Review Article

ISSN: 2574 -1241 DOI: 10.26717/BJSTR.2023.47.007577

Rapid Sequence Induction in Critically Ill Patients

Jordan Llerena-Velastegui1* , Paul Vaca-Perez1, Sebastian Velastegui-Zurita1, Kristina

Zumbana-Podaneva1, Mauricio Santander-Aldean1, Jesus Larco-Coloma1, Cecibel
Villacis-Lopez2, Ginna Yepez-Sisalema2, Ana Teran-Lopez3, Trigomar Correa-Sancho3,
Marcela Placencia-Silva4 and Wagner Ango-Ango5
1
Pontifical Catholic University of Ecuador, Ecuador
2
Central University of Ecuador, Ecuador
3
University of the Americas, Ecuador
4
Equinoctial Technological University, Ecuador
5
University of the Andes, Ecuador
*Corresponding author: Jordan Llerena-Velastegui, Pontifical Catholic University of Ecuador, Ecuador

ARTICLE INFO ABSTRACT

Received: November 11, 2022 Healthcare providers face several challenges in the evaluation and management of
Published: January 09, 2023 critically ill patients. The complexity lies in knowing the placement of an advanced air-
way device, mainly in challenging airway scenarios. A rapid sequence induction plan
related to pharmacological and non-pharmacological measures provides benefits and
Citation: Jordan Llerena-Velastegui, optimally avoids subsequent short- and long-term complications. This non-system-
Paul Vaca-Perez, Sebastian Velaste- atic review aims to perform an in-depth and analytical study of the different drugs,
gui-Zurita, Kristina Zumbana-Podaneva, techniques, and practical measures in rapid sequence induction (RSI) to provide rec-
ommendations adapted to different types of patients in the hospital setting.
Mauricio Santander-Aldean, et al. Rapid
Sequence Induction in Critically Ill Pa- Keywords: Airway; Critical Care; Rapid Sequence Induction
tients. Biomed J Sci & Tech Res 47(5)-
2023. BJSTR. MS.ID.007577.

Introduction
Rapid sequence induction (RSI) is defined as the administration Rapid Sequence Induction Process
of a hypnotic agent and a neuromuscular relaxant consecutively RSI consists of 7 steps:
(virtually simultaneously), as well as other procedures to facilitate
orotracheal intubation in the critically ill patient and reduce the 1) Planification and preparation;
risk of aspiration. RSI is indicated in the critically ill patient needing 2) Pre-oxygenation;
emergent airway isolation, with a high success rate for definitive
3) Pre-treatment;
orotracheal intubation. In addition, using RSI decreases stress
levels and unsafe actions by the healthcare professional when 4) Sedation (induction) with neuromuscular paralysis;
performing the technique. RSI is frequently applied in the surgical
5) Patient protection and positioning;
environment, especially when the intervention is urgent and in
emergencies in both in-hospital and out-of-hospital emergency 6) Checking the endotracheal tube or advanced airway
departments. Therefore, the healthcare professional in these areas device; and
must master this sequence to achieve airway securing with the
7) Post-intubation management. These steps can be
minimum risk of complications [1-3].

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Volume 47- Issue 5 DOI: 10.26717/BJSTR.2023.47.007577

