Rapid Sequence Induction

Introduction

• Rapid Sequence Induction (RSI) is recommended for patients at high risk of aspiration, with moderate-quality evidence supporting its use, in patients with inadequate fasting, active vomiting, ileus or sub-ileus, impaired protective reflexes, gastrointestinal motility disorders, pregnancy, bowel and stomach obstruction and distension, sepsis, and patients receiving opioids, as suggested by the World Journal of Emergency Surgery 1

Patient Selection

• Patients at high risk of aspiration, including those with inadequate fasting, active vomiting, ileus or sub-ileus, impaired protective reflexes, gastrointestinal motility disorders, pregnancy, bowel and stomach obstruction and distension, sepsis, and patients receiving opioids, are recommended for RSI, with moderate-quality evidence supporting its use, according to the World Journal of Emergency Surgery 1
• The European Society of Anaesthesiology and Intensive Care recommends RSI for patients with high risk of aspiration, with strong recommendation and moderate evidence 1

Positioning and Pre-Oxygenation

• A head and torso inclined (semi-Fowler) position during RSI is suggested, with conditional recommendation and very low-quality evidence, which may improve first-pass intubation success through enhanced preoxygenation, improved laryngeal view, and reduced risk of clinically significant aspiration, as recommended by the Critical Care Medicine 2
• High-flow nasal oxygen (HFNO) is suggested when laryngoscopy is expected to be challenging, according to the Critical Care Medicine 2
• Pre-oxygenation with high-flow oxygen for 3-5 minutes before RSI is recommended to prevent hypoxemia and ensure adequate preoxygenation, as suggested by the Critical Care Medicine and the American Thoracic Society 2, 3

Neuromuscular Blocking Agents and Induction Agents

• The administration of a Neuromuscular Blocking Agent (NMBA) when using a sedative-hypnotic induction agent is strongly recommended, with low-quality evidence, and options include succinylcholine and rocuronium, as recommended by the Critical Care Medicine and the European Society of Anaesthesiology and Intensive Care 2, 1
• Etomidate (0.2-0.3 mg/kg IV) is recommended as a first-line agent for rapid sequence intubation (RSI), which may cause adrenal suppression, though evidence suggests this doesn't significantly affect mortality outcomes, as suggested by the American Society of Anesthesiologists 2
• Succinylcholine (1.5 mg/kg IV) is a first-line agent for RSI in patients with vital signs of distress, with rapid onset and short duration, and has contraindications such as hyperkalemia, burns, crush injuries, and neuromuscular disorders, as recommended by the American Society of Anesthesiologists 3
• Rocuronium (0.9-1.2 mg/kg IV) is an alternative when succinylcholine is contraindicated, with a longer duration of action, and sugammadex should be readily available when rocuronium is used, as suggested by the American Society of Anesthesiologists 3
• Ketamine (1-2 mg/kg IV) is recommended by the American College of Cardiology for patients with septic or hypovolemic shock, as suggested by the American College of Cardiology 2

2, 3, 4

Technique and Modifications

• Cricoid pressure can make intubation more difficult and may not prevent aspiration of gastric contents, and if direct laryngoscopy is difficult, cricoid pressure should be released, as suggested by the World Journal of Emergency Surgery 1
• A "controlled" or "modified" RSI in children is recommended, which includes preoxygenation, deep anesthesia, non-depolarizing muscle relaxant, and gentle bag-mask ventilation before laryngoscopy, to decrease risks of hypoxemia, hemodynamic complications, and difficult intubation, as suggested by the Anaesthesia 5
• Nasogastric tube decompression is advised when benefits outweigh risks in patients at high risk of regurgitation, with best practice statement, as recommended by the Critical Care Medicine 2

Gastric Decompression and Aspiration Risk

• Despite widespread use, there is limited high-quality evidence specifically demonstrating RSI's efficacy in preventing aspiration, and the incidence of aspiration is rare, but consequences can be severe, as noted by the World Journal of Emergency Surgery 1
• Airway management is a critical aspect of patient care, requiring careful consideration of pharmacological agents, ventilation strategies, and patient-specific factors, as recommended by the American Society of Anesthesiologists and the Society of Critical Care Medicine 2, 3

Special Considerations

• In patients with head injury and increased intracranial pressure (ICP), etomidate (0.2-0.3 mg/kg) is recommended as a sedative, and either succinylcholine or rocuronium as a paralytic, with consideration of mannitol (0.25-1 g/kg) for acute intracranial hypertensive crisis, as suggested by the American Society of Anesthesiologists 6
• For COVID-19 patients, a modified rapid sequence induction with sufficient muscle paralysis after loss of consciousness is recommended, using midazolam 2-5 mg with etomidate (10-20 mg) or propofol for induction, fentanyl 100-150 μg or sufentanil 10-15 μg, and succinylcholine 1 mg/kg or rocuronium 1 mg/kg, as suggested by the American Society of Anesthesiologists 7
• In pediatric patients, etomidate is recommended for children >2 years except in sepsis, and ketamine (3-4 mg/kg before 18 months, 2 mg/kg after) is an alternative, as suggested by the American Society of Anesthesiologists 3
• Septic patients should consider avoiding etomidate due to concerns about adrenal suppression, and the choice of sedative agent should be adjusted based on hemodynamic status, with options including etomidate, ketamine, and propofol, as recommended by the American Society of Anesthesiologists and the Society of Critical Care Medicine 3, 2
• For patients with cardiogenic shock, the European Society of Cardiology recommends having norepinephrine immediately available, as suggested by the European Society of Cardiology 8
• For patients with pulmonary edema, the European Society of Cardiology suggests considering earlier intubation before severe hypoxemia develops, as recommended by the European Society of Cardiology 8
• For patients with right heart failure, the European Society of Cardiology advises avoiding excessive positive pressure ventilation, which can worsen venous return, as suggested by the European Society of Cardiology 8
• In patients with difficult airway, equipment for difficult airway should be available, and consideration should be given to extubation over an airway exchange catheter, as recommended by the American Society of Anesthesiologists and the Anaesthesia 4, 5

Post-Intubation Care

• Confirm tube placement with multiple methods and initiate appropriate sedation/analgesia immediately after intubation, ensuring ongoing sedation after initial RSI medications wear off to prevent paralysis without sedation, as recommended by the American Society of Anesthesiologists 3, 9
• Minimize sedation in mechanically ventilated septic patients when appropriate, targeting specific titration endpoints, and have vasopressors readily available to manage potential hypotension and monitor blood pressure closely during and after intubation, as suggested by the American Society of Anesthesiologists and the Society of Critical Care Medicine 3, 9
• A post-intubation recruitment maneuver should be considered in hypoxemic patients, as recommended by the American Thoracic Society 3
• Applying PEEP of at least 5 cmH2O after intubation of hypoxemic patients is recommended, as suggested by the American Thoracic Society 3