Anaesthesia 2020, 75, 313–322 doi:10.1111/anae.

14867

Original Article

An international survey about rapid sequence intubation of

10,003 anaesthetists and 16 airway experts*
M. Zdravkovic,1,2 J. Berger-Estilita,3 M. Sorbello,4 and C. A. Hagberg5

1 Resident, Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor,
Maribor, Slovenia
2 PhD Student, Faculty of Medicine, University of Maribor, Maribor, Slovenia
3 Consultant, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
4 Consultant, Department of Anesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele, Catania, Italy
5 Professor, Department of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer
Center, Houston, TX, USA

Summary
Pulmonary aspiration of gastric content is a significant cause of anaesthesia-related morbidity and mortality.
High-quality prospective randomised evidence to support prevention strategies, such as rapid sequence
intubation, is difficult to generate due to well-described practical, ethical and methodological barriers. We
aimed to generate an understanding of worldwide practice through surveying clinically practicing anaesthetists
and airway experts. Our survey was designed to assess the influence of: departmental standards; patient
factors; socio-economic factors; training; and supervision. We surveyed 10,003 anaesthetists who responded to
an invitation to participate on LinkedIn. We then surveyed 16 international airway experts on the same content.
When asked about a hypothetical patient with intestinal obstruction, respondents expressed preferences for
[OR (95%CI)]: the head-up or -down position 4.26 (3.98–4.55), p < 0.001; nasogastric tube insertion 29.5 (26.9–
32.3), p < 0.001; and the use of cricoid force 2.80 (2.62–3.00), p < 0.001, as compared with a hypothetical
patient without intestinal obstruction also requiring rapid sequence intubation. Respondents from lower
income countries were more likely to prefer [OR (95%CI]: the supine position 2.33 (2.00–2.63), p < 0.001;
nasogastric tube insertion 1.29 (1.09–1.51), p = 0.002; and cricoid force application 2.54 (2.09–3.09), p < 0.001
as compared with respondents from higher income countries for a hypothetical patient with intestinal
obstruction. This survey, which we believe is the largest of its kind, demonstrates that preferences for
positioning, nasogastric tube use and cricoid force application during rapid sequence intubation vary
substantially. Achieving agreed consensus may yield better training in the principles of rapid sequence
intubation.

.................................................................................................................................................................
Correspondence to: M. Zdravkovic
Email: [email protected]
Accepted: 5 September 2019
Keywords: airway management; gastric ultrasound; pulmonary aspiration; rapid sequence intubation; supervision
*Presented in part at the European Airway Congress in Catania, Italy, December 2018.
This article is accompanied by an editorial by Charlesworth and El-Boghdadly, Anaesthesia, 2020; 75: 298–300.
Twitter: @MZanaesthetist; @joanaberger3; @SorbelloMax; @CarinHagberg

[Correction added on 9 November 2019, after first online publication: Appendix 1 has been removed, Acknowledgements
section and all citations within text have been updated in this current version.]

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Introduction variation, which included: departmental standards and