modified according to the characteristics of the emergency and observation, it is classified into four grades, predicting the difficulty
the peculiarities of each patient [3,4]. of intubation in grades III and IV. In critically ill patients, in supine
decubitus, and sometimes with a low level of consciousness, the
Step 1. Preparation
hypopharynx is visualized by oral opening and manual extraction
The person responsible for intubation should check that of the tongue by the person responsible for intubation, which is
they have all the necessary equipment to carry it out in the best much more complex, calling into question the feasibility of this
conditions: oxygen source, suction system, self-inflating bag, manoeuvre in the critically ill patient [3,4].
laryngoscope, endotracheal tubes, complex intubation equipment
Obstruction of the Airway
(laryngeal mask, cricothyrotomy equipment), resuscitation
equipment, drugs, and patient monitoring (oxygen saturation, heart The presence of upper airway infections (epiglottitis,
rate, blood pressure, and electrocardiographic recording). There is peritonsillar and prevertebral abscesses), laryngeal masses or
a «SOAPME» mnemonic rule to help remember all the equipment tumours, foreign bodies, extrinsic airway compression, and direct
needed for intubation: Suction, Oxygen, Airway, Pharmacology, trauma, among others, is evaluated [3,4].
Monitoring, Equipment (solution, oxygen, airway, pharmacology,
Neck Mobility
monitoring, and equipment) [3,4].
Proper mobilization and alignment of the head and mobilization
Evaluate the presence of difficult airways with the LEMON
of the cervical spine are assessed. Failure to have adequate mobility
mnemonic:
will result in a possibly difficult airway. It is essential to select the
• Look externally laryngoscope blade and the orotracheal tube appropriate to age
and gender [3,4].
• Evaluation 3-3-2
Step 2. Pre-oxygenation
• Mallampati
Pre-oxygenation is performed simultaneously with the
• Obstruction of the airway
preparation. It consists of applying oxygen using a reservoir
• Neck mobility mask (FiO2 = 80 to 100%) for 5 min to replace the nitrogen of
the functional residual capacity with oxygen (denitrogenation
Look Externally
phenomenon), which allows a patient to be maintained for 3-8 min in
Short and directed examination of the jaw, mouth, neck, and apnea without hypoxemia. The desaturation time is directly related
internal airway. Anatomical features that could predict difficult to weight: a healthy 70 kg patient will maintain oxygen saturation
ventilation [3,4]. (SpO2) above 90% for 8 min, an obese 127 kg patient for 3 min,
• Obesity and a healthy 10 kg child for less than 4min. Some measures, such
as elevating the head 25◦ during preoxygenation, can lengthen the
• Abnormal facial shapes desaturation time in patients with obesity, as well as the application
• Facial or cervical trauma in these patients of preoxygenation with continuous positive airway
pressure (CPAP) at 7.5-10 cmH2O[3,4]. It is important to note that,
• Large tongue
at this time of RSI, manual ventilation with a mask and self-inflating
Evaluation 3-3-2 bag should not be performed due to increased gastric pressure
and the possibility of regurgitation or vomiting. However, if at
The use of 3-3-2 rule is employed, which consists of the
any time during RDS the patient presents respiratory depression
following:
or later, after induction with paralysis, presents SpO2 below 90%,
• Three fingers in the mouth (proper opening) manual ventilation with positive pressure and high-flow oxygen is
essential; the application of cricoid pressure or Zoellick’s technique
• Three fingers chin-floor of mouth (proper jaw)
to prevent regurgitation is ineffective and at risk of causing tracheal
• Two fingers from the floor of the mouth to the thyroid injury, so it should be avoided [3,4].
cartilage (adequate size and position of the neck)
Step 3. Pre-treatment
Mallampati
It consists of administering drugs before induction-relaxation
It is a technique explored with the patient seated and upright. to reduce the adverse side effects of orotracheal intubation
The patient is asked to open his mouth and stick out his tongue, (hypotension, bradycardia or tachycardia, increased intracranial
and the hypopharynx is visualized using a light source. After pressure, and airway resistance) (Table 1). The application of

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pre-treatment has benefits and risks adherent to the drug used. and short-acting opioids (fentanyl being the most commonly used).
It is prefire to administer only drugs that have demonstrated the They are not always used as a general rule [3,4]. Pre-treatment, to
greatest benefit and to omit those without clear evidence, such as be most effective, should be administered 3 min before starting
the previously non-depolarizing neuromuscular blocking agents. induction. In cases of urgency that do not let intubation be delayed,
The drugs used in the pre-treatment of RDS are atropine, lidocaine, it can be given with less time or be omitted [3,4].

Table 1: Premedication in RSI.

Medication IV dose Indications

Atropine 0,01-0,02 mg/kg • Decreases the incidence of bradycardia to laryngoscopic stimulation
Lidocaine 1 mg/kg • Decreases ICP and bronchospasm
• Administer in all possible cases
• Suspected elevated ICP
Fentanyl 0,5 µg/kg
• Ischemic heart disease
• Aortic dissection

Note: ICP: intracranial pressure; RSI: rapid sequence induction [4].

Step 4. Sedation with Neuromuscular Palsy (Tables 2 & 3). Currently, the most commonly used sedatives are
etomidate, ketamine, propofol, and midazolam, although the latter
Induction and simultaneous neuromuscular relaxation are
is without indication for any specific clinical scenario; the choice of
performed to produce unconsciousness and muscle relaxation to
the optimal sedative will depend on each specific clinical situation
facilitate orotracheal intubation and reduce the risk of aspiration
we are faced with [5,6].

Table 2: Inductors in RSI.

