19. RAPID SEQUENCE INDUCTION.

Rapid sequence induction (RSI) is a method of rapidly placing an endotracheal tube whilst
minimising the risk of regurgitation and aspiration of gastric contents. Pulmonary aspiration
is the inhalation of oropharyngeal or gastric contents below the level of the true vocal cords
into the larynx and the respiratory tract. Ideally all patients should be fasted before
anaesthesia. If the stomach is not empty when consciousness is lost, the patient may
regurgitate gastric material that may be aspirated into the lungs causing a chemical and
infective pneumonitis as well as airway obstruction (Mendelson’s syndrome). Based on
animal studies, as little as 0.4 ml/kg of gastric fluid with a pH less than 2.5 can cause severe
pneumonitis. 

Aspiration Pneumonitis

The risk of mortality and serious morbidity increases with greater volumes and acidity of
aspirated material. The acid causes a loss of surfactant. Pneumonitis develops within hours.
The patient will become dyspnoeic, tachypnoeic, tachycardic, hypoxic and may develop
bronchospasm. X-ray changes occur within 8 to 24 hours. Treatment includes oxygen,
bronchodilators and physiotherapy. Bronchoscopy can help remove large particles. If
secondary bacterial infection occurs the patient will require antibiotics. In non-hospital
patients, anaerobic organisms predominate and penicillin may be the appropriate choice of
antibiotic. In hospitalised patients both anaerobic and aerobic organisms are commonly
found and these patients may require penicillin plus gentamicin and metronidazole.
Corticosteroids are not of proven benefit in any aspiration syndrome.

Predisposing Patient Factors

The gastro-oesophageal junction, upper oesophageal sphincter, and protective laryngeal

reflexes provide the normal physiological mechanisms to reduce the risk of aspiration. All
are attenuated by drugs used to induce and maintain general anaesthesia.

Patient factors predisposing to aspiration include a full stomach (emergency surgery,

inadequate fasting, gastrointestinal obstruction, ileus), incompetent lower oesophageal
sphincter (hiatus hernia, reflux oesophagitis, pregnancy > 20 weeks gestation, nasogastric
tube), oesophageal disease (oesophageal achalasia, oesophageal strictures), delayed gastric
emptying (recent trauma, opioids, diabetes, pain, intrabdominal sepsis ), raised
intraabdominal pressure (morbid obesity, ascites) and ineffective laryngeal reflexes. Surgical
factors include lithotomy or head down position, laparoscopy and upper gastrointestinal
surgery. The anaesthesia provider must identify the patients at risk of aspiration of gastric
contents and undertake action to reduce the risk of aspiration.

Recommendations

1. Perform a preoperative evaluation for the aspiration risk on all patients. Inform
patients of fasting requirements. Verify patient compliance with fasting requirements at the
time of their procedure.
 
2. When these fasting guidelines are not followed, compare the risks and benefits of
proceeding, with consideration given to the amount and type of liquids or solids ingested. If
possible, delay anaesthesia/surgery until the patient has had adequate fasting time.
However, the patient must not be put at risk by delaying urgent surgery. Some patients will
not empty their stomach even after 6 hours of fasting and must be treated as non-fasted.

3. Attempt to reduce the volume and acidity of the stomach contents. Pre-emptive
nasogastric tube placement has been proposed as an option; however, evidence supporting
this practice is poor. Remember that a nasogastric tube is unlikely to completely empty the
stomach and placement may contribute to vomiting and subsequent aspiration in some
patients. The nasogastric tube should be removed immediately before anaesthesia. 

4. Gastrointestinal stimulants (metoclopramide) should not be routinely administered

in patients with no apparent increased risk of pulmonary aspiration.

5. Oral H-2 antagonists (ranitidine 150 mg, cimetidine 300 mg the night before and 2
hours preoperatively), I.V H-2 antagonists (cimetidine 300 mg, famotidine 20 mg, ranitidine
50 mg 60 minutes preoperatively), oral proton pump inhibitors (omeprazole 40 mg the night
before and 2 hours preoperatively) and I.V proton pump inhibitors (omeprazole 40 mg,
pantoprazole 40 mg 60 minutes preoperatively) are all effective in reducing gastric acidity
and volume. However, routine administration is not recommended in patients with no
apparent increased risk for pulmonary aspiration.

