What is rapid sequence intubation (RSI)?

Rapid Sequence Intubation (RSI)

Rapid Sequence Intubation (RSI) is the administration of a sedative-hypnotic agent and a neuromuscular-blocking agent (NMBA) in rapid succession with immediate placement of an endotracheal tube before assisted ventilation, particularly indicated for critically ill adult patients requiring emergency airway management. 1

Definition and Core Components

• RSI is the standard approach for most emergency intubations, particularly indicated for patients at risk of aspiration 1
• The technique involves a prescribed protocol designed to rapidly create ideal intubating conditions, attenuate pathophysiologic reflex responses, and reduce aspiration risk 2
• RSI is commonly used in emergency departments, ICUs, and other locations outside the operating room requiring emergency airway management 1

Key Steps in RSI

1. Positioning

• The head and torso inclined (semi-Fowler) position is recommended during RSI to reduce aspiration risk and improve first-pass intubation success 1

2. Preoxygenation

• High-flow nasal oxygen (HFNO) is suggested when laryngoscopy is expected to be challenging 3
• Noninvasive positive pressure ventilation (NIPPV) is recommended for patients with severe hypoxemia (PaO2/FiO2 < 150) 3
• For agitated, delirious, or combative patients who cannot tolerate preoxygenation devices, medication-assisted preoxygenation (sometimes called delayed sequence intubation) is suggested 3

3. Medication Selection and Administration

Induction Agents

• A sedative-hypnotic induction agent must be administered when a neuromuscular-blocking agent is used for intubation 3
• There is no significant difference between etomidate and other induction agents (ketamine, midazolam, propofol) with respect to mortality or hypotension 3

Neuromuscular Blocking Agents (NMBAs)

• The American College of Critical Care Medicine strongly recommends administering an NMBA when a sedative-hypnotic induction agent is used for intubation 3
• Either rocuronium or succinylcholine is suggested for RSI when there are no contraindications to succinylcholine 1
• Rocuronium at doses of 0.6-1.2 mg/kg provides excellent to good intubating conditions in most patients within 2 minutes 4

4. Gastric Decompression

• Nasogastric tube decompression is advised for patients at high risk of regurgitation of gastric contents 1

Special Considerations

Medication-Assisted Preoxygenation (Delayed Sequence Intubation)

• Recommended for agitated, delirious, or uncooperative patients who cannot tolerate standard preoxygenation methods 3
• Involves administering a sedative-hypnotic agent (commonly ketamine) to facilitate preoxygenation before administering the NMBA 3
• Studies show a mean oxygen saturation increase of 8.9% after ketamine administration for preoxygenation 3

Dosing Considerations

• For rapid sequence intubation, rocuronium doses of 0.6-1.2 mg/kg provide excellent or good intubating conditions in most patients in less than 2 minutes 4
• In obese patients, the initial dose of rocuronium 0.6 mg/kg should be based on actual body weight rather than ideal body weight 4

Safety Measures and Complication Prevention

• Implementation of an RSI checklist significantly reduces complications, particularly desaturation (OR 0.1,95% CI 0.04-0.27) 5
• Apneic oxygenation during RSI reduces the risk of desaturation (2.0% vs 22.2% without apneic oxygenation) 5
• Video laryngoscopy improves first-pass success rates (88.2% vs 72.9% with standard laryngoscopy) 5
• Bougie use improves first-pass success (88.9% vs 73.0% without bougie) 5

Common Pitfalls and How to Avoid Them

• Failure to identify difficult airways before attempting RSI can lead to complications - use standardized criteria to assess airway difficulty 6
• Inadequate preoxygenation increases risk of desaturation - ensure proper preoxygenation technique and consider medication-assisted preoxygenation for uncooperative patients 3
• Hemodynamic instability during RSI - choose appropriate induction agents based on patient's hemodynamic status 7
• Awareness during paralysis - ensure adequate sedation before administering NMBA 7

RSI requires appropriate training, knowledge, technical skill, and sound medical judgment to minimize adverse complications and ensure successful airway management 2.