Sedatives IV dose (mg/kg) Start (min) BP PIC

Etomidate 0,2-0,3 Less than 1 Minimum/increase
Thiopental 3-5 Less than 1 Decrease Decrease
Ketamine 1-2 One Minimum/increase Increase
Propofol 1-3 Less than 1 Decrease Decrease
Fentanyl 1-2 µg 3-5 Decrease Decrease
Midazolam 0,05-0,1 1-2 Minimum Minimum

Note: IV: intravenous; ICP: intracranial pressure; RSI: rapid sequence induction; BP: blood pressure.

Table 3: Neuromuscular relaxants in RSI.

Muscle relaxants IV dose (mg/kg) Onset of effect (min) Recovery (min)

Rocuronium 1-1,2 <1 > 20
Succinylcholine 1-2 <1 3-10

Note: RSI: rapid sequence induction.

Step 5. Patient Positioning and Laryngoscopy the trunk (except in the patient with suspected cervical spinal cord
injury). This position is facilitated by slightly elevating the head
In this phase, the patient is placed in the ideal position to
of the bed or placing a small pillow on the occiput. This position
facilitate intubation. Optimization of airway visualization is
achieves the ideal alignment of the three axes (oral, pharynx, and
performed with the BURP manoeuvre. The ideal position for
larynx) for optimal glottis visualization and facilitates orotracheal
orotracheal intubation is the so-called «sniffing of the morning air»
intubation. During direct laryngoscopy, a rapid assessment of the
or «sipping English tea.» This position is achieved with the head
glottis visualization is performed. Here, it is determined whether
hyperextended concerning the neck and the neck flexed concerning

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intubation can be difficult or not; it is evaluated with the Cormack- • Capnography

Lehane classification, where grade I-II predicts easy intubation and
• Chest X-ray
grade III-IV predicts difficult intubation [6,7].
• Fibrobronchoscopy
Step 6. Check the Placement of the Endotracheal Tube
• Ultrasound (pleural sliding)
Verification of correct endotracheal tube placement is
performed immediately after endotracheal intubation. Accidental Step 7. Post-Intubation Management
intubation into the oesophagus or selective intubation into a In this last phase, in addition to treating the underlying disease,
bronchus can result in severe injury. There are several methods to adequate sedation, analgesia, and maintenance relaxation are
verificate optimal endotracheal tube placement [8-10]: administered when necessary, appropriate mechanical ventilation
• Direct visualization of endotracheal tube insertion parameters are adjusted, monitoring is exhaustive (oxygen
through the vocal cords. saturation, capnography, heart rate, blood pressure), and a chest
X-ray is performed to diagnose the most frequent intubation
• Auscultation (at 5 points: both infraclavicular mid zones,
complications rapidly. Precise adjustment of mechanical ventilation
bilateral axillary zone, axillary midline at the level of the fifth
parameters should be performed to avoid ventilator-induced lung
intercostal space and the epigastrium).
injury caused by a combination of volutrauma, atelectrauma,
• Measurement of the introduced depth of the endotracheal barotrauma, and biotrauma [10] (Table 4).
tube through its markings at the level of the incisors.

Table 4: Rapid Sequence Intubation Summary.

· Telemetry, pulse oximetry, capnography

1. Preparation · Material needed for intubation: laryngoscope, blades, orotracheal tubes,
laryngeal mask, drugs, previous DA
2. Pre-oxygenation
· Administer FiO2 between 80 to 100%, avoiding the use of pressure
Perform in 3 min positive
· Lidocaine 1 mg/kg in bronchospasm
3. Pre-treatment · Fentanyl 0.5 µg/kg for analgesia
· Atropine 0.01-0.02 mg/kg if bradycardia or abundant secretions
· Propofol 1-3 mg/kg
· Ketamine 1,5 mg/kg
4. Induction · Etomidate 0.2-0.3 mg/kg
After 3 to 5 min after the start of premedication · Fentanyl 1-2 µg/kg
Paralysis · Tiopental 3 to 5 mg/kg
Immediately after inducer · Midazolam 0.05-0.1 mg/kg
· Succinylcholine (depolarizing) 1-2 mg/kg
· Rocuronium (non-depolarizing) 1.2 mg/kg
5. Patient positioning · Axis alignment
· Pulmonary auscultation with adequate bilateral aeration
· Capnography or capnometry
6. Endotracheal tube check
· Ultrasound lung displacement
· Tip of the orotracheal tube 2 cm above the carina on chest radiograph
7. Post-intubation management · Monitor SpO2 > 90%, EtCO2 35-45 mmHg, perfusive BP

Note: EtCO2: exhaled carbon dioxide; FiO2: inspired oxygen fraction; BP: blood pressure; SpO2: peripheral oxygen saturation; DA:
difficult airway.