Pulmonary aspiration of gastric content has long been guidelines; patient factors; socio-economic factors, as
recognised as a leading cause of death due to anaesthesia determined by national income groups defined by the
[1]. In the 1960s, anaesthetists developed improved World Bank [21]; and level of training.
techniques for airway management, including cricoid force We also asked about: supervision; personal
and rapid sequence intubation (RSI) for selected patients [2, experiences of pulmonary aspiration during anaesthesia;
3]. However, the 2011 4th UK National Audit Project (NAP4) the use of and experience with pre-operative gastric
revealed that aspiration of gastric content, rather than ultrasound to assess pulmonary aspiration risk; and the
inability to oxygenate, remained the single most common number of team members present during RSI when cricoid
cause of death related to airway management [4]. force is applied.
Best practices for the prevention of pulmonary A 19-item questionnaire was constructed
aspiration have not yet been elicited by high-quality (Appendix. S1). Three items were compulsory, including:
clinical trials [5, 6]. Additionally, the choice of induction participant consent; the existence of departmental
agents for RSI likely depend on their availability; the guidelines, leading to a question on clinical decision-
experience and familiarity of the operator; and many making for a hypothetical patient with intestinal obstruction;
other clinical factors [7]. A standardised approach in the and the level of training of the respondent, which leads to
more technical aspects of the RSI technique, including questions about supervision. Respondents were then asked
patient positioning, nasogastric tube insertion and cricoid to include their city and country of practice, which was a
force application, might be achievable [5, 6]. Three non-compulsory field. Following the survey of clinically
positions might include head-up (reverse-Trendelenburg); practicing anaesthetists (Phase 1), we sought the
supine; and head-down (Trendelenburg). The head-up independent opinions of recognised international airway
position provides better pre-oxygenation and possibly management experts (Phase 2). The experts received a
less reflux of gastric content, but the head-down position content blueprinted version of the same questionnaire with
might be used in the event of vomiting [5, 8, 9]. The use slight modifications (Appendix. S2).
of cricoid force is likewise controversial [10], as is the The draft Phase-1 questionnaire was piloted among
insertion and aspiration of a nasogastric tube before eight external clinicians from all groups of interest,
induction of anaesthesia [11]. including: two trainees in the first half of training; two
The incidence of pulmonary aspiration is thought to be trainees in the second half of training; two consultants with
between 0.01% and 0.04% [4, 12]. This rises to 0.5% and less than 10 years’ experience; and two consultants with
2.8% for RSIs conducted in and outside of the operating more than 10 years’ experience. All were requested to
theatre, respectively [10, 13]. These incidences are greater comment on the language used, which had to be simple
than the incidence of a failure to oxygenate scenario, which enough to be understood globally. Google Forms (Google
is estimated to be 0.002% of all general anaesthetics [4, 14]. Inc, Mountain View, CA, USA) was chosen to host both
Few national guidelines on RSI practices exist and practice questionnaires, as it is free to use and has branching
across and within departments likely varies [6, 15–17]. The possibilities, unlimited response collection and only records
extent of these clinical practice variations across the world each response after the submit button is activated at the end
has not been previously demonstrated [18–20]. Our survey of the survey. The clinician survey was available for
aims to explore these variations and the influence of: completion for 56 weeks, from June 2018 to June 2019.
departmental standards; patient factors; socio-economic The survey link was primarily distributed through
factors; training; and supervision. We also wished to elicit LinkedIn. A search was performed for individuals working as
areas for further research. anaesthetists, and they were invited to connect with the lead
author. We used other social media platforms such as
Methods Facebook and Twitter to a much lesser extent. We gained
This international, Internet-based, cross-sectional, two- the support of several national and international societies by
phased survey was approved by the Maribor University publishing the survey link on websites, newsletters and
Medical Centre ethics committee, Slovenia. Respondents emails.
provided consent for participation at the end of the survey. A ‘snowballing’ sampling technique was used [22]. As
We developed questions focusing on patient positioning, the primary mode of distribution was through social media,
nasogastric tube insertion and the use of cricoid force selection bias was reduced by the aim to collect between
during RSI. We explored four potential sources of practice 7800 and 13,400 responses from at least 100 countries. This

