Rapid Sequence Induction

Rapid Sequence Induction

1. Indications. Patients at risk for aspiration include those who have recently eaten (full stomach), pregnant patients, and those with bowel obstruction, morbid obesity, or symptomatic reflux.
2. Technique
   1. Equipment necessary for a rapid sequence induction should include the following:
      1. Functioning tonsil-tip (Yankauer) suction
      2. Several different laryngoscope blades (Macintosh and Miller)
      3. Several styletted ETTs, including one that is of size smaller than normal
      4. An assistant who can apply cricoid pressure effectively
   2. The patient is preoxygenated using high flow rates of 100% oxygen for 3 to 5 minutes (denitrogenation). Four to five vital capacity breaths of 100% oxygen achieve nearly similar results when time is of the essence. The patient can also be placed in a head up, reverse Trendelenburg position during preoxygenation, which will delay the onset of desaturation upon apnea.
   3. The neck is extended so the trachea is directly anterior to the esophagus. The administration of an induction agent (e.g., propofol or ketamine) is immediately followed by succinylcholine (1 to 1.5 mg/kg IV). When succinylcholine is contraindicated, the use of a high dose nondepolarizing neuromuscular blockers or remifentanil (3 to 5 μg/kg) as an additional induction agent is warranted. An assistant places firm downward digital pressure on the cricoid cartilage, effectively compressing and occluding the esophagus (Sellick maneuver). This maneuver theoretically reduces the risk of passive regurgitation of gastric contents into the pharynx and may bring the vocal cords into better view by displacing them posteriorly. It should not be used if the patient is actively vomiting, because high pressures could injure the esophagus.
   4. There should be no attempt to ventilate the patient by mask. Cricoid pressure is maintained until successful endotracheal intubation is verified.
   5. Intubation can usually be performed within 30 seconds. If intubation attempts are unsuccessful, cricoid pressure should be maintained continuously during subsequent intubation maneuvers and while mask ventilation is in progress.