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Macocha Scale disease per se, and factors related to the physician performing the
intubation11, with a score ranging from 0 to 12.
Currently, we have many predictive scales for difficult
ventilation/intubation, such as Mallampati, intensivist distance, The problem with this scale is that there is a grey area in
sternomental distance, sternothyroid distance, Bell House-Dore, between since the score of 0 is simple intubation, and 12 is very
mandibular protrusion, Langeron criteria for ventilation, and IPID difficult intubation, with the intermediate scores undetermined,
scale, to know if it will be easy or if we will require assistance/ basing the highest score on the Mallampati scale. Consequently,
manoeuvres/special equipment for intubation. The Macocha scale the clinician’s evaluation will always be the most important for
has a negative predictive value of 97% and a sensitivity of 76%. It decision making, given that there are difficult airways not foreseen
integrates different variables, considering three collection groups: with a higher percentage in emergency scenarios (Table 5).
factors associated with the patient, factors associated with the

Table 5: Macocha scale.

Variables Score
Patient-related factors
5
Mallampati III-IV
2
Obstructive sleep apnea
1
Decreased neck mobility
1
Oral opening less than 3 cm
Disease-related factors
1
Coma
1
Respiratory insufficiency
Operator-related factors
1
Non-anesthesiologist
Total 12
Scoring: 0 points: easy intubation; 12 points: difficult intubation.

Discussion plane to the patient and effective analgesia but without affecting the
hemodynamic status; they are classified into inducers, analgesics,
Techniques used during RSI are those in which the patient
and neuromuscular plaque blockers [19,20].
can ventilate independently, achieving adequate oxygenation for
intubation without requiring manual ventilation and techniques Inducers
to prevent bronchoaspiration [11,12]. The Sellick manoeuvre Etomidate: The induction agent of choice in the unstable
is described as a temporary occlusion of the upper oesophagus patient is its mechanism of action by increasing GABA’s inhibitory
by the pressure of the cricoid cartilage ring to prevent stomach effect. Its action is rapid 30-60 s, and its duration is 3-5 min, with
contents from reaching the pharynx, thus preventing regurgitation a dose of 0.3-0.5 mg/kg. Side effects: inhibition of 11ß-hydroxylase
[13,14]. The Sellick manoeuvre must be differentiated from the important in adrenal steroid secretion [21].
BURP manoeuvre, which arises due to the inability to visualize
the glottis adequately and its adjacent structures (Back, Up, Right, Ketamine
and Pressure). This manoeuvre facilitates intubation and is even The inducing agent that acts on NMDA receptors by antagonizing
described as a 2-handed manoeuvre 2 [15-18]. their active metabolites is called norketamine. It is ideal for
Clinical Scenarios asthmatics as it creates bronchodilation in unstable patients with
aminergic reserve. Dose: 1-4 mg/kg IV, with an onset of action
In the different critical scenarios, teamwork is essential to of 20-60 s and a duration of 15-20 min. Side effects: tachycardia
offer more significant benefits to the patient and reduce the risk of due to noradrenaline reuptake, increased myocardial oxygen
comorbidities. It is essential to remember the pharmacology of the consumption, sympathetic stimulation increasing arterial pressure
drugs involved in RDS since they should facilitate intubation in the and heart rate, pulmonary arterial pressure, systemic vascular
shortest possible time, offering an adequate sedation-anaesthetic resistance, sialorrhea, dissociative states, and hallucinations [21].

