Stacey Schlesinger, CRNA, MSN,
MBA
Statesville, North Carolina
Diane Blanchfield, CRNA, MS
Charlotte, North Carolina
The purpose of this study was to
identify the use of rapid-sequence
induction (RSI) and its hybrids. For
the study, 67 Certified Registered
Nurse Anesthetists at 1 hospital
completed a survey describing
their experience using a modified
technique for patients with a mod-
erately increased risk of regurgita-
tion and aspiration. Patient selec-
tion criteria and the use of
aspiration prophylaxis, preoxy-
genation, cricoid pressure, and
positive-pressure ventilation were
evaluated. In contrast with routine
induction and standard RSI tech-
niques, the modified RSI technique
consisted of aspiration prophy-
laxis, preoxygenation, application
of cricoid pressure, and positive-
pressure ventilation. The survey
revealed that a modification of
standard RSI is used commonly in
clinical practice. These modified
RSI techniques are not standard-
ized, as variation was noted in the
delivery of positive pressure venti-
lation. Further study is necessary
to identify widespread use of mod-
ified RSI techniques and to clarify
the risks and benefits of modified
RSI.
Key words: Modified rapid-se-
quence induction, preoxygenation,
cricoid pressure, positive-pressure
ventilation.
Modified rapid-sequence induction of
anesthesia: A survey of current
clinical practice
Introduction
R
apid-sequence induction
(RSI) is a commonly used
anesthetic technique for
patients considered at risk
for regurgitation and pul-
monary aspiration. This technique con-
sists of preoxygenation, cricoid pressure,
and the avoidance of postive-pressure
ventilation until the airway has been
secured with an endotracheal tube.
Patients at risk for aspiration include
those with “full stomachs” and patients
with a history of gastrointestinal surgery,
hiatal hernia, gastroesophageal reflux
disease, esophageal motility disorders,
hyperchlorhydria, peptic ulcer, obesity,
or diabetes mellitus.1
Although RSI is well established in
anesthetic practice, it is not without
possible risk to the patient. The most
alarming risk is the potential inability
to secure an airway or to ventilate a
patient who is unconscious and apneic.
The decision to use RSI needs to be
based on a thorough assessment of a
patient’s potential risk of aspiration and
the potential risks associated with RSI.
Potential risks of RSI include inability
to ventilate leading to hypoxia and
hypercarbia, alteration in heart rate and
blood pressure, and trauma to the air-
way. These risks may not be warranted
or appropriate for a patient at minimal
risk of regurgitation and aspiration. For
these cases, a modification of the stan-
dard RSI technique consisting of pre-
oxygenation, cricoid pressure, and gen-
tle positive-pressure ventilation before
tracheal intubation may be more appro-
priate. The purpose of this study was to
determine whether any such modifica-
tion of RSI technique is used currently
in clinical practice.
AANA Journal/August 2001/Vol. 69, No. 4
The primary objective of RSI is to
minimize the time between patient loss
of consciousness and tracheal intuba-
tion. RSI is a standard technique con-
sisting of preoxygenation and cricoid
pressure.2 Positive-pressure ventilation
generally is avoided until the airway is
secured with an endotracheal tube,
unless attempts at intubation are
unsuccessful or desaturation occurs.
Considerable variation, however, exists
among anesthesia providers in the use
of this technique. Variability exists in
the duration of preoxygenation; the
selection, dosage, and timing of admin-
istration of the induction agent and
muscle relaxant; the use of adjunct
medications; the application of cricoid
pressure; and the management of a
failed intubation.2
Preoxygenation is a standard com-
ponent of RSI.2 According to basic
anesthetic texts, preoxygenation on
high fresh gas flows of 100% oxygen
via face mask with a good mask fit for
3 to 5 minutes is recommended. Alter-
natively, a series of 4 vital capacity
breaths of 100% oxygen may be used in
an emergency.3,4
Sodium thiopental is selected most
frequently as the induction agent in
RSI.2 Other agents used include keta-
mine,5 etomidate,6 and propofol.7 Suc-
cinylcholine has long been considered
the “gold standard” muscle relaxant for
RSI, but adverse effects such as
arrhythmias, hyperkalemia, and fascic-
ulations may preclude its safe use in
certain situations such as burn injury
or spinal cord injury. Other muscle
relaxants that can be considered
include vecuronium8-10 and rocuro-
nium.6,10-12 Nondepolarizing muscle
relaxants, however, have a significantly
longer duration of action than suc-
291
cinylcholine and could prove disastrous if a patient
could not be adequately ventilated or intubated. Non-
depolarizing muscle relaxants also may be undesir-
able for surgical procedures of short duration.
The timing of administration of the induction
agent in relation to the muscle relaxant in RSI also