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number was estimated from the World Federation of There were 7235 (75.2%) respondents who reported
Societies of Anaesthesiologists as representing 10% of each the existence of departmental RSI guidelines. The existence
national society’s members, or as five responses per million of guidelines was weakly associated with: an individual
population (Table S1). Only anaesthetists able to preference for either head-up or -down positioning;
understand English, with Internet access to the Google nasogastric tube insertion; and the use of cricoid force
Forms platform were able to participate. (Table 1). There was an overall preference for, with OR (95%
The expert questionnaire was sent to 30 airway experts CI): using either a head-up or -down position, 1.16 (1.03–
from 23 countries between December 2018 and February 1.30), p = 0.013; nasogastric tube insertion 1.18 (1.04–
2019. Experts were contacted through email (either taken 1.33), p = 0.012; and cricoid force application 1.55 (1.38–
from their latest publications, online profiles or as 1.74), p < 0.001 for a hypothetical patient with intestinal
suggested when asked which email address they could be obstruction in those from departments with RSI guidelines
contacted with). Two reminders were sent to non- or standards as compared with those without guidelines or
responders. standards.
Statistical analysis was performed using SPSS Statistics Respondents were asked about their preferences for
20 (IBM Inc., Chicago, IL, USA). Pearson’s Chi-square rapid sequence intubation in patients with and without
statistics were used for contingency table analysis. Effect intestinal obstruction (Table 2). For a hypothetical patient
size estimations were performed on ‘2 9 2’ contingency with intestinal obstruction, there was a preference for, with
tables (excluding ‘uncertain’ replies) and reported as OR OR (95%CI): the head-up or -down position 4.26 (3.98–
with 95%CI and significance set at p < 0.05. Fisher’s exact 4.55), p < 0.001; nasogastric tube insertion 29.5
tests were used for the Phase-2 analysis. Content analysis (26.9–32.3), p < 0.001; and cricoid force application 2.80
and inductive coding of open-ended questions were (2.62–3.00), p < 0.001 as compared with a patient without
analysed for nomothetic properties in clusters of 1000 intestinal obstruction requiring rapid sequence intubation.
responses. Emergent themes were cross-checked by both Furthermore, for a hypothetical patient with intestinal
authors, to ensure consistency. Differences were resolved obstruction, anaesthetists from lower income countries
by discussion. preferred the supine position, nasogastric tube insertion
and cricoid force application as compared with
Results respondents from higher income countries: OR (95%CI):
Out of the 10,003 respondents from 141 countries (Fig. 1a), 2.33 (2.00–2.63), p < 0.001; 1.29 (1.09–1.51), p = 0.002;
382 (3.8%) withheld permission for analysis and 839 (8.4%) and 2.54 (2.09–3.09), p < 0.001, respectively. For a
did not declare their country of practice. We achieved the hypothetical patient without intestinal obstruction but
set minimum target participants for 95 (67%) countries requiring RSI, there was less preference for the head-up
(Table S2). Although it was not possible to precisely position, nasogastric tube use and cricoid force application
determine the response rate, we estimate this to be in all income categories (Fig. 2).
between 40% and 60%, as more than 50% of respondents Preferences for RSI practices varied little as a function of
were recruited through LinkedIn (Fig. 1b). This was evident level of training. Cricoid force application was slightly more
from LinkedIn notifications when respondents completed preferred by consultants with more than 10 years’
the survey. experience, and by trainees in the first half of training

(a) (b)

Figure 1 (a) World map (created at: www.mapchart.net) of the countries and territories from which responses were collected
(green). (b) Rates of survey responses (red) and LinkedIn connections (blue).

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Anaesthesia 2020, 75, 313–322 Zdravkovic et al. | International rapid sequence intubation survey

Table 1 Respondent preferences for patient positioning, nasogastric tube insertion and cricoid force use for hypothetical
patients with and without intestinal obstruction requiring rapid sequence intubation. Responses for those working in
departments with and without guidelines are compared. Values are number (proportion).
Patient positioning Nasogastric tube insertion Cricoid force use

Rapid sequence Head-

intubation Head-up down
indication position position Supine p value Uncertain Yes No p value Uncertain Yes No p value

Intestinal obstruction
Guidelines 4498 668 1259 0.011 1546 4405 1271 < 0.001 622 5355 1250 < 0.001
(70.0%) (10.4%) (19.6%) (21.4%) (61.0%) (17.6%) (8.6%) (74.1%) (17.3%)
No guidelines 1641 214 526 671 1275 433 385 1461 530
(68.9%) (9.0%) (22.1%) (28.2%) (53.6%) (18.2%) (16.2%) (61.5%) (22.3%)
Any other
Guidelines 2695 265 3194 0.260 1501 650 5067 0.023 853 3815 2558 < 0.001
(43.8%) (4.3%) (51.9%) (20.8%) (9.0%) (70.2%) (11.8%) (52.8%) (35.4%)
No guidelines 1042 83 1254 481 124 1776 497 954 928
(43.8%) (3.5%) (52.7%) (20.2%) (5.2%) (74.6%) (20.9%) (40.1%) (39.0%)