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Propofol the other inducers mentioned. Its onset of action is 20-40 s, lasting
8 to 15 min. It is not superior to the other inducers and does not
Lipid emulsion inducing agent 1% (soybean oil 10%, glycerol
show improvement in any clinical context, so its abandonment
2.25%, and phosphatide 1.2%) acts by GABA inhibition. Dose
in RDS is becoming increasingly frequent. Side effects: nausea,
in patients of 1-2 mg/kg IV (in unstable patients, it is not highly
vomiting, cough, delirium, euphoria, residual apnea, paradoxical
recommended, but doses of 1 mg/kg IV can be used). The onset of
reactions [21].
action is 20-60 s, lasting 8 min. It is helpful for cerebral protection; it
decreases myocardial and cerebral oxygen consumption, decreases Neuromuscular Plate Blockers
mean arterial pressure by 20%, decreases intraocular pressure,
Succinylcholine: Succinylcholine remains the gold standard
and has an antiemetic effect. Side effects: rash, bradycardia, arterial
in RSI. It is a neuromuscular blocker (NMB) of the depolarizing
hypotension, decreased systemic vascular resistance (SVR) and
type due to its similarity to acetylcholine (ACH), presenting a high
pulmonary vascular resistance, pain at the site of application,
affinity for nicotinic receptors.
contraindication in preload-dependent cardiac patients, and SVR
[22]. Its effective dose is 0.25 mg/kg, requiring 4 SD for ISR: 1 mg/
kg, acting at a maximum of 60 s with an ultra-short duration of
Diazepam
action of 8 min. Side effects: hyperkalemia (a single dose increases
Long-acting benzodiazepines act by inhibiting GABA-A. It is 0.5 mEq/l), tachyfilaxia, tachycardia due to stimulation of nicotinic
rarely used in the context of RDS; however, in the cardiac surgery receptors, fasciculations, muscle pain, increased intraocular
patient, it is widely used for induction, being a useful and safe pressure, and intragastric pressure if the patient does not present
alternative at doses of 0.2-0.4 mg/kg IV, with an onset of action with hydro-electrolytic disorders, tachycardia, glaucoma. This drug
of 60-90 s. Its duration is extended with a plasma peak of 30-90 is the one considered the drug of choice [23,24]. In 2018, the master
min, and its active metabolite N-desmethyldiazepam can last of neuroanesthesia, James E. Cotrell, conducted a study published
in its elimination life of 20-70 h. Side effects: ataxia, euphoria, in the ASA journal about succinylcholine’s effect on intracranial
somnolence, rash, diarrhoea, fatigue, respiratory depression, pressure. Administering boluses of 1-1.5 mg/kg in cats monitoring
urinary retention, hypotension, depression, incontinence, blurred ICP, they observed an increase in normal conditions of 8 mmHg ICP
vision, dysarthria [22]. Soleimani et al. conducted a prospective up to 16 mmHg and in induced ICP increases of up to 10-20 mmHg,
study comparing diazepam, propofol, and etomidate in the concluding that succinylcholine is associated with increased
induction of patients with left ventricular failure and LVEF of less mortality when used for RSI in patients with brain damage, due to
than 40% who were to undergo cardiac surgery, concluding that alterations in brain dynamics [25].
diazepam is the most favourable in maintaining hemodynamic
Rocuronium
status compared to propofol and etomidate [22].
This drug is a non-depolarizing type of BNM, preventing ACH
Thiopental
from binding to them and activating them. Its DE is 0.3 mg/kg,
This drug is a barbiturate used as an inducer. It acts at the requiring 4 DE for ISR: 1.2 mg/kg to obtain complete relaxation in
NAD level, altering the respiratory chain and inhibiting GABA-A a maximum of 60 s and duration at 4 DE of up to 120 min26. Side
and AMPA receptors. Inducer dose of 3-5 mg/kg IV with the onset effects: idiosyncratic blood pressure disturbances (1.2%), dose-
of action in 15-30 s; recovery time is 10 min after induction. It dependent tachycardia, histamine release, pruritus, malignant
decreases metabolic oxygen consumption at the cerebral level and hyperthermia, residual neuromuscular blockade [23,24].
is used as a neuroprotector. However, its effects on hemodynamic
Opioids
stability are very marked, so the risk-benefit of this versus other
drugs such as propofol would have to be assessed. Side effects: Fentanyl: This drug is the opioid of choice for laryngoscopy,
decreases cardiac output by 25%, decreases systemic vascular inhibits vagal reflexes, and produces dose-dependent analgesia at
resistance, negative inotropic, reflex tachycardia due to hypotension, doses of 0.5-3 µg/kg, causing minimal hemodynamic instability,
refractory hypotension, bronchoconstriction, decreases the effect with a time of action of 3.6 min to reach the effector site (ES)
of catecholamines, ADH, and corticosteroids, hyperglycemia, and and a duration of 30-50 min [23,24]. Side effects: nausea, emesis,
can produce attacks of porphyria by increasing the production of pruritus, urinary retention, constipation, apnea, and bradycardia.
the heme group [23]. It is the most studied agent in RDS and is considered the ideal
analgesic opioid for this dose-dependent scenarios [26].
Midazolam
The combination of these drugs lets the airway be approached
This drug is used as an inductor in RDS at doses of 0.05-0.3 mg/
faster and safer; the KETASED study was performed in critically
kg IV, but it is not of choice in any scenario, only in the absence of