seems to be variable. In 1 study of 210 anesthetists,
the muscle relaxant was administered immediately
after the induction agent by 46.5% of anesthetists,
after loss of lid reflex by 38% of anesthetists, and after
loss of verbal contact by 15% of anesthetists.2 Other
descriptions of RSI include administration of muscle
relaxant 5 seconds after administration of the induc-
tion agent5 or even before administration of the induc-
tion agent.8,9 In any event, the rapid administration of
a barbiturate with an alkaline pH and a muscle relax-
ant with an acidic pH can result in immediate and
substantial precipitation and occlusion of the intra-
venous line.13-15 The loss of intravenous access after a
patient loses consciousness and protective airway
reflexes might prove disastrous.
Another key component of RSI is the application of
cricoid pressure. Cricoid pressure consists of com-
pression and occlusion of the esophagus in an attempt
to minimize the risk of regurgitation. Cricoid pressure
has been demonstrated to prevent air entry into the
stomach as long as a patent airway is maintained.16
Excessive force applied to the cricoid cartilage can
obstruct the airway and interfere with successful tra-
cheal intubation. Possible complications of cricoid
pressure include difficult tracheal intubation, airway
obstruction, pulmonary aspiration, and esophageal
rupture.17 Other unusual but reported complications
include bilateral subconjunctival hemorrhage from a
patient bucking against cricoid pressure18 and cricoid
cartilage fracture.19
Positive-pressure ventilation generally is avoided to
prevent aspiration and gaseous distention of the stom-
ach in RSI.16 This, however, precludes the ability to
“test the airway” and verify that a patient can be ven-
tilated by mask before the administration of a muscle
relaxant. This also mandates a period of apnea that
may not be well tolerated by patients with compro-
mised respiratory status or increased baseline oxygen
requirements.
The use of a modified RSI technique would allow
for a patient to be gently ventilated by mask before the
insertion of an endotracheal tube. Positive-pressure
ventilation via a face mask could be provided before
administration of a muscle relaxant to test the airway
in patients with an airway assessed as marginal. Alter-
natively, positive-pressure ventilation via a face mask
could be provided before and after administration of a
292 AANA Journal/August 2001/Vol. 69, No. 4
muscle relaxant for patients unable to tolerate the
brief period of apnea associated with RSI. An exten-
sive review of the literature, however, has revealed no
descriptions of a modified RSI technique for these
patients.
Materials and methods
This descriptive study consisted of a survey of Certi-
fied Registered Nurse Anesthetists (CRNAs) em-
ployed at a large tertiary care hospital located in the
southeastern United States. The anesthetists were
asked to complete a survey describing their experi-
ence performing both RSI and modifications of RSI in
their clinical practice. CRNAs who reported having
used a modified RSI technique were asked additional
questions to determine how patients were selected
and whether preoxygenation, cricoid pressure, and
positive-pressure ventilation were used. One of the
investigators (S.S.) developed the data collection tool
for the sole purpose of this study.
The survey (Figure 1) included 4 basic questions
on the anesthetist’s experience, practice setting, and
use of RSI and modified RSI techniques. CRNAs who
reported using a modified RSI technique in clinical
practice were asked 5 additional questions regarding
patient selection, provision of prophylaxis for aspira-
tion pneumonia, preoxygenation, cricoid pressure,
and positive-pressure ventilation.
Institutional review board approval was obtained
before the distribution of surveys to all employed
CRNAs in the inpatient and outpatient operating
rooms. Responses were compiled and analyzed to
identify the frequency of clinical use of RSI and mod-
ified RSI techniques, CRNA experience, and clinical
practice setting. For CRNAs who reported using a
modified RSI technique in clinical practice, further
review of the data identified patient selection consid-
erations and the anesthetist’s definition of the modi-
fied RSI technique.
Results
Of 84 surveys distributed, 67 were returned for an
overall response rate of 80%; 31 CRNAs (46%) had
more than 10 years of clinical experience, 21 (31%) had
5 to 10 years of experience, and 15 (22%) had fewer
than 5 years of experience. Of the 65 respondents who
answered question 2 (type of practice setting), 51
(78%) were employed primarily in the inpatient oper-
ating room, while 14 (22%) were employed primarily
in the outpatient department (Figures 2 and 3).
Nearly all respondents reported using both RSI and
modified RSI techniques in their clinical practice
(Figure 4). The reported use of a standard RSI tech-
Figure 1. Survey*

