Is aspiration during rapid sequence induction (RSI) of anesthesia an indication of malpractice?

Is Aspiration During RSI an Indication of Malpractice?

Aspiration during rapid sequence induction is not automatically an indication of malpractice, as even properly performed RSI with cricoid pressure does not provide 100% protection against aspiration. 1

Understanding the Baseline Risk

The occurrence of aspiration during RSI must be understood in the context of its inherent risk profile, even with optimal technique:

• Modern aspiration rates are approximately 1 in 7,000 for elective patients, with mortality at 1:1,000 1
• Emergency surgery carries higher risk at approximately 1:900 cases 1
• The UK's NAP4 audit documented 36 cases of aspiration of gastric contents in 2,872,600 general anesthetics, resulting in 8 deaths—making aspiration the single most common cause of anesthesia-related death 1
• Critically, NAP4 concluded that RSI with cricoid pressure remains the standard for at-risk patients despite not providing 100% protection 1

When Aspiration May Indicate Substandard Care

Malpractice considerations arise primarily from omission of appropriate precautions rather than from aspiration occurrence itself:

• NAP4 identified several cases where omission of RSI with cricoid pressure despite strong indications was followed by patient harm or death from aspiration 1
• Failure to identify patients requiring RSI (those with <2 hours liquid fasting, <6 hours food fasting, acute vomiting, ileus, absent protective reflexes, gastrointestinal disorders, or pregnancy after 3rd trimester) 2
• Inadequate pre-oxygenation (failing to achieve FetO2 >0.9 with 3-5 minutes of 100% oxygen at >10 L/min flow) 2
• Failure to achieve deep anesthesia and muscle relaxation before intubation, leading to coughing or choking 2, 3
• Lack of supervision: three factors reduce aspiration risk—expertise, support from experienced anesthesiologist, and close monitoring of inexperienced practitioners 2

Essential Components That Define Standard of Care

The following elements constitute appropriate RSI technique:

• Pharmacologic approach: Use of fast-acting muscle relaxants—succinylcholine 1-2 mg/kg or rocuronium 0.9-1.2 mg/kg 4, 2
• Pre-treatment: Antacids (sodium citrate) for high-risk patients or proton pump inhibitors/H2 blockers the evening before for others 2
• Positioning and equipment: Optimized upper body elevation, adequate equipment availability 2
• Team composition: RSI should ideally be performed by three persons with trainee supervision by a consultant 5

Critical Nuance: Modified RSI in Special Populations

In pediatric patients and pregnant women, the classical "induction-apnea-intubation" approach may itself constitute substandard care due to hypoxemia risk:

• French guidelines recommend "controlled" or "modified" RSI with gentle bag-mask ventilation (peak inspiratory pressure <15 cmH2O) to prevent hypoxemia 4
• This modified approach has shown decreased hypoxemia, hemodynamic complications, and difficult intubation with no observed aspiration events in retrospective studies 4
• Failure to provide continuous oxygenation in these vulnerable populations could be considered inappropriate 3

The Cricoid Pressure Controversy

The role of cricoid pressure has evolved and is no longer universally considered mandatory:

• NAP4 found no cases where cricoid pressure led to major complications 1
• However, cricoid pressure can cause airway obstruction, impede intubation (failed intubation is almost 8 times more frequent during RSI), and paradoxically trigger vomiting if applied incorrectly 1
• If active vomiting occurs with cricoid pressure applied, it should be removed immediately 1
• Some current guidelines no longer include cricoid pressure for pediatric aspiration-risk patients 4

Legal and Clinical Bottom Line

Aspiration occurrence alone does not equal malpractice—the determination hinges on whether:

1. The patient was appropriately identified as requiring RSI 2
2. Proper technique was employed (adequate pre-oxygenation, appropriate medications, deep anesthesia before intubation) 2, 4
3. Appropriate supervision and expertise were present 2, 5
4. Population-specific modifications were applied when indicated (pediatrics, pregnancy) 4, 3

The majority of aspiration events actually occur during maintenance or extubation rather than induction, further supporting that induction aspiration alone is not inherently negligent 1.