(Fig. 3). Out of 9527 respondents answering questions codes that were organised into nine major themes
about supervision, 5998 (77%) consultants and 877 (51%) (Table 4). Each respondent answer could have up to four
trainees reported that trainees were always closely different codes. Ninety-eight answers were coded as ‘other’
supervised during RSI (p < 0.001). However, 1211 (71.2%) because they did not fit into the previous major themes, and
trainees felt they should always be closely supervised 351 were not included because they were not meaningful
during RSI. Both groups expressed significantly different enough.
opinions on training in RSI and pulmonary aspiration risk Although only 978 (10.2%) respondents were trained in
assessment, (Table 3). Trainees and consultants perceived the use of gastric ultrasound for pulmonary aspiration risk
the RSI skills of trainees as better than their ability for assessment, 1320 (13.8%) indicated that someone in their
pulmonary aspiration risk assessment. department knew how to use gastric ultrasound for this
The open-ended questions about experiences of purpose. Of 5678 consultants who would use cricoid force
pulmonary aspiration were answered by 6663 (69.3%) for a hypothetical patient with intestinal obstruction, 3616
respondents. Of these, 2624 (39.4%) had experience of (63.7%) reported there are usually two team members
pulmonary aspiration for a patient under their care during present; 1741 (30.7%) reported three team members; and
anaesthesia. From these responses, we generated 4719 321 (5.7%) more than three.

Table 2 Respondent preferences for positioning, nasogastric tube insertion and cricoid force use for a hypothetical patient with
and without intestinal obstruction requiring rapid sequence intubation. Values are number (proportion).
Rapid sequence intubation indication
Intestinal obstruction Any other p value
Patient positioning
Head-up 6128 (70%) 3736 (44%) <0.001
Supine 1791 (20%) 4446 (52%)
Head-down 886 (10%) 352 (4%)
Nasogastric tube use
Yes 5678 (59%) 771 (8%) <0.001
No 1709 (18%) 6845 (71%)
Uncertain 2214 (23%) 1983 (21%)
Cricoid force use
Yes 6816 (71%) 4766 (50%) <0.001
No 1782 (19%) 3491 (36%)
Uncertain 1004 (10%) 1347 (14%)

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(a)

(b)

Figure 2 Preferences for rapid sequence intubation from respondents from high-income countries (filled circles), upper
middle-income (diamond), lower middle-income (triangle) and low-income (empty circles). The upper three panels (a) are for a
hypothetical patient with intestinal obstruction. The lower three panels (b) are for any other rapid sequence intubation
indication.

In the Phase-2 questionnaire (Appendix. S2), 16 (53%) the use of gastric ultrasound for pulmonary aspiration risk
airway management experts independently provided their assessment. However, the need for further validation and
RSI preferences and opinions (Table 5). Fourteen (87.5%) consensus on the clinical application of gastric ultrasound
agreed that all anaesthetic departments should have RSI was emphasised.
guidelines. Additionally, seven (43.8%) agreed that all One half of airway management experts stated there
anaesthetists who might perform RSI should be trained in should be two team members for an RSI when cricoid force

(a)

(b)

Figure 3 Preferences for rapid sequence intubation from respondents including trainees in the first half of the training (filled
circle), trainees in the second half of the training (diamond), specialists for less than 10 years (triangle), and specialists for more
than 10 years (empty circle). The upper three panels (a) are for a hypothetical patient with intestinal obstruction. The lower three
panels (b) are for any other rapid sequence intubation indication.

