Rapid Sequence Induction in Anesthesia

Core Recommendations

The Society of Critical Care Medicine recommends performing rapid sequence induction using a fast-acting neuromuscular blocking agent (succinylcholine 1-2 mg/kg OR rocuronium 0.9-1.2 mg/kg) combined with a sedative-hypnotic agent, with pre-induction nasogastric decompression when feasible, head-up positioning, and immediate availability of backup airway equipment for patients with a full stomach or reflux requiring emergency surgery 1, 2, 3, 4
A neuromuscular blocking agent MUST be administered when a sedative-hypnotic induction agent is used (strong recommendation from the Society of Critical Care Medicine) 1, 4

Point-of-care gastric ultrasound can assess gastric volume and guide risk stratification, as 6-16% of appropriately fasted patients still have gastric content associated with aspiration risk 5
Use semi-Fowler position (head and torso elevated 20-30 degrees) during RSI to reduce aspiration risk and improve first-pass intubation success 2

For hemodynamically unstable patients, use etomidate 0.3 mg/kg or ketamine 1-2 mg/kg 2, 4
For hemodynamically stable patients, propofol is acceptable 3, 4
Use succinylcholine 1-2 mg/kg OR rocuronium 0.9-1.2 mg/kg for rapid onset and excellent intubation conditions 2, 3, 4

Have video laryngoscopy, supraglottic airways, and surgical airway equipment immediately available 2
If intubation fails after maximum three attempts, immediately move to failed intubation plan 2
Administer sedative-hypnotic and NMBA in rapid succession with immediate endotracheal tube placement before assisted ventilation to minimize aspiration risk 4
The American Society of Anesthesiologists recommends having sugammadex immediately available when using rocuronium for reversal in "cannot intubate/cannot oxygenate" scenarios 4

Administration of prokinetics (erythromycin 3 mg/kg 1-2 hours before induction) when time permits 5
Select tracheal tube rather than supraglottic airway device 5
Consider orogastric/nasogastric tube placement before induction and extubation 8

Do NOT use inadequate NMBA doses: full RSI doses are succinylcholine 1-2 mg/kg or rocuronium 0.9-1.2 mg/kg 2, 4
Do NOT delay emergency surgery excessively for optimization in true surgical emergencies like high-grade bowel obstruction 2
Do NOT persist with cricoid pressure if it impairs laryngoscopy 2, 3
Do NOT avoid gentle ventilation if hypoxemia develops during induction, as the risk-benefit calculation favors preventing critical hypoxemia 6, 7, 8, 9