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ill patients using ketamine versus etomidate as an inducer. Both increase in intracranial pressure with succinylcholine [25], with
maintained hemodynamic stability of the patient; however, the rocuronium at four effective doses in RDS being the agent of choice
use of etomidate was associated with a period of relative adrenal in these cases. Kramer, et al. in 2018 mentioned that lidocaine could
insufficiency [27]. Jabre et al. compared two groups of drugs: be associated with hypotension events during induction in the
etomidate and fentanyl versus ketamine and midazolam, with 20 neurocritical patient [29]. However, a study by Staikou et al. using
patients per group, finding that etomidate and fentanyl obtain good the bispectral index showed that adding lidocaine to induction
results in terms of hemodynamic maintenance, being superior to did not show that it affected anaesthetic depth or hemodynamic
midazolam as an inducer, and ketamine is an excellent alternative changes [30]. Pharmacological suggestions are proposed according
in the septic patient [28]. Soleimani, et al., in a study comparing the to the patient’s clinical scenario: hemodynamic instability,
inducers diazepam, propofol, and etomidate in patients with heart neurocritical, cardiopathic, and bronchospasm (Tables 6-9). In the
disease with decreased left ventricular ejection fraction (LVEF), end, an algorithm is established to help with decision-making when
concluded that diazepam showed better hemodynamic stability faced with a patient who merits airway invasion (Figure 1).
than the other inducing agents [22]. Cotrell has published the

Table 6: RSI Suggestions in the hemodynamically unstable patient.

Pre-treatment
· Fentanyl: 0.5 to 1 µg/kg IV (essential to provide adequate analgesia to the patient and avoid vagal reflection offered by laryngoscopy, and
· Lidocaine: 1 mg/kg IV has demonstrated benefits in the cardiac patient and the context of the patient’s hemodynamically compromised
Induction
· Etomidate: 0.2 mg/kg (avoid in the septic patient), or
· Ketamine: 1.5 mg/kg (avoid in the cardiac patient or those without aminergic reserve)
Neuromuscular relaxant
· Succinylcholine: 1 mg/kg (avoid in hyperkalemia, burn or glaucoma, or neurocritical patients)

Note: RSI: rapid sequence induction.

Table 7: RSI suggestions in neurocritical patient.

Pre-treatment
• Fentanyl: 0.5 to 1 µg/kg IV, and
• Lidocaine: 1 mg/kg IV; in neurotrauma, its benefit does not seem entire.
Induction
• Propofol: 1-2 mg/kg IV, decreases cerebral oxygen consumption. MAP must be monitored during induction so as not to compromise CPP, or
• Thiopental: 3-5 mg/kg IV, decreases cerebral oxygen consumption, ideal for neuroprotection; patient’s hemodynamic status must be monitored so as
not to compromise CPP, or
• Etomidate: 0.3 mg/kg
Neuromuscular relaxant
• Rocuronium: 1 mg/kg

Note: MAP: mean arterial pressure; CPP: cerebral perfusion pressure; RSI: rapid sequence induction.

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Table 8: RSI suggestions in patients with heart disease.

Pre-treatment
• Fentanyl: 0.5 to 1 µg/kg IV (essential to provide adequate analgesia to the patient and avoid vagal reflection offered by laryngoscopy), and
• Lidocaine: 1 mg/kg IV has demonstrated benefits in the cardiac patient and the context of the hemodynamically compromised patient
Induction
• Etomidate: 0.2 mg/kg, or
• Diazepam: 0.2-0.4 mg/kg (ideal in the cardiopathic patient), or
• Propofol: 1 mg/kg (can be used while monitoring the hemodynamic context to avoid compromise of coronary perfusion pressure)
Neuromuscular relaxant
• Succinylcholine: 1 mg/kg, or
• Rocuronium: 1 mg/kg (in case succinylcholine is not available or contraindicated)

Note: RSI: rapid sequence induction.

Table 9: RSI recommendations in patients with bronchospasm.

Pre-treatment
• Fentanyl: 0.5 to 1 µg/kg IV, and
• Lidocaine: 1 mg/kg IV, beneficient for a patient with bronchospasm
Induction
• Ketamine: 2-4 mg/kg IV (agent of choice in a patient with bronchospasm), or
• Etomidate: 0.2 mg/kg (avoid in a patient with coexisting sepsis)
Neuromuscular relaxant
• Succinylcholine: 1 mg/kg, or
• Rocuronium: 1 mg/kg (in case succinylcholine is not available or contraindicated)

Note: RSI: rapid sequence induction.

