Safety and feasibility of a rapid reversible induction strategy in anesthesia induction

Unexpected airway management challenges during anesthesia induction-particularly "Cannot Intubate, Cannot Ventilate" (CICV) scenarios-pose significant risks of hypoxemia and hemodynamic instability. Rapid reversal of anesthesia to restore adequate spontaneous ventilation represents a critical clinical objective. Our research focuses on developing safe and rapidly reversible induction strategies, which aim to provide alternative solutions for difficult airway management before the onset of irreversible intubation or ventilation failure.

High-flow oxygen inhalation (40 L·min^-1) and FiO₂ (100 %) were administered preoperatively for five minutes. During anesthesia induction, target controlled infusion was performed with remifentanil 4 ng·mL^-1 and propofol 4 μg·mL^-1, and rocuronium 0.6 mg·kg^-1 was injected intravenously. Subsequently, the oxygen flow was adjusted to 60 L·min^-1, with the patients' jaws lifted after the patients had lost consciousness. A direct laryngoscope was used for laryngoscopy and grading. The tracheas of patients with Cormack-Lehane (CL) grade I-II were intubated directly. For the patients with CL grade III-IV, sugammadex (16 mg·kg^-1) was administered and TCI was stopped. Then conscious intubation was performed after the patients were fully awake. The primary outcome was the rate of reversion success within 15 min from induction.

In total, 20 patients with CL grade 3-4 undergoing elective surgery needed reversion. The reversion success rate was 100 %. The shortest time to reversion was 333 s, the longest was 900 s, and the median time was 455 s. During the whole procedure, no hypoxia occurred, and acceptable hypercapnia appeared.

The findings of this study demonstrate that the rapid reversible induction (RRI) strategy is both safe and technically feasible. Prompt reversal of anesthesia to restore spontaneous ventilation should be prioritized as a proactive intervention in cases of unanticipated difficult airways, before the situation progresses to a "Cannot Intubate, Cannot Ventilate" (CICV) crisis.