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Table 3 Respondent perception as trainee vs. consultant Discussion

for adequacy of supervision and pulmonary aspiration
For respondents working in settings with RSI standards or
prevention skills among trainees. Values are number
guidelines, there was a small association with a preference
(proportion).
for the use of cricoid force. The training level of respondents
Level of training
was not associated with preferences for patient positioning,
Perception Trainee Consultant p value nasogastric tube use and cricoid force application. Major
Trainees always closely supervised differences were found among the four national income
Yes 877 (51%) 5998 (77%) < 0.001 groups. With decreasing national income of the
No 827 (49%) 1825 (23%) respondent’s location, the preference for using a head-up
Trainees adequately trained in rapid sequence intubation position decreased, with the supine position preferred
Yes 855 (50%) 4328 (56%) < 0.001 among respondents from low-income countries. Likewise,
No 351 (21%) 1055 (14%) preferences for nasogastric tube insertion and cricoid force
Uncertain 498 (29%) 2300 (30%) application were more common among respondents from
Trainees adequately trained in pulmonary aspiration risk low-income countries. For a hypothetical patient with
assessment intestinal obstruction, respondents preferred the use of a
Yes 616 (36%) 3550 (46%) < 0.001 head-up or -down position as compared with supine.
No 550 (32%) 1526 (20%) Cricoid force application was also preferred as compared
Uncertain 535 (32%) 2581 (34%) with a hypothetical patient without intestinal obstruction.
This global survey reveals aspects of RSI practices that can
now be the topic of further focussed research (Table 6).
is used and the other half responded, three. Fifteen (93.8%) In patients with intestinal obstruction, gastric
believed that trainees should always be closely supervised decompression is one possible strategy for the prevention
during an RSI, which was the domain of highest agreement of pulmonary aspiration [11]. With the insertion of a
among the experts surveyed. When encountering nasogastric tube, the driving pressure for regurgitation and
pulmonary aspiration of gastric content in practice, they the volume of the gastric content are decreased before
emphasised the importance of self-reflection and anaesthesia, hence lowering the likelihood and severity of
debriefing to reinforce ‘good practice’ and to avoid pulmonary aspiration [23]. Our data suggest an association
potential underperformance in the future. between increasing nasogastric tube popularity in this

Table 4 Nine major themes obtained from qualitative analysis of open-ended questions on experience of pulmonary aspiration
incidents.
1. Non-technical skills
Anticipation; planning; situational awareness; team members; and team dynamics
2. Procedures
Algorithms and protocols; cricoid force; achieving unconsciousness; adequate paralysis and intubating conditions; use of regional
anaesthesia where appropriate
3. Risk
Full stomach; anxiety; pregnancy; trauma; haemodynamic instability; sepsis; shock; pain
4. Aspiration management
Repositioning; head-down; suction; bronchoscopy; lavage; steroids; antibiotics; bronchodilators
5. Gastric content
Nasogastric tube insertion and aspiration; imaging; gastric ultrasound; ileus; premedication
6. Equipment
Gastric ultrasound; suction catheters; laryngoscopy; second generation supraglottic airway device; transparent facemasks
7. Danger
Underestimation of risk; consequences of aspiration
8. Education
Regular training; reflection; debriefing; experience
9. Distress
Clinical consequences; second victim

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Table 5 Responses from 16 recognised international airway experts on practice preferences for a hypothetical patient with and
without intestinal obstruction requiring rapid sequence intubation. Values are number (proportion).
Indication for rapid sequence intubation
Intervention Intestinal obstruction Any other p value
Patient positioning
Head-up 10 (63%) 13 (82%) 0.685
Supine 1 (6%) 1 (6%)
Head-down 5 (31%) 2 (12%)
Nasogastric tube use
Yes 11 (69%) 1 (6%) 0.001
No 3 (19%) 12 (75%)
Uncertain 2 (12%) 3 (19%)
Cricoid force use
Yes 9 (56%) 7 (44%) 0.626
No 4 (25%) 7 (44%)
Uncertain 3 (19%) 2 (12%)
Fisher’s exact test reported comparing frequency distributions within 2 9 3 contingency tables.

Table 6 Key topics identified for further research and consensus.

