What type of patient is suitable for rapid sequence intubation (RSI)?

From the Guidelines

Rapid sequence intubation (RSI) is most suitable for patients who require immediate airway management but have a risk of aspiration, including those with full stomachs, emergency situations, trauma patients, and critically ill individuals. The ideal RSI candidate has difficult or compromised airways but without anticipated anatomical challenges that would make intubation extremely difficult. RSI involves administering a sedative (such as etomidate 0.3 mg/kg, ketamine 1-2 mg/kg, or propofol 1-2 mg/kg) followed immediately by a neuromuscular blocking agent (typically succinylcholine 1-1.5 mg/kg or rocuronium 1-1.2 mg/kg) to rapidly achieve optimal intubation conditions while minimizing aspiration risk 1.

Before proceeding with RSI, clinicians should perform a thorough airway assessment using tools like the LEMON assessment (Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility) to identify potential difficulties. RSI is contraindicated in patients where bag-mask ventilation and intubation are anticipated to be extremely difficult or impossible, as the procedure eliminates the patient's spontaneous breathing. In these cases, an awake intubation approach may be more appropriate. The rapid paralysis in RSI helps prevent vomiting and aspiration while creating optimal conditions for quick, successful tube placement.

Some key considerations for RSI include:

• Pre-oxygenation to minimize the risk of hypoxia during the procedure
• The use of cricoid force to help prevent gastric aspiration
• The selection of appropriate sedative and neuromuscular blocking agents based on the patient's medical history and clinical situation
• The availability of equipment and personnel to manage potential complications

It's also important to note that RSI is a high-risk procedure that requires careful planning and execution to minimize complications. Clinicians should be trained in the technique and have experience with airway management to perform RSI safely and effectively 1.

In terms of specific patient populations, RSI may be particularly useful in trauma patients, critically ill individuals, and those with full stomachs or other risk factors for aspiration. However, the decision to perform RSI should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances.

Overall, RSI is a valuable tool for managing the airway in patients who require immediate intubation, but it should be used judiciously and with careful attention to the patient's overall clinical condition.

From the FDA Drug Label

To be administered only by experienced clinicians or adequately trained individuals supervised by an experienced clinician familiar with the use, actions, characteristics, and complications of neuromuscular blocking agents. Rapid sequence intubation: 0.6 to 1.2 mg/kg. Use only if facilities for intubation, mechanical ventilation, oxygen therapy, and an antagonist are immediately available. Rocuronium bromide is not recommended for rapid sequence induction in patients undergoing Cesarean section. Rocuronium bromide injection is not recommended for rapid sequence intubation in pediatric patients.

The type of patient suitable for rapid sequence intubation (RSI) with rocuronium bromide includes:

• Adult patients who require rapid sequence intubation and have no contraindications to the use of rocuronium bromide.
• Patients who are ASA physical status I or II, as most patients in clinical studies had these classifications.
• Geriatric patients (65 years or older) who have no contraindications, as they exhibited a slightly prolonged median clinical duration.
• Obese patients who should be dosed based on their actual body weight.

However, the following patients are not recommended for rapid sequence intubation with rocuronium bromide:

• Pediatric patients.
• Patients undergoing Cesarean section. 2 2 2

From the Research

Patient Selection for Rapid Sequence Intubation

The following types of patients are suitable for rapid sequence intubation (RSI):

• Critically ill patients who require emergent intubation 3, 4, 5
• Patients with risk of aspiration, such as those with no 2h liquid and no 6h food fasting or acute vomiting, sub-ileus or ileus, or no protective reflexes or a gastrointestinal passenger disorder 6
• Pregnant women after the 3rd trimester and during birth 6
• Patients who are uncooperative, nonfasted, unstable, and/or critically ill 5

Contraindications for RSI

The presence of severe acidosis, depletion of intravascular volume, heart failure, and severe pulmonary disease may complicate the pre-induction period and lead to vasodilatation and hypotension, making RSI less suitable for these patients 3

Key Considerations for RSI

• The algorithm of RSI consists of six steps: pre-oxygenation, premedication, myo-relaxation and induction, intubation, primary and secondary confirmation, and post-intubation patient management 3
• Choosing the appropriate premedication, induction drug, and paralytic is crucial to maximize the success of tracheal intubation and minimize complications 5
• Expertise, support from an experienced anesthesiologist, and close monitoring of an inexperienced anesthesiologist can reduce the risk of aspiration during RSI 6