Modified rapid-sequence induction (RSI) techniques

A Survey of Current Clinical Practice
RSI is a commonly used procedure in patients with ‘full stomachs’ to minimize the risk of regurgitation and aspiration.
Standard components of RSI are preoxygenation, cricoid pressure and the avoidance of positive pressure ventilation via face
mask until an endotracheal tube is placed. In some circumstances, a modification of this rapid-sequence technique may be
warranted. The purpose of this questionnaire is to identify the clinical definition of modified RSI.
Please select the response that most closely reflects your current clinical practice.
1. Years anesthesia experience __< 5 years __5-10 years __> 10 years
2. Type of practice setting __ Inpatient operating room __ Outpatient operating room
3. In my clinical practice, I currently use RAPID-SEQUENCE INDUCTION (RSI)
__Never __ Rarely __Occasionally __Often __Always
4. In my clinical practice, I currently use MODIFIED RSI
__Never __Rarely __Occasionally __Often __Always
If you have NEVER used a modified RSI technique in your clinical practice, THANK YOU for your participation.
If you have used a MODIFIED RSI technique, please answer the following questions.
5. Patients that I have utilized a MODIFIED RSI technique upon include: (check all that apply)
__ Moderately obese patients
__ Morbidly obese patients
__ Diabetic patients with no clinical symptoms of reflux disease
__ Patients with a history of prior esophageal surgery
__ Patients with a history of GERD but with no recent symptoms
__Other. Please explain:__________________________________________________
6. Based on your definition of modified RSI, is aspiration prophylaxis appropriate?
___ No ___ Yes If Yes, your usual management is: (check all that apply)
__Premedication with sodium citrate
__Premedication with metoclopramide
__Premedication with H2 antagonist
__Other: _____________________________ (please specify)
7. Based on your definition of Modified RSI, is preoxygenation required prior to induction?
___ No ___ Yes If Yes, for how long? (select the best answer)
__PreO2 on 100% × > 5 min
__PreO2 on 100% × 3-5 min
__PreO2 on 100% × < 3 min
__PreO2 on 100% × 4 vital capacity breaths
8. Based on your definition of modified RSI, is the application of cricoid pressure necessary?
___ No ___ Yes If yes, when is it applied? (select the best answer)
__Prior to induction agent
__At the same time as induction agent
__After loss of lid reflex
__After loss of verbal contact
9. Based on your definition of modified RSI, is an attempt to ventilate via face mask appropriate?
___ No ___ Yes If yes, when do you attempt to ventilate? (select the best answer)
__PRIOR to administration of a muscle relaxant
__FOLLOWING administration of muscle relaxant
__BOTH before and after administration of muscle relaxant

* GERD indicates gastroesophageal reflux disease; PreO2 indicates preoxygenation.

AANA Journal/August 2001/Vol. 69, No. 4 293

Figure 2. Reported experience of Certified Registered Figure 4. Use of standard rapid-sequence induction
Nurse Anesthetists (N=67)* (RSI) and modified RSI techniques in clinical practice
(N=67)*

100 100
RSI
90
80 Modified
75 RSI
Percentage of responses

70 67%

Percentage of responses
63%
60

50 31(46%) 50
40
21(31%) 30
30% 28%
25 15(22%)
20
10 4%
1% 3% 1% 0% 1%
0
0 Never Rarely Occasion- Often Always
<5 5-10 > 10 ally

Years of clinical experience How often technique is used

* Due to rounding, percentages may not add up to 100%. * Due to rounding, percentages may not add up to 100%.

