What are the essential items to check prior to endotracheal intubation (ETI)?

From the Guidelines

Before proceeding with endotracheal intubation (ETI), it is crucial to check for several essential items to ensure patient safety and the success of the procedure, including patient assessment, equipment preparation, and medication readiness, as outlined in the most recent guidelines 1.

Essential Items to Check

The following items should be checked prior to ETI:

• Patient assessment for difficult airway characteristics, such as limited mouth opening, short neck, obesity, or facial trauma, and checking oxygen saturation 1
• Equipment preparation, including a functioning laryngoscope (with backup), appropriately sized endotracheal tubes (ETT), stylet, bougie, bag-valve-mask, suction device, end-tidal CO2 detector, and backup airway devices like laryngeal mask airways or video laryngoscopes 1
• Medication readiness, including induction agents (ketamine 1-2 mg/kg), paralytics (rocuronium 1.2 mg/kg), and post-intubation sedation 1
• Team communication and assignment of clear team roles, including who will administer medications, perform intubation, provide cricoid pressure if needed, and monitor vital signs 1

Key Considerations

• Meticulous pre-oxygenation with a well-fitting mask for 3-5 minutes is recommended 1
• A heat and moisture exchange (HME) filter should be placed between the catheter mount and the circuit 1
• Patient positioning, including ramping in the obese and reverse Trendelenburg positioning, should be adopted to maximize safe apnoea time 1
• Ensure full neuromuscular blockade before tracheal intubation is attempted, using a peripheral nerve stimulator or waiting 1 minute 1
• Have a vasopressor for bolus or infusion immediately available for managing hypotension 1

Equipment Preparation

• Use a videolaryngoscope with a separate screen to enable the operator to stay further from the airway 1
• Intubate with a tracheal tube size 7.0-8.0 mm internal diameter (ID) in women or 8.0-9.0 mm ID in men, in line with local practice 1
• Use a tracheal tube with a subglottic suction port where possible 1

From the Research

Essential Items to Check Prior to Endotracheal Intubation (ETI)

The following essential items should be checked prior to ETI:

• Patient evaluation, including assessment for difficult laryngoscopy 2, 3
• Normalization of vital signs prior to intubation 2
• Evaluation for difficult airway predictors, such as HEAVEN criteria 3
• Preparation of necessary equipment and personnel 4, 5
• Use of personal protective equipment (PPE) to minimize exposure risk, particularly in high-risk situations such as COVID-19 patients 5
• Verification of patient identity and procedure to be performed 4

Pre-Intubation Checklist

A pre-intubation checklist can improve the safety of ETI by:

• Reducing intubation-related complications 4
• Improving adherence to safety process measures 4, 2
• Increasing first-pass success rates 3
• Reducing peri-intubation hypoxia 3
• Minimizing aerosolization of secretions and exposure risk 5

Benefits of Checklists

The use of checklists prior to ETI has been shown to:

• Improve patient safety 4, 2, 3
• Reduce complications and adverse events 4, 3
• Increase efficiency and accuracy of airway management 2, 3
• Provide a practical tool for bedside practitioners 5