What is the process and significance of rapid endotracheal intubation (Fast intubation)?

From the Guidelines

Rapid sequence intubation (RSI) is a critical medical procedure that should be performed with the administration of a sedative-hypnotic agent and a fast-acting neuromuscular-blocking agent in rapid succession, along with the placement of an endotracheal tube, to reduce the risk of aspiration and optimize intubating conditions in critically ill adult patients. The process of RSI begins with pre-oxygenation for 3-5 minutes using 100% oxygen via a non-rebreather mask or bag-valve-mask 1.

Key Steps in RSI

• Pre-oxygenation to minimize hypoxemia risk
• Administration of a sedative agent such as etomidate, ketamine, or propofol, followed by a neuromuscular blocking agent like succinylcholine or rocuronium
• Application of cricoid pressure (Sellick maneuver) if deemed necessary, though its use is becoming less common
• Performance of laryngoscopy using either direct or video laryngoscopy within 45-60 seconds
• Confirmation of proper tube placement using end-tidal CO2 detection, chest rise observation, and auscultation

The choice between succinylcholine and rocuronium as the neuromuscular blocking agent depends on several factors, including the patient's medical history and the presence of any contractions or allergies 1. The use of videolaryngoscopy is recommended in the first instance to facilitate tracheal intubation and reduce the risk of intubation failure, especially in emergency conditions 1.

Importance of RSI

• Reduces the risk of aspiration in at-risk patients
• Optimizes intubating conditions to minimize difficult or failed airways
• Essential for emergency airway management in critically ill patients
• Requires careful assessment for difficult airway characteristics and preparation of backup devices and suction

In real-life clinical practice, the decision to perform RSI should be made with caution, considering the patient's overall condition, potential risks, and benefits, and always prioritizing morbidity, mortality, and quality of life as outcomes 1.

From the FDA Drug Label

In appropriately premedicated and adequately anesthetized patients, rocuronium bromide injection 0.6 to 1.2 mg/kg will provide excellent or good intubating conditions in most patients in less than 2 minutes [see CLINICAL STUDIES (14.1)]. 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. Excellent or good intubating conditions were achieved in 119/120 (99% [95% confidence interval 95% to 99.9%]) patients receiving rocuronium bromide and in 108/110 (98% [94% to 99.8%]) patients receiving succinylcholine.

The process of rapid endotracheal intubation (Fast intubation) involves administering a dose of rocuronium bromide injection (0.6 to 1.2 mg/kg) to provide excellent or good intubating conditions in most patients in less than 2 minutes.

• Key factors for successful rapid sequence intubation include:
  • Appropriate premedication
  • Adequate anesthesia
  • Administration of rocuronium bromide injection at a dose of 0.6 to 1.2 mg/kg
• Significance: Rapid endotracheal intubation is crucial in emergency situations where quick and secure airway management is necessary. The use of rocuronium bromide injection facilitates this process by providing excellent intubating conditions in a short period, allowing for safe and effective airway management 2.

From the Research

Process of Rapid Endotracheal Intubation

• Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation 3, 4.
• The steps involved in the intubation process include pretreatment, induction, paralysis, and post-intubation sedation and analgesia 3.
• Pretreatment medications such as atropine, lidocaine, and fentanyl may be used, but their use has fallen out of favor due to limited evidence for their effectiveness outside of select clinical scenarios 3.
• Induction agents such as etomidate and ketamine are commonly used due to their favorable hemodynamic profiles 3, 5.
• Neuromuscular blocking agents such as succinylcholine and rocuronium are preferred, with the selection based on patient-specific factors, half-life, and adverse effect profiles 3, 6, 7.

Significance of Rapid Endotracheal Intubation

• RSI is the most common and preferred method for intubation of patients presenting to the emergency department (ED) 3.
• A standardized RSI protocol can facilitate airway management in critically injured patients and reduce the need for medication redosing and medication-related hypotension 5.
• The use of a standardized RSI medication protocol can simplify the intubation process and allow for efficient airway management of critically injured trauma patients in the ED 5.
• The selection of appropriate sedative and neuromuscular blocker during RSI can be facilitated by an ED pharmacist, and the optimal selection, dosing, and administration of RSI medications is critical for success 3, 4.
• Studies have compared the effectiveness of different medications, such as succinylcholine and rocuronium, for RSI, with varying results 6, 7.