Figure 3. Reported primary employment setting Figure 5. Modified rapid-sequence induction

(n=65) indications (n=65)

Clinical practice setting 100

90 88%

80 74%
Percentage of responses

14(22%) 70 66%
60
50
51(78%)
40 35%
30 28%

20
Outpatient Inpatient 10
operating room operating room
0
Moderate Morbid Diabetes, Prior History of
obesity obesity no signs esoph- gastroesophageal
and ageal reflux disease but
symptoms surgery no current signs
nique was described as “often” by 45 (67%) and of reflux and symptoms

“occasional” by 20 (30%). Only 2 respondents (3%)
reported “never” or “rarely” having used a standard
RSI technique. No CRNA reported “always” using a
standard RSI technique.
Of the respondents, 65 (97%) reported they have
used a modified RSI technique in their clinical prac-
tice. The use of this technique was described as “occa-
sional” by 42 (63%), “often” by 19 (28%), and
“always” by 1 (1%). Only 3 (4%) reported “rarely”
using a modified RSI technique.
The 65 CRNAs who reported using a modified RSI
technique were asked to answer 5 additional ques-
tions on the survey. Five patient scenarios were
described, and the anesthetists were asked to identify
those in which they had used a modified RSI tech-
nique for the induction of general anesthesia. A total
of 57 respondents (88%) reported they had used a
modified RSI technique for patients with moderate
obesity, while 23 (35%) reported its use for patients
Indication
with morbid obesity. In addition, 43 respondents
(66%) reported they had used modified RSI for
patients with diabetes who had no current signs and
symptoms of reflux disease. For patients with a his-
tory of esophageal surgery, 18 (28%) responded they
had used a modified RSI technique. For patients with
a history of gastroesophageal reflux disease but no
recent symptoms, 48 respondents (74%) reported
using a modified RSI technique. These findings are
summarized in Figure 5.
CRNAs also were asked to identify any other
patient situations in which they had used a modified
RSI technique (Table).
The remaining survey questions addressed the spe-
cific components of a modified RSI technique. The

294 AANA Journal/August 2001/Vol. 69, No. 4

Table. Other proposed indications for modified Figure 6. Methods of prophylaxis for aspiration
rapid-sequence induction (RSI)* pneumonia in modified rapid-sequence induction
(n=55)
Patient at risk for desaturation but RSI is indicated
100 52 (95%)
49 (89%)
Trauma patient who has been NPO for 8 h
End-stage renal disease without symptoms of GERD
75

Percentage of responses
Patient for heart surgery with GERD

50
Consistent history of reflux
Patient > 24 h postpartum

25
Patient who is > 5 mo pregnant

2 (4%)
Inhalation induction
0
Sodium citrate H2 receptor Metoclopramide
antagonist
* GERD indicates gastroesophageal reflux disease; NPO indicates nothing by

Method
mouth.

preoperative administration of medication to alter

gastric pH and/or gastrointestinal motility (aspiration
pneumonia prophylaxis) was reported by 55 (85%) of Figure 7. Duration of preoxygenation in modified
the CRNAs who reported using a modified RSI tech- rapid-sequence induction (n=61)
nique. Regarding their choice of drug administration,
100
52 (95%) of these 55 respondents administered H2
receptor antagonists, 49 (89%) administered metoclo-
75
pramide, and 2 (4%) administered sodium citrate.
Percentage of responses

