Rapid Sequence Induction and Intubation in Anesthesia

Primary Indications

The American College of Critical Care Medicine indicates that RSI is used for aspiration risk reduction in patients with full stomach, ileus, bowel obstruction, gastroesophageal reflux disease, or increased intra-abdominal pressure 1, 4
The Society of Critical Care Medicine recommends RSI for optimization of intubating conditions to reduce the occurrence of difficult or failed airways, esophageal tube placement, and complications 1, 2

The Society of Critical Care Medicine suggests using semi-Fowler position (head and torso inclined) during RSI to reduce aspiration risk and potentially improve first-pass intubation success 4
High-flow nasal oxygen (HFNO) is suggested when laryngoscopy is expected to be challenging, according to the Praxis Medical Insights guidelines 5
Noninvasive positive pressure ventilation (NIPPV) is recommended for patients with severe hypoxemia, as stated by the Praxis Medical Insights guidelines 5
Medication-assisted preoxygenation (delayed sequence intubation) using ketamine is suggested for agitated, delirious, or combative patients who cannot tolerate preoxygenation devices, with studies showing mean oxygen saturation increases of 8.9%, according to the Praxis Medical Insights guidelines 5

A sedative-hypnotic induction agent must be administered when an NMBA is used for intubation, as recommended by the Praxis Medical Insights guidelines 5, 6
No significant difference exists between etomidate and other induction agents (ketamine, midazolam, propofol) with respect to mortality or hypotension, according to the Critical Care Medicine guidelines 7, 5
For hemodynamically unstable patients, etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) are recommended, as stated by the Praxis Medical Insights guidelines 6
Administering an NMBA when a sedative-hypnotic induction agent is used is strongly recommended (strong recommendation, low quality evidence), according to the Critical Care Medicine guidelines 7, 5
Either succinylcholine (1-1.5 mg/kg) or rocuronium (0.9-1.2 mg/kg) is suggested when no contraindications to succinylcholine exist, as recommended by the Praxis Medical Insights guidelines 5, 6
Sugammadex must be immediately available when rocuronium is used for potential "cannot intubate/cannot oxygenate" scenarios, according to the Praxis Medical Insights guidelines 6

The Society of Critical Care Medicine guidelines emphasize that RSI involves rapid succession administration of both agents without delay 1, 2, 5
Immediate endotracheal tube placement before assisted ventilation begins is recommended, as stated by the Critical Care Medicine guidelines 4

These guidelines apply to critically ill adult patients in the emergency department, ICU, or other locations outside the operating room requiring emergency airway management, according to the Critical Care Medicine guidelines 4, 2, 3, 9

RSI differs from standard intubation in that it specifically avoids the traditional period of mask ventilation between induction and intubation, though this practice is evolving based on hypoxemia risk, as stated by the Critical Care Medicine guidelines 1, 2

Inadequate preoxygenation increases desaturation risk—ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients, according to the Praxis Medical Insights guidelines 5
Failure to have backup airway equipment immediately available can lead to "cannot intubate/cannot oxygenate" scenarios, as stated by the Praxis Medical Insights guidelines 6
Inappropriate medication selection or dosing can cause hemodynamic instability, according to the Praxis Medical Insights guidelines 6
Delayed post-intubation analgosedation when using rocuronium may increase awareness risk due to its longer duration compared to succinylcholine, as recommended by the Praxis Medical Insights guidelines 5