The editorial about the PreVent trial in the NEJM a few months back is entitled "Preventing Dogma from Driving Practice". If we are not careful, we will let the newest dogma replace the old dogma and become practice.The PreVent trial compared bagging versus no bagging after induction of anesthesia for rapid sequence intubation (RSI). Careful readers of this and another recent trial testing the dogma of videolaryngoscopy will notice several things that may significantly limit the external validity of the results.
- The median time from induction to intubation was 130 seconds in the no bag ventilation group, and 158 seconds in the bag ventilation group (NS). That's 2 to 2.5 minutes. In the Lascarrou 2017 JAMA trial of direct versus video laryngoscopy, it was three minutes. Speed matters. The time that a patient is paralyzed and non-intubated is a very dangerous time and it ought to be as short as possible
- The induction agent was Etomidate (Amidate) in 80% of the patients in the PreVent trial and 90% of patients in the Larascarrou trial (see supplementary appendix of PreVent trial)
- The intubations were performed by trainees in approximately 80% of intubations in both trials (see supplementary appendix of PreVent trial)
I don't think these trials are directly relevant to my practice. Like surgeon Robert Liston who operated in the pre-anesthesia era and learned that speed matters (he could amputate a leg in 2.5 minutes), I have learned that the shorter the time from induction to intubation, the better - it is a vulnerable time and badness occurs during it: atelectasis, hypoxemia, aspiration, hypotension, secretion accumulation, etc.