Aspect of practice Suggested topics for further research or consensus
Gastric decompression The use of nasogastric tubes in patients with and without intestinal obstruction before
anaesthesia
The use of gastric ultrasound to monitor strategies for gastric decompression
Consensus on gastric tube handling
Patient positioning The difference between and outcomes associated with positioning preferences for low- and
higher income countries
Cricoid force Global registries on aspiration incidents
Consensus on when and how cricoid force should be applied
Education Consensus on and study of consultant supervision of trainees conducting rapid sequence
intubations
Improve awareness of the value of deliberate practice and its key elements
Team dynamics The optimal number of team members, and their skill mix, for rapid sequence intubation
Management of pulmonary aspiration Universal recommendations on how best to manage pulmonary aspiration during anaesthesia
Rapid sequence intubation Consensus on the range of acceptable practices

context with decreasing national income. Reasons why this changing the patient position on the operating table to
very affordable intervention, which is often considered a facilitate gastric emptying.
standard of care, might be omitted in clinical practice in In specific patient populations, the advantages of the
higher income countries warrants further investigation [23, head-up position appear to outweigh the risks of other
24]. positions [25]. For non-obese patients, opinions differ. The
Regardless of whether the gastric tube is removed supine position was not popular amongst the airway
immediately before anaesthesia or not, it is reasonable to experts. They preferred the head-up position, followed by
perform gastric decompression in patients with intestinal the head-down position. Similarly, for respondents from
obstruction [11, 23]. Over 350 respondents reported that high-income countries, head-up positioning was more
their major learning point from experiencing aspiration was popular for a hypothetical patient with intestinal
to address gastric decompression before anaesthesia. This obstruction. But for a hypothetical patient requiring RSI
includes placing a nasogastric tube if not already present, without intestinal obstruction, supine and head-up
applying suction through it, administering a small amount of positioning were the most popular. Unfortunately, there is
saline to unblock a potentially obstructed tube, and no high-quality evidence to support any of these choices.

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Our survey demonstrates that cricoid force was popular regular training, cricoid force might not be applied correctly
among respondents, with 70% and 50% preferring to apply [31, 32]. Surveyed experts were much more consistent in
it to patients with and without intestinal obstruction, avoiding the supine position and cricoid force use for RSI.
respectively. Nonetheless, this popularity varied between Surveyed experts agreed that trainees should always
the countries of respondents. For example, it was less be closely supervised during RSI, but this would have
popular in Austria, Denmark, the Netherlands, Sweden and important implications for departments, personnel and
Switzerland as compared with the UK, which agrees with training. Some might argue that ‘close supervision’ is only
previous reports [18]. Its popularity probably reflects the possible if the supervisor is present in the same room. Close
potential legal repercussions of avoiding cricoid force use in supervision of this kind has many advantages [33], but some
patients with intestinal obstruction, who are a high-risk may argue it is not always necessary, and may instead have a
patient group, whereas clinicians might be more reluctant negative resource implication. As some respondents noted,
to apply it when the aspiration risk is perceived to be less [6]. supervision for tracheal extubation should not be
Finally, for cricoid force, there was no consensus on the overlooked, as this is also a high-risk time for pulmonary
number of anaesthetic team members required for RSI. aspiration [4, 34]. Only half of trainee respondents were
Experts were split between two and three team members, confident in their RSI skills, and only 36% had confidence in
while 3616 (63.7%) of anaesthetists reported working in a their ability to correctly assess aspiration risk. We argue
two-member team model as originally described in 1961 better supervision together with more guidance and
[2]. Given the current evidence, it remains unknown whether consensus on the range of acceptable techniques are the
cricoid force can be successfully applied and sustained by best options to improve confidence with RSI practices [35].
the same person who also might be delivering drugs or Pre-operative gastric ultrasound is a new tool that may
assisting with intubation. It would be reasonable to expect allow precise estimation of pulmonary aspiration risk in
that one person remains solely focused on cricoid force patients deemed neither high nor low [6, 36–38]. Currently,
application [26, 27]. When designing further research on the although only 10% of respondents are familiar with its use in
effectiveness and safety of cricoid force, key design clinical practice, 44% of experts believe those who perform
elements should be considered, such as: the definition of RSIs should be trained in this simple bed-side technique.
pulmonary aspiration; adequate training of the participating Surprisingly, almost one-third of the respondents
anaesthetists; appropriate power calculations; and mentioned the use of at least one non-technical skill as a
assessing the volume and nature of gastric content [6]. learning point after an aspiration event. These include a set
The variable popularity of cricoid force and patient of social and cognitive abilities that encompass: situational
positioning for a hypothetical patient with and without awareness; risk assessment; clinical decision-making;
intestinal obstruction conflicts with deliberate practice, leadership; communication skills; and teamwork [39, 40].
which is an essential principle for the development of Their use in crisis management scenarios in operating
clinical expertise [26]. Performance improvement through theatres has been increasingly recognised over the last 20
deliberate practice is based on four key elements: a years [41].
motivated learner; a well-defined task; detailed and Our study has strengths and limitations. The response
immediate feedback; and ample opportunities to improve rate calculation is a rough approximation, but given that
through repetition [28]. This regular, focused practice is most respondents were recruited through LinkedIn, a
required for the acquisition of reproducible expert reasonable estimation is 40–60%. Additionally, the pre-
performance and its maintenance [28]. Every anaesthetic calculated minimum target number of respondents was
provider expected to undertake RSI should perhaps be an met. We did not reach the minimum target number of
RSI expert, as slight deviations from optimal practice might responses in some countries, and although most continents
adversely affect outcome [29]. were well covered, there was a poor response from
Personalised medicine opposes, to some extent, the countries in Asia. We were also unable to collect some
deliberate practice principle. Although individual patient responses due to country-specific site access restrictions or
adjustment emerges as modern clinical practice, only when language barriers. Nevertheless, for the main analysis, we
mastery in all RSI variants is achieved can the practitioner compared countries by income categories rather than
truly safely individualise patient care [30]. Although it might individually. An important strength is allowing respondents
be reasonable to individualise the choice of to opt for or against inclusion at the end of the survey, rather
pharmacological agents with consideration of their side- than inferring consent from survey completion. As with all
effects, there is good evidence otherwise that without anonymous surveys, duplicate responses were a possibility

