Induction of the CF patient must be carried out safely and effectively to help ensure a positive postoperative recovery. If thoughtfully completed, a comprehensive preoperative assessment will adequately prepare the anesthesia provider for the induction of the adult CF patient. Preoxygenation should be performed for a full three to five minutes. The high incidence of gastroesophageal reflux suggests that a rapid sequence induction (RSI) technique should be utilized. The experienced provider can sometimes use a modified RSI or standard intravenous or inhalation induction. If an inhalation induction is the chosen method, the anesthesia provider must consider the CF patient’s decreased tidal volume, decreased functional residual capacity, and the ventilation to perfusion mismatch that will slow inhalation induction times. This approach may need to be augmented by intravenous agents, avoiding agents that can irritate the airway, since bronchospasm should be avoided.
Propofol is a safe intravenous induction agent because it has a short half-life and lacks histamine release. Ketamine should be avoided for induction. Ketamine is associated with increased sympathetic activity and bronchial secretions, which could compromise the patient’s stability.
Succinylcholine is the best choice for a paralytic agent when an intravenous induction and endotracheal intubation are warranted due to the patient’s high aspiration risk. If the procedure requires paralysis, nondepolarizing neuromuscular blocking agents associated with rapid clearance should be used. Mivacurium should be considered because it has a short duration of action. Other intermediate-acting, nondepolarizing neuromuscular-blocking agents such as rocuronium and cisatracurium are also acceptable.
Endotracheal intubation is recommended for most surgical procedures.
This approach allows for adequate and proper ventilation control. This is important in the adult CF population because these patients require higher carbon dioxide levels to maintain their respiration drive. Caution must be used during nasal intubation due to the high incidence of nasal polyps in CF patients. If the placement of an endotracheal tube is not possible, using a laryngeal mask airway (LMA) is an option. Routine use of an LMA is not the best choice for surgical procedures because there is an increased risk of aspiration and an inability to remove viscous secretions. The use of the LMA has also been associated with gas trapping and pneumothorax in CF patients.
| Agent or device | Use in CF | Rationale |
|---|---|---|
| Propofol | Safe induction agent | Short half-life and no histamine release |
| Ketamine | Avoid | Increased sympathetic activity and bronchial secretions could compromise stability |
| Succinylcholine | Best paralytic with intravenous induction and intubation | High aspiration risk favors rapid sequence technique |
| Mivacurium | Consider when paralysis is required | Short duration of action |
| Rocuronium, cisatracurium | Acceptable alternatives | Intermediate-acting nondepolarizers with rapid clearance |
| Endotracheal tube | Recommended for most procedures | Allows ventilation control; use caution with nasal intubation given frequent nasal polyps |
| Laryngeal mask airway | Fallback only when an endotracheal tube cannot be placed | Increased aspiration risk, inability to remove viscous secretions, gas trapping and pneumothorax |