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Note: CAP: continuous airway pressure; NMR: neuromuscular relaxation; RSI: rapid sequence induction; ETT: endotracheal tube;
MV: mechanical ventilation; NIV: non-invasive mechanical ventilation.
Figure 1: Specific RSI scenarios
1. Lidocaine with no proven benefit in neurotrauma.
2. Diazepam at high doses of 0,2-0,4 mg/kg.

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Conclusion 4. Stollings JL, Diedrich DA, Oyen LJ, Brown DR (2014) Rapid-sequence
intubation: a review of the process and considerations when choosing
RSI is an action guide to invade the airway and provide medications. Ann Pharmacother 48(1): 62-76.

ventilatory support either by pulmonary or extrapulmonary causes; 5. Kallstrom TJ, American Association for Respiratory Care (AARC) (2002)
AARC Clinical Practice Guideline: oxygen therapy for adults in the acute
it requires knowledge of the technique of orotracheal intubation,
care facility--2002 revision & update. Respir Care 47(6): 717-720.
the pharmacology of the drugs used, as well as identifying the
6. Smally AJ, Nowicki TA, Simelton BH (2011) Procedural sedation and
benefits and adverse effects of them. A rapid approach to the analgesia in the emergency department. Curr Opin Crit Care 17(4): 317-
airway aims to minimize the risk of bronchoaspiration and protect 322.
oxygenation. The critically ill patient usually requires ventilatory 7. Soltani Mohammadi S, Saliminia A, Nejatifard N, Azma R (2016)
support; clinical scenarios range from shock to respiratory failure, Usefulness of Ultrasound View of Larynx in Pre-Anesthetic Airway
Assessment: A Comparison With Cormack-Lehane Classification During
and knowledge of the pros and cons of each drug used in RSI steps Direct Laryngoscopy. Anesth Pain Med 6(6): e39566.
is imperative.
8. Fein DG, Zhao D, Swartz K, Nauka P, Andrea L, et al. (2021) The Impact
Highlights of Nighttime on First Pass Success During the Emergent Endotracheal
Intubation of Critically Ill Patients. J Intensive Care Med 36(12):1498-
1506.
What is already known regarding this topic?
9. DuCanto J, Serrano KD, Thompson RJ (2017) Novel Airway Training
I. The patient must be pre-oxygenated with 100% oxygen Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted
during induction to maximize their functional residual capacity. It is Decontamination (SALAD) System. West J Emerg Med 18(1): 117-120.

recommended to administer oxygen for 3 to 5 minutes or until the 10. Denton G, Green L, Palmera M, Jones A, Quinton S, et al. (2022) Advanced
airway management and drug-assisted intubation skills in an advanced
expired oxygen fraction is at least 85%.
critical care practitioner team. Br J Nurs 31(11): 564-570.
II. The effectiveness of cricoid pressure in preventing 11. De Jong A, Jung B, Jaber S (2014) Intubation in the ICU: we could improve
regurgitation varies according to the study. our practice. Crit Care 18(2): 209.
12. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, et al. (2017) Official
III. Cricoid pressure application may fail to disrupt ERS/ATS clinical practice guidelines: noninvasive ventilation for acute
laryngoscopy, laryngeal distortion, occlusion of the oesophagus, respiratory failure. Eur Respir J 50(2): 1602426.
and, less frequently, oesophagus rupture during active vomiting. 13. Sellick BA (1961) Cricoid pressure to control regurgitation of stomach
contents during induction of anaesthesia. Lancet 2(7199): 404-406.
What does this research add?
14. Salem MR, Khorasani A, Zeidan A, Crystal GJ (2017) Cricoid Pressure
I. RSI requires knowledge of the technique of orotracheal Controversies: Narrative Review. Anesthesiology 126(4): 738-752.

intubation, the pharmacology of the drugs used, and the ability 15. Knill RL (1993) Difficult laryngoscopy made easy with a “BURP”. Can J
Anaesth 40(3): 279-282.
to identify their benefits and adverse effects.
16. Snider DD, Clarke D, Finucane BT (2005) The “BURP” maneuver worsens
II. Pre-oxygenation is performed simultaneously with the the glottic view when applied in combination with cricoid pressure. Can
preparation. It consists of applying oxygen using a reservoir J Anaesth 52(1): 100-104.

