What is the correct medication and procedural sequence for rapid‑sequence induction of general anesthesia for a cesarean delivery in an obese, short‑neck, gravida 2 para 1 patient with prior spine surgery who cannot receive regional anesthesia?

Correct Rapid Sequence Induction Protocol for Cesarean Section in High-Risk Obstetric Patient

The Sequence You Witnessed Was Dangerously Wrong

The procedure you described violates every major guideline for obstetric general anesthesia and places both mother and fetus at unacceptable risk of aspiration, awareness, and failed airway management. 1, 2 The administration of atracurium before induction agents and allowing surgical incision before intubation represents a catastrophic deviation from evidence-based practice that could result in maternal death.

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The Correct RSI Sequence for Cesarean Section

Pre-Induction Preparation (Before ANY Medications)

1. Patient Positioning

• Place patient in 20-30° head-up position with left uterine displacement to prevent aortocaval compression 1, 3
• In obese patients with short neck, use "ramped" position aligning external auditory meatus with suprasternal notch 1
• This positioning must occur BEFORE any medications are given 1

2. Pre-Oxygenation (3 Minutes Minimum)

• Apply tight-fitting facemask with 100% oxygen at fresh gas flow ≥10 L/min for 2-3 minutes 1, 2
• Target end-tidal oxygen fraction (FetO₂) ≥0.9 1, 2
• Consider nasal cannulae at 5 L/min for apneic oxygenation during laryngoscopy 2
• This MUST be completed before any induction agents 1, 2

3. Team Briefing

• Confirm "wake vs. proceed" decision if intubation fails 2, 4
• Ensure difficult airway equipment immediately available (videolaryngoscope, supraglottic devices, front-of-neck access kit) 4

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The Correct Medication Sequence

Step 1: Induction Agent (FIRST medication given)

• Propofol 2-2.5 mg/kg (approximately 200 mg for average-weight patient) 2, 5, 6
• This is given FIRST to ensure loss of consciousness before paralysis 2, 5

Step 2: Neuromuscular Blocker (IMMEDIATELY after propofol)

• Rocuronium 0.6-1.0 mg/kg OR Succinylcholine 1.0 mg/kg 2, 5, 6
• For your 50 mg atracurium dose: This is inadequate and wrong agent - atracurium has slower onset (3-5 minutes) versus rocuronium/succinylcholine (45-60 seconds) 5, 7

Step 3: Cricoid Pressure Application

• Apply 10 N initially, then 30 N after loss of consciousness 2
• Maintain until airway is secured 2
• Release if intubation becomes difficult 5

Step 4: NO Positive Pressure Ventilation

• Do NOT ventilate unless "can't intubate, can't oxygenate" scenario 2
• Apneic oxygenation via nasal cannulae continues 2

Step 5: Intubation (45-60 seconds after rocuronium/succinylcholine)

• Perform laryngoscopy and intubate trachea 1, 2
• Confirm placement with capnography 1

Step 6: ONLY AFTER Airway Secured - Surgery May Begin

• Surgical incision occurs ONLY after confirmed endotracheal intubation 1, 2

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Critical Errors in the Sequence You Witnessed

Error #1: Fentanyl 100 mcg Given First

• Problem: Opioids are NOT part of standard RSI for cesarean section 2, 5, 6
• Exception: Short-acting opioids (remifentanil, NOT fentanyl) may be considered in severe preeclampsia to blunt hypertensive response to intubation 5, 6
• Your patient: G2P1 with preeclampsia - remifentanil 0.5-1 mcg/kg could be justified, but fentanyl 100 mcg is inappropriate timing and agent 5

Error #2: Atracurium 50 mg Before Propofol

• Problem: This paralyzes the patient while AWAKE - guaranteeing awareness and inability to protect airway 2, 5
• Correct: Neuromuscular blocker comes AFTER induction agent 2, 5, 6
• Additional problem: Atracurium has 3-5 minute onset; rocuronium/succinylcholine have 45-60 second onset 5, 7

Error #3: Propofol After Paralysis

• Problem: Patient is paralyzed but potentially conscious - this guarantees awareness 5, 6
• Correct: Propofol must be given FIRST to ensure unconsciousness 2, 5

Error #4: Surgical Incision Before Intubation

• Problem: This is the most dangerous error - unprotected airway during surgical stimulation with paralyzed patient 1, 2
• Aspiration risk: Massively increased with unprotected airway during abdominal manipulation 1, 2
• Awareness risk: Surgical stimulation before adequate anesthetic depth 5, 6
• Correct: Surgery begins ONLY after confirmed endotracheal intubation 1, 2

Error #5: Skin Prep and Local Anesthesia During Induction

• Problem: Distracts team during critical airway management period 1
• Correct: Theatre team should minimize noise and activity during induction 1
• Skin prep: Should be completed BEFORE induction begins 3

