Do you induce paralysis first in Rapid Sequence Intubation (RSI)?

From the Guidelines

No, in Rapid Sequence Intubation (RSI), sedation is administered first, immediately followed by paralysis. The typical sequence involves pre-oxygenation, then administration of a sedative agent (such as etomidate 0.3 mg/kg, ketamine 1-2 mg/kg, or propofol 1-2 mg/kg), immediately followed by a neuromuscular blocking agent (such as succinylcholine 1-2 mg/kg or rocuronium 1-1.2 mg/kg) 1. This sequence is crucial because administering paralysis before sedation would leave the patient conscious but unable to move or breathe, causing significant distress. The sedative provides amnesia and unconsciousness, while the paralytic relaxes the muscles to optimize intubation conditions.

Some key points to consider in RSI include:

• The choice of neuromuscular blocking agent (NMBA) is important, with both succinylcholine and rocuronium being commonly used options 1.
• The use of rocuronium may delay the provision of post-intubation analgosedation compared to succinylcholine 1.
• Continuous monitoring of vital signs and preparation for potential difficult airway scenarios are essential for patient safety 1.
• The availability of sugammadex to reverse rocuronium rapidly may have encouraged the use of rocuronium in some settings when a selective relaxant binding agent (SRBA) is available 1.

Recent guidelines from the European Society of Anaesthesiology and Intensive Care make a strong recommendation, based on a moderate level of evidence, for the use of a fast-acting muscle relaxant such as succinylcholine 1–2 mg kg-1 or rocuronium 0.9 to 1.2 mg kg-1 for RSII 1. However, the most recent and highest quality study suggests that the choice of NMBA should be based on individual patient factors and clinical judgment 1.

In terms of patient outcomes, the most important consideration is to prioritize morbidity, mortality, and quality of life. The sequence of sedation followed by paralysis in RSI is designed to minimize the risk of aspiration and ensure a safe and successful intubation. By following this sequence and using the most appropriate NMBA for each patient, clinicians can help to optimize patient outcomes and reduce the risk of complications 1.

From the FDA Drug Label

Rapid Sequence Intubation Intubating conditions were assessed in 230 patients in six clinical studies where anesthesia was induced with either thiopental (3 to 6 mg/kg) or propofol (1.5 to 2. 5 mg/kg) in combination with either fentanyl (2 to 5 mcg/kg) or alfentanil (1 mg). Most patients had intubation attempted within 60 to 90 seconds of administration of rocuronium bromide 0.6 mg/kg or succinylcholine 1 to 1. 5 mg/kg.

In Rapid Sequence Intubation (RSI), paralysis is typically induced first, but the provided text does not directly answer whether paralysis is induced before other steps. However, it does describe the administration of a neuromuscular blocking agent (rocuronium bromide) in conjunction with anesthetic agents, followed by intubation attempts within 60 to 90 seconds.

• The sequence of events in RSI is crucial and typically involves the administration of an induction agent followed by a neuromuscular blocking agent to facilitate intubation.
• The text does not explicitly state that paralysis is induced before other steps in the RSI process, but it implies that neuromuscular blockade is achieved rapidly after the administration of rocuronium bromide, allowing for intubation within a short time frame 2.

From the Research

Rapid Sequence Intubation (RSI) Procedure

• The process of RSI involves administering a sedative and a neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation 3.
• The selection and use of medications to facilitate RSI is critical for success, and there are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia 3.

Induction of Paralysis in RSI

• The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in RSI is debated 4.
• A study found that administering the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds 4.
• However, another study suggests that the choice between succinylcholine and rocuronium, two commonly used neuromuscular blocking agents, is based on patient-specific factors, half-life, and adverse effect profiles, rather than the order of administration 3.
• There is currently no consensus on whether to induce paralysis first in RSI, and the decision may depend on the specific clinical scenario and patient factors 3, 4.

Considerations for RSI Medication Administration

• The use of pretreatment medications, such as atropine, lidocaine, and fentanyl, has fallen out of favor due to limited evidence for their use outside of select clinical scenarios 3.
• The selection of an appropriate sedative and neuromuscular blocker during RSI can be facilitated by an emergency department pharmacist 5.
• The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas, including the optimal order of medication administration 3, 4.