These data are summarized in Figure 6. No other

31 (51%)
medications were identified as being administered as
part of a modified RSI. 50
Preoxygenation is another key component of stan-
25 11 (18%) 13 (21%)
dard RSI and possibly of modified RSI. Of the CRNAs
6 (10%)
who have used a modified RSI technique, 63 (97%)
0
reported that preoxygenation is required before
>5 3-5 <3 4 vital
minutes minutes minutes capacity
induction. Of those respondents, 61 reported meth-
ods (Figure 7), which included preoxygenation on breaths
100% FIO2 (fraction of inspired oxygen) for 3 to 5 Duration

minutes (31 [51%]), for 4 vital capacity breaths (13

[21%]), for fewer than 3 minutes (11 [18%]), and for
Figure 8. Timing of the application of cricoid pressure
more than 5 minutes (6 [10%]).
in modified rapid-sequence induction (n=57)
Cricoid pressure is another usual component of
both standard and modified RSI. A total of 62 CRNAs
(95%) who have used a modified RSI technique 100
reported that the application of cricoid pressure is
75 40 (70%)
necessary. Of the respondents (n = 57) who reported
Percentage of responses

when cricoid pressure is applied, 40 (70%) reported

50
that cricoid pressure was applied at the same time as
administration of the induction agent. Other re-
sponses included before administration of the induc-
tion agent (11 [19%]), after loss of lid reflex (3 [5%]), 25 11 (19%)

3 (5%) 3 (5%)
and following loss of verbal contact (3 [5%]). These
0
data are summarized in Figure 8.
Before Same time After loss After loss
induction as induction of lid of verbal
In standard RSI, positive-pressure ventilation is
avoided until the airway is secured. Of those using a agent agent reflex contact

modified RSI technique, 61 (94%) reported that an Timing of cricoid pressure

attempt to ventilate via a face mask is appropriate. Of

AANA Journal/August 2001/Vol. 69, No. 4 295

the respondents who reported when they attempt to Figure 9. Use of positive-pressure ventilation via face
ventilate (n = 60), 30 (50%) reported that they did so mask in modified rapid-sequence induction (n=60)
both before and after administration of a muscle
100
relaxant. An additional 13 (22%) reported providing
positive-pressure ventilation before administration of
a muscle relaxant, and 17 (28%) reported providing
75

Percentage of responses
positive-pressure ventilation following administration
30 (50%)
of a muscle relaxant. These data are summarized in
Figure 9. 50

17 (28%)
25 13 (22%)
Discussion
The analysis of the data confirms that a modified RSI
technique often is used by CRNAs in clinical practice
0
Before Following Before
at 1 institution. As shown in Figure 10, the modified
administration administration and after
of muscle of muscle administration
RSI technique most often consists of pharmacological
relaxant relaxant of muscle
relaxant
prophylaxis, preoxygenation, cricoid pressure, and
positive-pressure ventilation. This differs from a stan- Timing of positive-pressure ventilation
dard RSI technique, which does not include positive-
pressure ventilation, and from a routine induction,
which does not include aspiration prophylaxis or
Figure 10. Reported components of modified rapid-
cricoid pressure. sequence induction (n=65)
Although survey respondents were CRNAs with
63 (97%) 62 (95%)
varying experience from inpatient and outpatient set-
tings, the reported use of standard RSI and modified 100 61 (94%)

RSI was consistent among all practioners (Figures 11 55 (85%)

75
Percentage of responses

and 12). It is important to note that most of the anes-

thetists surveyed graduated from the same nurse anes-
50
thesia training program.
Patients selected for the modified RSI technique
included those in whom the relative risks of regurgi-
tation and aspiration seemed to be less than the risks 25

associated with the use of standard RSI. These include

moderately obese patients and patients with underly-
ing gastroesophageal reflux disease or a disease
process (diabetes, renal failure) associated with gas-
troesophageal reflux disease but who have no current
symptoms. The low reported use of modified RSI for
patients with morbid obesity or who have undergone
esophageal surgery most likely reflects a tendency to
select a standard RSI technique for these patients.
There were some differences among clinicians in
the specific application of each component of modi-
fied RSI. Variation was demonstrated in the duration
of preoxygenation, the timing of application of cricoid
pressure, and the choice of preoperative medications
to alter gastrointestinal motility and gastric pH. There
was wide variation in the timing of positive-pressure
ventilation in modified RSI.
Aspiration prophylaxis was reported by most
CRNAs as part of a modified RSI. This most com-
monly consisted of the administration of an H2 recep-
tor antagonist, metoclopramide, or both.
Preoxygenation with 100% oxygen was provided
0
Aspiration Preoxy- Positive-
Cricoid
prophylaxis genation pressure pressure
ventilation
Components of rapid-sequence induction
most often for 3 to 5 minutes and was followed by the
application of cricoid pressure. Cricoid pressure gen-
erally was applied at the same time as administration
of an induction agent. The use of cricoid pressure was
reported by nearly all anesthetists as part of a modi-
fied RSI technique.
Positive-pressure ventilation is used as part of a
modified RSI technique by most CRNAs surveyed.
This represents the most substantial difference of
modified RSI with standard RSI, in which positive-
pressure ventilation generally is avoided. The timing
of positive-pressure ventilation in relation to the
administration of a muscle relaxant in modified RSI,
however, is variable. Some anesthetists reported that
they administered positive-pressure ventilation both
before and after administration of a muscle relaxant.

