Rapid Sequence Induction

What is a Rapid Sequence Induction (RSI)? 1

  • General anesthesia usually involves impairment of airway reflexes, thereby increasing aspiration risk
  • If patients who require general anesthesia are at a higher risk of gastric aspiration during the perioperative phase, rapid sequence induction can be performed to reduce risk of aspiration
  • An RSI revolves around minimizing the time from loss of airway to protection to securement of a definitive airway (endotracheal tube). This is achieved through rapid administration of induction agents and paralytics.

A classic indication for an RSI is a patient coming to the operating room for a small bowel obstruction.

Indications 1

  1. Increased intragastric pressure or delayed gastric emptying - full stomach, pregnancy, medications delaying gastric emptying, diabetic neuropathy
  2. Altered level of alertness with impaired airway reflexes - substances, TBI, shock, trauma, etc.

Contraindications

The main detriments to an RSI include hemodynamic changes and the commitment to asleep airway management.

Hemodynamic Instability

Induction agents like PropofolPropofol
What is Propofol? 12

Sedative agent for induction and maintenance of anesthesia.
Rapid redistribution allows brief, deep sedation (e.g., joint reductions, cardioversions, ECT).


Mechanism of ... cause hypotension. Here are some steps to mitigate the hemodynamic response to an RSI:

  1. Continue fluid resuscitation prior to induction
  2. Bolus vasopressors with induction
  3. Infusions of vasopressors along with induction
  4. Be ready to reposition patient after induction to head down (unless contraindicated)

Airway Management

Plans and backup plans for airway management should be made prior to the induction of anesthetic

Steps for RSI 1

  1. Preoxygenation - this should be done with a good mask seal to maximize apneic time
  2. Cricoid pressure - pressure on the esophagus is thought to reduce the risk of aspiration from gastric contents. Pressure is held until confirmation of tube placement. Evidence on the effeciveness of cricoid pressure is mixed, and generally should be relieved if it is interfering with intubation.
  3. Administer IV anesthetics and muscle relaxants - neuromuscular blockade achieved with either succinylcholine or rocuronium. See Induction of General AnesthesiaInduction of General Anesthesia
    Introduction
    The start of a case represents one of the highest risk periods in the operation.

    After a surgical time-out, the tools required for a safe induction can be remembered with the MDSOLES ...    .
  4. Endotracheal intubation - inflated cuff is crucial, preparation ensures proper placement with the first attempt
  5. Confirmation of ETT placement - visualization of the tube passing between the vocal cords, chest rise, EtCO2, auscultation for bilateral equal breath sounds
  6. Removal of cricoid pressure

Generally, hemodynamics are managed simultaneously during this procedure (consider delegating management).

References

  1. Sullivan, P. (2012). Ottawa Anesthesia Primer. Echo Book Publishing ↩ ↩2 ↩3