mask (FiO2 = 80 to 100%) for 5 min to replace the nitrogen of 17. Yentis SM (1997) The effects of single-handed and bimanual cricoid
pressure on the view at laryngoscopy. Anaesthesia 52(4): 332-335.
the functional residual capacity with oxygen (denitrogenation
phenomenon), which allows a patient to be maintained for 3-8 18. Thiagarajah S, Lear E, Keh M (1990) Anesthetic implications of Zenker’s
diverticulum. Anesth Analg 70(1): 109-111.
min in apnea without hypoxemia.
19. Matioc AA (2019) An Anesthesiologist’s Perspective on the History
III. The application of cricoid pressure or Zoellick’s technique of Basic Airway Management: The “Modern” Era, 1960 to Present.
Anesthesiology 130(5): 686-711.
to prevent regurgitation is ineffective, and at risk of causing
tracheal injury, so it should be avoided. 20. Taboada M, Doldan P, Calvo A, Almeida X, Ferreiroa E, et al. (2018)
Comparison of Tracheal Intubation Conditions in Operating Room and
References Intensive Care Unit: A Prospective, Observational Study. Anesthesiology
129(2): 321-328.
1. Li J, Murphy-Lavoie H, Bugas C, Martinez J, Preston C (1999)
Complications of emergency intubation with and without paralysis. Am 21. Chaiyakulsil C, Chantra M, Katanyuwong P, Khositseth A, Anantasit N
J Emerg Med 17(2): 141-143. (2018) Comparison of three non-invasive hemodynamic monitoring
methods in critically ill children. PLoS One 13(6): e0199203.
2. Sivilotti ML, Filbin MR, Murray HE, Slasor P, Walls RM (2003) Does the
sedative agent facilitate emergency rapid sequence intubation? Acad 22. Soleimani A, Heidari N, Habibi MR, Kiabi FH, Khademloo M, et al.
Emerg Med 10(6): 612-620. (2017) Comparing Hemodynamic Responses to Diazepam, Propofol and
Etomidate During Anesthesia Induction in Patients with Left Ventricular
3. Tayal VS, Riggs RW, Marx JA, Tomaszewski CA, Schneider RE (1999) Dysfunction Undergoing Coronary Artery Bypass Graft Surgery: a
Rapid-sequence intubation at an emergency medicine residency: Double-blind, Randomized Clinical Trial. Med Arch 71(3): 198-203.
success rate and adverse events during a two-year period. Acad Emerg
Med6(1): 31-37. 23. Stewart JC, Bhananker S, Ramaiah R (2014) Rapid-sequence intubation
and cricoid pressure. Int J Crit Illn Inj Sci 4(1): 42-49.

Copyright@ Jordan Llerena-Velastegui | Biomed J Sci & Tech Res | BJSTR. MS.ID.007577. 39023
Volume 47- Issue 5 DOI: 10.26717/BJSTR.2023.47.007577

24. Sparr HJ, Beaufort TM, Fuchs-Buder T (2001) Newer neuromuscular 28. Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, et al.
blocking agents: how do they compare with established agents? Drugs (2009) Etomidate versus ketamine for rapid sequence intubation in
61(7): 919-942. acutely ill patients: a multicentre randomised controlled trial. Lancet
374(9686): 293-300.
25. Cottrell JE (2018) Succinylcholine and Intracranial Pressure.
Anesthesiology 129(6): 1159-1162. 29. Kramer N, Lebowitz D, Walsh M, Ganti L (2018) Rapid Sequence
Intubation in Traumatic Brain-injured Adults. Cureus 10(4): e2530.
26. Quintard H, l’Her E, Pottecher J, Adnet F, Constantin JM, et al. (2019)
Experts’ guidelines of intubation and extubation of the ICU patient of 30. Staikou C, Paraskeva A, Karmaniolou I, Vezakis A, Tsaroucha A (2013)
French Society of Anaesthesia and Intensive Care Medicine (SFAR) and Intravenous lidocaine does not affect the anesthetic depth during rapid
French-speaking Intensive Care Society (SRLF): In collaboration with the sequence induction and intubation as assessed by Bispectral Index
pediatric Association of French-speaking Anaesthetists and Intensivists monitoring: a randomized double blind study. Arch Med Sci 9(4): 713-
(ADARPEF), French-speaking Group of Intensive Care and Paediatric 718.
emergencies (GFRUP) and Intensive Care physiotherapy society (SKR).
Ann Intensive Care 9(1): 13.
27. Freund Y, Jabre P, Mourad J, Lapostolle F, Reuter PG, et al. (2014)
Relative adrenal insufficiency in critically ill patient after rapid sequence
intubation: KETASED ancillary study. J Crit Care 29(3): 386-389.

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