open access
RSII rapid-sequence induction of anaesthesia and intubation of the trachea
open access
Abstract
Rapid sequence induction and intubation (RSII) is the preferred method of tracheal intubation in emergency situations for patients presenting with a full stomach. The aim of RSII is to intubate the trachea within 60 seconds, without having to use bag-valve-mask ventilation to avoid air insufflation into the stomach. After preoxygenation and while cricoid pressure is applied, an induction dose of intravenous anaesthetic agent is administered and rapidly followed by a fast-acting muscle relaxant, and after 60 seconds tracheal intubation is performed.
Preoxygention increases apnoea tolerance. This is particularly important for infants and young children, and in patients who are in critical condition, obese or pregnant. Cricoid pressure (the Sellick manouver) is recommended to prevent regurgitation of the gastric contents to the throat.
Propofol or thiopental are routinely used for induction. Ketamine or etomidate may be used if propofol or thiopental administration is contraindicated. Succinylcholine or rocuronium are used to facilitate tracheal intubation. Poor jaw relaxation, patient resistance to a laryngoscope, closed or closing vocal cords, vigorous limb movements or sustained coughing after tube insertion are not clinically acceptable.
Modified rapid sequence induction, used in patients at risk of rapid development of hypoxaemia, allows gentle positive pressure ventilation after administration of the induction agent and muscle relaxant, but before the tracheal intubation.
If the attempt of intubation fails, sugammadex, 16 mg/kg body weight is recommended for the immediate reversal of the neuromuscular block produced by rocuronium, but not for other muscle relaxants.
Abstract
Rapid sequence induction and intubation (RSII) is the preferred method of tracheal intubation in emergency situations for patients presenting with a full stomach. The aim of RSII is to intubate the trachea within 60 seconds, without having to use bag-valve-mask ventilation to avoid air insufflation into the stomach. After preoxygenation and while cricoid pressure is applied, an induction dose of intravenous anaesthetic agent is administered and rapidly followed by a fast-acting muscle relaxant, and after 60 seconds tracheal intubation is performed.
Preoxygention increases apnoea tolerance. This is particularly important for infants and young children, and in patients who are in critical condition, obese or pregnant. Cricoid pressure (the Sellick manouver) is recommended to prevent regurgitation of the gastric contents to the throat.
Propofol or thiopental are routinely used for induction. Ketamine or etomidate may be used if propofol or thiopental administration is contraindicated. Succinylcholine or rocuronium are used to facilitate tracheal intubation. Poor jaw relaxation, patient resistance to a laryngoscope, closed or closing vocal cords, vigorous limb movements or sustained coughing after tube insertion are not clinically acceptable.
Modified rapid sequence induction, used in patients at risk of rapid development of hypoxaemia, allows gentle positive pressure ventilation after administration of the induction agent and muscle relaxant, but before the tracheal intubation.
If the attempt of intubation fails, sugammadex, 16 mg/kg body weight is recommended for the immediate reversal of the neuromuscular block produced by rocuronium, but not for other muscle relaxants.
Keywords
intubation endotracheal, intubation methods, muscle relaxants depolarizing, muscle relaxants non-depolarizing, cyclodextrines
About this articleTitle
RSII rapid-sequence induction of anaesthesia and intubation of the trachea
Journal
Disaster and Emergency Medicine Journal
Issue
Pages
33-38
Published online
2017-03-31
Page views
1270
Article views/downloads
2476
DOI
Pubmed
Bibliographic record
Disaster Emerg Med J 2017;2(1):33-38.
Keywords
intubation endotracheal
intubation methods
muscle relaxants depolarizing
muscle relaxants non-depolarizing
cyclodextrines
Authors
Bogumila Woloszczuk-Gebicka
References (25)- https://cprguidelines.eu/.
- https://www.das.uk.com/guidelines/das_intubation_guidelines.
- Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet. 1961; 2(7199): 404–406.
- Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth. 1987; 59(3): 315–318.
- Rice MJ, Mancuso AA, Gibbs C, et al. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg. 2009; 109(5): 1546–1552.
- Vanner RG, Asai T. Safe use of cricoid pressure. Anaesthesia. 1999; 54(1): 1–3.
- Hagberg CA, Artime CA. Airway management in the adult. In: Miller RD. ed. Miller’s Anesthesia. Eight Edition. Elsevier, Philadelphia 2014: 1647–1687.
- Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia. 1999; 54(4): 376–381.
- Fuchs-Buder T, Claudius C, Skovgaard LT, et al. 8th International Neuromuscular Meeting. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand. 2007; 51(7): 789–808.
- Koscielniak-Nielsen ZJ, Bevan JC, Popovic V, et al. Onset of maximum neuromuscular block following succinylcholine or vecuronium in four age groups. Anesthesiology. 1993; 79(2): 229–234.
- El-Orbany MI, Joseph NJ, Salem MR, et al. The neuromuscular effects and tracheal intubation conditions after small doses of succinylcholine. Anesth Analg. 2004; 98(6): 1680–1685.
- Leary NP, Ellis FR. Masseteric muscle spasm as a normal response to suxamethonium. Br J Anaesth. 1990; 64(4): 488–492.
- Meakin G, Walker RW, Dearlove OR. Myotonic and neuromuscular blocking effects of increased doses of suxamethonium in infants and children. Br J Anaesth. 1990; 65(6): 816–818.
- Pandey K, Badola RP, Kumar S. Time course of intraocular hypertension produced by suxamethonium. Br J Anaesth. 1972; 44(2): 191–196.
- Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology. 2006; 104(1): 158–169.
- Minton MD, Grosslight K, Stirt JA, et al. Increases in intracranial pressure from succinylcholine: prevention by prior nondepolarizing blockade. Anesthesiology. 1986; 65(2): 165–169.
- Patel PM, Drummond JC, Lemkuil BP. Cerebral physiology and the effects of anesthetic drugs. In: Miller RD. ed. Miller’s Anesthesia. Eight Edition. Elsevier, Philadelphia 2014: 387–422.
- https://www.drugs.com/health-guide/malignant-hyperthermia.html.
- http://www.medicines.org.uk/emc/medicine/23095/SPC.
- Kirkegaard-Nielsen H, Caldwell JE, Berry PD. Rapid Tracheal Intubation with Rocuronium. A probability approach to determining dose. Anesthesiology. 1999; 91(1): 131–136.
- http://www.medicines.org.uk/emc/medicine/23095/SPC.
- Jones RK, Caldwell JE, Brull SJ, et al. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology. 2008; 109(5): 816–824.
- Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. Core Evid. 2013; 8: 57–67.
- Wołoszczuk-Gębicka B, Zawadzka-Głos L, Lenarczyk J, et al. Two cases of the "cannot ventilate, cannot intubate" scenario in children in view of recent recommendations. Anaesthesiol Intensive Ther. 2014; 46(2): 88–91.
- Clements P, Washington SJ, McCluskey A. Should patients be manually ventilated during rapid sequence induction of anaesthesia? Br J Hosp Med (Lond). 2009; 70(7): 424.