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What Should Have Happened: Step-by-Step

Pre-Theatre (15-20 minutes before):

1. Airway assessment documented (Mallampati, thyromental distance, neck extension, mouth opening) 1, 4
2. H₂-receptor antagonist IV (if not already given) 1, 4
3. Sodium citrate 30 mL PO 1, 4
4. Skin preparation with chlorhexidine-alcohol 3
5. Team briefing: "wake vs. proceed" decision, difficult airway plan 2, 4

In Theatre (Before Induction):

1. Patient positions herself on table in ramped position (obese, short neck) 1
2. Left uterine displacement applied 3
3. Monitoring: ECG, BP, SpO₂, capnography ready 4
4. Difficult airway equipment checked and immediately available 4
5. Suction ready 1

Induction Sequence (Total time: 2-3 minutes):

1. Pre-oxygenation: 100% O₂ via tight-fitting mask, 3 minutes, FetO₂ ≥0.9 1, 2
2. Nasal cannulae: 5 L/min O₂ applied 2
3. Propofol 2-2.5 mg/kg IV push (e.g., 200 mg) 2, 5
4. Rocuronium 1.0 mg/kg IV push (e.g., 80-100 mg) OR Succinylcholine 1.0 mg/kg 2, 5
5. Cricoid pressure: 10 N initially, 30 N after loss of consciousness 2
6. Wait 45-60 seconds (no ventilation unless SpO₂ drops) 2
7. Laryngoscopy and intubation 1, 2
8. Confirm placement: Capnography, auscultation 1
9. Release cricoid pressure 2
10. NOW surgical incision may begin 1, 2

Maintenance:

• Sevoflurane >0.7 MAC OR propofol infusion 5, 6
• Avoid awareness: maintain adequate anesthetic depth throughout 5, 6

Post-Delivery:

• Oxytocin 5-10 units slow IV (NOT bolus) 3
• Multimodal analgesia: paracetamol IV, NSAIDs IV, consider low-dose ketamine 3

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Regarding TXA and Citicoline

Tranexamic Acid (TXA):

• Timing: Given within 3 hours of delivery if postpartum hemorrhage occurs OR prophylactically before incision in high-risk cases 3
• Dose: 1 gram IV over 10 minutes 3
• NOT part of routine RSI sequence 3

Citicoline:

• No role in cesarean section anesthesia - this is a neuroprotective agent used for stroke/cognitive disorders
• Not mentioned in any obstetric anesthesia guideline 1, 2, 3
• Likely error or confusion with another medication

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Special Considerations for Your Patient

Obesity + Short Neck + Previous Spine Surgery:

• Regional anesthesia contraindicated due to spine surgery - you correctly identified this 1
• High-risk airway: Obesity and short neck predict difficult intubation 1
• Ramped positioning mandatory: Aligns external auditory meatus with suprasternal notch 1
• Videolaryngoscopy should be first-line: Higher success rate in obese patients 1, 8
• Senior anesthetist required: OS-MRS score likely >3 1
• Extended pre-oxygenation: Obese patients desaturate faster 1

Preeclampsia:

• Consider remifentanil 0.5-1 mcg/kg at induction to blunt hypertensive response (NOT fentanyl 100 mcg at wrong time) 5, 6
• Magnesium sulfate: Potentiates neuromuscular blockers - may need reduced rocuronium dose 4
• Avoid excessive fluid: Risk of pulmonary edema 4

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Why This Matters: Potential Consequences of Wrong Sequence

Maternal Risks:

• Aspiration pneumonitis: Unprotected airway during surgical stimulation (Mendelson's syndrome) 1, 6
• Awareness: Paralysis before adequate anesthesia depth 5, 6
• Failed intubation with paralyzed patient: Cannot ventilate, cannot intubate scenario 1, 2
• Hypoxic brain injury or death: Rapid desaturation in obese pregnant patient 1

Fetal Risks:

• Prolonged maternal hypoxemia: Fetal bradycardia and acidosis 1
• Delayed delivery: Incorrect sequence wastes critical time 8

Medicolegal:

• Indefensible practice: Violates every major guideline 1, 2, 5
• Standard of care breach: No expert would support this sequence 1, 2

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What You Should Do Now

Immediate Actions:

1. Document what you witnessed in detail with times 4
2. Report to department head/clinical director as patient safety concern 4
3. Do NOT replicate this sequence - it is dangerous 1, 2

System-Level:

• Request departmental protocol review for obstetric RSI 1, 2
• Simulation training for obstetric emergencies 1, 4
• Cognitive aids (checklists) posted in obstetric theatres 1, 4

Your Learning:

• You were correct to be shocked - this was dangerous practice 1, 2
• Trust evidence-based guidelines over "senior experience" when they conflict 1, 2, 5
• Speak up for patient safety even with senior colleagues 4