6. Non-particulate antacids (sodium citrate 30 ml 30 minutes preoperatively) will

reduce acidity and may be preoperatively administered to patients at increased risk of
pulmonary aspiration. 

7. The administration of preoperative anticholinergics to reduce the risk of pulmonary

aspiration is not recommended.

8. Consider the best type of anaesthesia. Local anaesthetic techniques without

sedation will maintain laryngeal reflexes and will protect against aspiration. If general
anaesthesia is required, the lungs must be protected by a cuffed endotracheal tube. The
majority of aspiration events occur during induction of anaesthesia. One approach for
intubation is a “rapid sequence induction” (RSI) using preoxygenation and cricoid pressure.

Rapid Sequence Induction

Rapid sequence induction requires careful preparation and good assistance. Intravenous
induction of anaesthesia, with the application of cricoid pressure, is swiftly followed by the
placement of an endotracheal tube. The anaesthesia provider must carefully assess the
patient’s airway. It may be wise to choose a different anaesthetic technique if endotracheal 
intubation is considered difficult.

Recommended technique of Rapid Sequence Induction

Prepare all equipment and drugs.
Oxygen, suction, anaesthetic machine, anaesthetic circuit, masks, endotracheal tubes,
laryngoscopes, tilting operating table, induction agent, suxamethonium.
Ensure you have an assistant.

Insert an intravenous cannula and connect monitoring. (Pulse oximetry, capnography, BP,
ECG)

Demonstrate the position for cricoid pressure to the assistant. The cricoid cartilage is the
first complete ring of cartilage below the thyroid cartilage. Using the dominant hand, place
the index finger and thumb on either side of the cricoid cartilage and apply pressure. The
cricoid pressure must not be released until the anaesthesia provider is certain that the
endotracheal tube is correctly placed within the trachea and that the cuff is inflated. There
must be no air leak.
Though a standard of care in many countries, application of cricoid pressure is not
universally practiced as there is lack of evidence of effectiveness in preventing reflux and
aspiration, and concerns that cricoid pressure may reduced quality of laryngoscopy,
worsening of undetected laryngeal or cervical spine injury, and cause patient discomfort,
gagging or coughing. 

Preoxygenate the patient. The lungs contain approximately 79% nitrogen and 21% oxygen.
At the end of a normal expiration there is a volume of air remaining in the lungs called the
functional residual capacity (FRC). The FRC has several physiological functions including
acting as an oxygen reserve on which the patient depends when they are not breathing. The
normal FRC is 30 ml/kg in adults. At a minimum, three minutes of tidal breathing, or eight
vital capacity breaths in one minute should be performed with an inspired oxygen
concentration of 100%.  If a gas analyser is available, the end-tidal oxygen fraction should
reach at least 0.8. Ideally this allows the patient up to 7 minutes of apnoea before becoming
hypoxic. 

Administer the induction agent and, as soon as consciousness is lost, ask the assistant to
increase cricoid pressure (Sellick’s manoeuvre). The cricoid is the only complete ring of
cartilage in the larynx and trachea. When firm backward pressure is applied to the cricoid, it
will compress the oesophagus between the cricoid and a vertebral body, attenuating any
regurgitated gastric fluid from entering the pharynx. Cricoid pressure requires 1 to 3 kg (10 -
30 Newtons) of pressure. An explanation of cricoid pressure must be provided to the
patient.  Cricoid pressure is applied initially at 10 Newtons, increasing to 30 Newtons once
consciousness is lost. If the cricoid pressure is incorrectly applied it may hinder intubation. If
intubation is unexpectedly difficult, the anaesthesia provider must check that the cricoid
pressure is not pushing the larynx to one side. The anaesthesia provider should move the
assistant’s hand to the correct position but the cricoid pressure should not be released. If
intubation is impossible, the cricoid pressure should be maintained.

