the chest rise and fall, tube misting, normal feeling of air flow or capnography, and releasing of cricoid pressure were applied by all anesthetists as per the standard (Figure 1).

Discussion
is clinical audit showed that the current practice of rapid sequence induction and intubation in GUH needs some improvement in some of the standards as recommended by the international guidelines.
Before intubating a patient with rapid sequence induction and intubation technique in this audit, around 48.5% of the anesthetists confirmed the role of the team what to do during the procedure, and around 57.1% of the anesthetists told to the team to do the activity they were assigned to. e intubator is the leader who also preoxygenates and administers drugs, while the assistant applies cricoid pressure and passes equipment to the intubator. A third person may be required for manual in-line stabilization of the neck if cervical spine injury is suspected [13].
Only around 14.3% of anesthetists in UOGH used bougie or stylet as a routine practice during rapid sequence induction to maximize the chance of success of intubation.
Many scholars recommend the use of bougie or stylet as routine, and if available a video laryngoscope to maximize the chance of success of intubation is important [13]. In this clinical audit, 68.6% of anesthetists prepared difficult airway equipment [10].
Attempt to ventilate in using positive pressure ventilation via a face mask was applied by 62.9% of the anesthetists.  Nowadays, some experts strongly recommend the routine use of positive pressure ventilation before tracheal intubation in certain RSII scenarios [3,14]. If the standards are not applied correctly, it may result in desaturation, pulmonary aspiration, pneumonia, atelectasis, and finally death. e main reason for missing to apply the standards correctly may be secondary to lack of local working guidelines. Oxygen desaturation is the commonest complication for emergency patients, and greater emphasis should be put on formal preoxygenation as an essential part of RSI [1,15].
is audit also showed that the practice of assigning the team for specific activity, preparation of difficult airway equipment like cricothyroidotomy kit, and attempt to ventilate patients during RSI is poor that needs some improvement [2].

Areas of Good
Practice. Most anesthetists were good at preparing all available monitoring and drugs, making sure that IV line is well-functioning, preparing suction with a suction machine, preoxygenation, and application of cricoid pressure, and checking the position of the ETT after intubation is performed.

Areas Which Need to
Be Improved. Preparing difficult airway equipment during planning of rapid sequence induction and intubation, giving roles and told to proceed the assigned role for each member of the team, attempt to ventilate with a small tidal volume, and routine use of bougie or stylet to increase the chance of success of intubation should be improved.