Is a rapid sequence induction in the supine position for an adult patient with a small bowel obstruction, possibly with a history of abdominal surgery or underlying conditions such as cancer or inflammatory bowel disease (IBD), a deviation from the standard of care and considered malpractice?

Rapid Sequence Induction in Supine Position for Small Bowel Obstruction: Standard of Care Analysis

Performing rapid sequence induction (RSI) in the supine position for a patient with small bowel obstruction is the standard of care and is NOT malpractice. 1

Standard Anesthetic Approach for Emergency Laparotomy

Rapid sequence induction and intubation (RSII) is explicitly recommended as standard practice for patients undergoing emergency laparotomy, including those with small bowel obstruction. 1 The 2023 Enhanced Recovery After Surgery (ERAS) Society consensus guidelines for emergency laparotomy state that patients undergoing emergency laparotomy are at particularly high risk of aspiration after regurgitation of gastric contents due to bowel and stomach obstruction and distension, sepsis, opioids, and the emergency nature of surgery. 1

Key Technical Components of Standard RSI

• Fast-acting muscle relaxants are strongly recommended: The European Society of Anaesthesiology and Intensive Care makes a strong recommendation (based on moderate evidence) for using succinylcholine 1-2 mg/kg or rocuronium 0.9-1.2 mg/kg for RSII. 1

• Cricoid pressure application varies by jurisdiction: The use of cricoid pressure should follow current standard practice in the anesthesia practitioner's respective country (e.g., UK guidelines and 2015 Difficult Airway Society Guidelines), though practice varies internationally and cricoid pressure should be released if direct laryngoscopy is difficult. 1

• Supine positioning is standard: There is no guideline recommendation requiring alternative positioning (such as reverse Trendelenburg or head-up position) for RSI in small bowel obstruction patients. 1

Clinical Context Supporting Standard RSI

High Aspiration Risk Justifies RSI Approach

Patients with small bowel obstruction have multiple risk factors that mandate airway protection via RSI: 1

• Bowel and stomach obstruction with distension
• Emergency surgical timing preventing adequate fasting
• Potential sepsis affecting gastric emptying
• Opioid administration for pain control

Surgical Urgency Considerations

The decision for immediate vs. delayed surgery depends on clinical presentation, not anesthetic technique: 1

• Patients with signs of peritonitis, strangulation, or ischemia require urgent surgical intervention regardless of positioning during induction. 1
• Hemodynamically unstable patients require open surgical approach but this relates to surgical technique, not anesthetic induction positioning. 1
• The 70-90% of patients who can be managed conservatively are not undergoing surgery at all. 1, 2

Common Pitfalls and Caveats

What Would Constitute Deviation from Standard of Care

The following would represent actual deviations from standard anesthetic care: 1

• Failing to perform RSI in a patient with known bowel obstruction and instead using standard induction with mask ventilation prior to intubation
• Inadequate preoxygenation before induction
• Using inadequate doses of muscle relaxants (e.g., rocuronium <0.9 mg/kg when using it as alternative to succinylcholine)
• Failing to have appropriate airway equipment and backup plans available

Patient-Specific Modifications

While supine RSI is standard, the anesthesiologist must still assess for factors requiring technique modification: 1

• Anticipated difficult airway may require awake fiberoptic intubation rather than RSI
• Severe hemodynamic instability may require modified drug dosing (not positioning changes)
• Massive abdominal distension causing respiratory compromise may benefit from gastric decompression via nasogastric tube prior to induction, but this does not change the supine positioning for RSI itself

Evidence Quality Assessment

The 2023 ERAS Society guidelines represent the most recent, high-quality consensus specifically addressing anesthetic management for emergency laparotomy. 1 These guidelines explicitly describe RSII as standard practice for this patient population without any recommendation for alternative positioning. 1 The World Journal of Emergency Surgery guidelines (2021) focus on surgical decision-making and approach but defer to standard anesthetic principles for airway management. 1

No guideline or high-quality evidence suggests that supine positioning during RSI for small bowel obstruction represents substandard care or increases patient risk when proper RSI technique is employed. 1