Administer suxamethonium (1.5 mg/kg) (scoline, succinylcholine). 

Suxamethonium has an ultra-short duration of action (3 to 5 minutes). Preoxygenation may
provide up to 7 minutes reserve of oxygen. If intubation is impossible the patient should
have return of spontaneous respiration before they become hypoxic. If the patient does
become hypoxic before the return of spontaneous respiration, the anaesthesia provider
must give gentle mask ventilation. The cricoid pressure should not be released. (Cricoid
pressure has been shown to prevent gastric distension during mask ventilation).
Contraindications to suxamethonium such as allergy, susceptibility to malignant
hyperthermia or hyperkalaemia should prompt usage of an alternative muscle relaxant such
as high-dose rocuronium/sugammadex. If suxamethonium is contraindicated and
rocuronium is unavailable then the anaesthesia provider may need to use a local
anaesthetic technique or consider using an inhalation induction with the patient in a head-
down position on the left side. Once the patient is deeply anaesthetised they are intubated
whilst still in the lateral position. Any regurgitated material should drain away from the
airway.

Prepare to intubate. Once the suxamethonium has been given, the the facemask should
remain in place but there should not be any attempt to ventilate the patient manually,
unless the patient becomes hypoxic, as some of the oxygen may be forced into the stomach,
increasing intragastric pressure and increasing the risk of aspiration. As soon as the
suxamethonium is effective the anaesthesia provider must intubate the patient, inflate the
endotracheal tube cuff, check the position and check that there is no air leak.

Release cricoid pressure only when the patient is intubated and endotracheal tube
placement is confirmed.  Observing chest rise and fall, tube misting, and a normal feeling
bag compliance with ventilation and auscultation of breath sounds are useful signs of
successful intubation, however they are not sensitive nor specific. The gold standard is the
appearance of a capnography waveform for 5 breaths.

Extubate the patient when fully awake and on their side. The patient is at risk of aspiration
when recovering from the anaesthesia. They should be turned onto their side to allow any
stomach contents that are regurgitated to drain away from their airway. Any regurgitated
gastric contents should be removed with gentle suction. The patient must be fully awake
and capable of protecting their own airway before the endotracheal cuff is deflated and the
tube removed.

RSI INTUBATION CHECKLIST

PREPARE PREPARE PREPARE FOR PREPARE

PATIENT EQUIPMENT DIFFICULTY TEAM

Explanation Oxygen supply Failed intubation Confirm

plan team
Monitoring Airway equipment
Difficult airway Team
Pulse oximetry Facemask trolley
Capnography Airway adjuncts Intubator
BP Self-inflating bag Cricoid
ECG 2 laryngoscopes pressure
Appropriate ET Drugs
Positioning tubes
 Bougie or stylet
Preoxygenation Suction
Tube tape or tie
I V access
Drugs

RSI drugs
Vasopressor
Maintenance drugs

RSI Drugs

Induction agents.
Propofol (1-3 mg/kg) and thiopentone (3-5 mg/kg) provide rapid and reliable induction;
however in shocked patients a very modest dose of these agents is required as these drugs
can easily lead to circulatory collapse and cardiac arrest. Resuscitation drugs should be
readily available. Ketamine (1-2 mg/kg) is a suitable alternative in unstable patients. 

Muscle relaxants
Suxamethonium (succinylcholine)  (1-2 mg/kg I.V or 3 mg/kg I.M) is usually easily available
and reliable. It has been considered the gold standard for RSI because suxamethonium
produces a profound neuromuscular block with rapid onset and (usually) rapid recovery. In
full dose it produces fasciculations, paralysis, and excellent intubating conditions within one
circulation time (15-45 seconds), however the adverse effects of suxamethonium are well
described. 
Rocuronium, reversed in the event of failed tracheal intubation with sugammadex 16 mg/kg,
is an alternative. In high doses (1.2 mg/kg) profound relaxation is obtained within 60 - 90
seconds. Whilst a more costly alternative, this combination has fewer adverse effects,
however, in order to undertake this safely, a large dose of sugammadex must always be
directly available.