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Rapid sequence induction with videolaryngoscopy for category 1 caesarean delivery in parturients with anticipated difficult intubation: the use of decision analysis based on data from systematic reviews.
Abstract Number: T-10
Abstract Type: Original Research
Introduction: Predicted difficult airway is considered by many to be an absolute contraindication for rapid sequence induction (RSI) even in category 1 caesarean deliveries. This risk may be diminished by using videolaryngoscopy (VL), but quantifying this risk is hampered by the rarity and urgency of these cases.
Methods: We used decision analysis, based on multiple systematic literature searches (Pubmed 1966-2015 and Cochrane Library), to quantify probability of failure and time to success of three management strategies: RSI with VL; awake fibreoptic intubation (FOI); and spinal anaesthesia. Studies were analysed that assessed either success rate (nominator and denominator), or time to success (reported in a way that allowed calculation of mean and standard error). Mean time for each node was the average of the times from each trial, weighted according to number of successes. Standard error for time was estimated pragmatically depending on how variation was presented in the relevant paper: 95% CI÷2; standard deviation/√(n-1);or interquartile range/1.35/√(n-1). Cumulative probabilities were calculated by multiplying the probabilities of each of the preceding nodes. Standard errors for cumulative probabilities were calculated by adding the relative errors in quadrature (square root of the sum of the squares) of probabilities for each of the preceding nodes. Cumulative pathway times were calculated by adding the times for each of the preceding nodes. Standard errors for cumulate times were calculated by adding absolute errors in quadrature. Numbers of accepted / rejected studies were: videolaryngoscopy 7/17, rescue mask ventilation 1/98, rescue LMA ventilation 16/241, surgical cricothyroidotomy 1/36, awake fibreoptic intubation 1/33, and spinal anaesthesia for category 1 caesarean delivery 2/294. Full list of accepted and rejected papers, including reasons for rejection, are available on request. Results for each node have been populated in the figure.
Results: There was a shorter time to induction using RSI-VL (102 ± 2 sec) compared with awake fiberoptic intubation (approximately 9 ± 2 min, p=0.0001) or spinal anaesthesia (6.3 ±2.6 min, p=0.038). The risk of ultimate failed airway after RSI-VL was 5.5 ± 1.0 per 100,000 cases.
Conclusion: Data from decision analysis may be used to inform clinical decision making. We suggest that many mothers would accept such a low additional risk in order to reduce delivery time and potentially reduce fetal harm.