296 AANA Journal/August 2001/Vol. 69, No. 4

Figure 11. Reported use of standard rapid-sequence anesthetist subsequently is unable to intubate or ven-
induction (RSI) by length of Certified Registered tilate, results could prove disastrous. During modified
Nurse Anesthetist experience RSI, the provision of positive-pressure ventilation via
a face mask allows the anesthetist to affirm the ability
100 < 5 y (n = 15)
to ventilate before administering a muscle relaxant.
5-10 y (n = 21)
For patients who cannot be ventilated safely via a face
75
mask during modified RSI, a decision can be made
> 10 y (n = 31)
Percentage of responses

before the administration of a muscle relaxant to

reawaken the patient and proceed with an awake intu-
50 bation. This may be of added importance for patients
in whom succinylcholine is contraindicated, since the
25
resulting period of paralysis with a nondepolarizing
muscle relaxant can be substantially longer.
0
The modified RSI technique also may be valuable
Never Rarely Occasion- Often Always
for patients who may not tolerate even brief periods of
ally apnea, because careful, low-peak airway pressure ven-
Frequency of RSI tilation can be provided throughout the induction
period. The use of positive-pressure ventilation before
and after the administration of a muscle relaxant
Figure 12. Reported use of modified rapid-sequence allows the anesthetist to test the airway and avoid
induction (RSI) by length of Certified Registered desaturation.
Nurse Anesthetist experience
Modified RSI seems to be an acceptable and com-
mon clinical technique for the induction of general
100 <5 y (n=15) anesthesia in selected patients at this institution. Fur-
5-10 y (n=21) thermore, the modified technique seems to be well-
75
>10y (n=31)
defined as the sequence of aspiration prophylaxis with
Percentage of responses

an H2 receptor antagonist and metoclopramide, pre-

50
25
0
Never Rarely Occasion- Often
ally
Frequency of modified RSI
Other anesthetists provided positive-pressure ventila-
tion only before or only after administration of a mus-
cle relaxant. A few anesthetists reported that they did
not provide positive-pressure ventilation at any time
during modified RSI. It is unclear to the investigators
how this modified RSI technique differed from stan-
dard RSI.
The variability in the use of positive-pressure ven-
tilation may represent different objectives for individ-
ual patients in the selection of a modified RSI tech-
nique. During standard RSI, patients are made apneic
and unconscious without establishing that they can
be ventilated by mask. This theoretically avoids
gaseous distention of the stomach and subsequent
possible regurgitation and aspiration. However, if the
oxygenation with 100% oxygen for 3 to 5 minutes or
4 vital capacity breaths, application of cricoid pressure
at the same time as administration of the induction
agent, and provision of positive-pressure ventilation
before and after administration of a muscle relaxant.
As with standard RSI, there seems to be variation in
Always
the specific application of each of these components.
The purpose of the present study was to determine
whether a modified RSI technique is used in clinical
practice for the induction of general anesthesia. Fur-
ther study is warranted to evaluate the use of a modi-
fied RSI technique in other clinical settings and to
determine the safety and efficacy of the technique.
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AUTHORS
Stacey Schlesinger, CRNA, MSN, MBA, is a nurse anesthetist for Uni-
four Anesthesia Associates in Hickory, NC.
Diane Blanchfield, CRNA, MS, is a clinical coordinator at Carolinas
Health System in Charlotte, NC.