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Acknowledgements sequence induction of anesthesia. The IRIS randomized clinical
trial. Journal of the American Medical Assocation - Surgery
CH has received funding for clinical research from Ambu,
2019; 154: 9–17.
Karl Storz Endoscopy and Vyaire Medical. Additionally, she 11. Mellin-Olsen J, Fasting S, Gisvold SE. Routine preoperative
has received honoraria from UpToDate and Elsevier. MS has gastric emptying is seldom indicated. A study of 85,594
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received paid consultancies from Teleflex Medical, Athlone, Anaesthesiologica Scandinavica 1996; 40: 1184–8.
Ireland, MSD and DEAS Italia. He is also patent co-owner (no 12. Landreau B, Odin I, Nathan N. Pulmonary aspiration:
royalties). We acknowledge the assistance provided by epidemiology and risk factors. Annales francßaises d'anesth esie
et de reanimation 2009; 28: 206–10.
national societies of anaesthetists from: Bosnia and 13. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S.
Herzegovina; Cyprus; Egypt; Hong Kong; Hungary; Iran; 3,423 emergency tracheal intubations at a university hospital:
airway outcomes and complications. Anesthesiology 2011;
Israel; Japan; Kenya; Latvia; Lebanon; Lithuania; Maldives;
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Malta; Morocco; New Zealand; Nigeria; Oman; Paraguay; 14. Kheterpal S, Martin L, Shanks MA, Tremper KK. Prediction and
Serbia; Singapore; Slovenia; Sudan; and Tunisia. We also outcomes of impossible mask ventilation: a review of 50,000
anesthetics. Anesthesiology 2009; 110: 891–7.
acknowledge the assistance of: All India Difficult Airway 15. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society
Association; European Airway Management Society; 2015 guidelines for management of unanticipated difficult
European Society for Regional Anaesthesia; and Society for intubation in adults. British Journal of Anaesthesia 2015; 115:
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Airway Management. 16. Jensen AG, Callesen T, Hagemo JS, Hreinsson K, Lund V,
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Kompan; O. Loskutov; N. Beley; T. Vymazal; A. Sargsjan; M.
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Abdelaziz; I. Ahmad; T. Cook; R. Cooper; R. Greif; C.A. anaesthesia for emergency situations. Acta Anaesthesiologica
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322 © 2019 Association of Anaesthetists