What is the correct sequence of steps and medications for rapid‑sequence induction to obtain a general endotracheal anesthesia for a scheduled cesarean delivery in an obese, short‑neck, pre‑eclamptic G2P1 patient who cannot receive spinal or epidural anesthesia?

Critical Errors in the Described Sequence

The sequence you witnessed contains multiple dangerous deviations from guideline-recommended rapid sequence induction for cesarean section, most critically: administering atracurium before propofol, performing surgical incision before securing the airway, and using atracurium (which has a 3-5 minute onset) instead of rocuronium or succinylcholine for RSI. 1

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The Correct RSI Sequence for This High-Risk Patient

Step 1: Pre-Induction Positioning and Preparation (BEFORE any medications)

• Position the patient in 20-30° head-up with left uterine displacement BEFORE administering any drugs to prevent aortocaval compression and increase functional residual capacity 2, 3
• Use "ramped" positioning in this obese, short-neck patient—align the external auditory meatus with the suprasternal notch to optimize laryngoscopy view and airway patency 2, 1
• Complete a minimum 3 minutes of tight-fitting mask pre-oxygenation with 100% O₂ at ≥10 L/min, targeting end-tidal O₂ ≥0.9 before any induction agent 2, 1
• Confirm difficult airway equipment (videolaryngoscope, supraglottic device, front-of-neck access kit) is immediately available 1

Step 2: Induction Agent FIRST

• Administer Propofol 2-2.5 mg/kg IV FIRST to ensure loss of consciousness before any paralysis 1
• In this pre-eclamptic patient, consider adding Remifentanil 0.5-1 µg/kg (NOT fentanyl 100 mcg) at induction to blunt the hypertensive response to laryngoscopy 1

Step 3: Neuromuscular Blocker IMMEDIATELY After Propofol

• Give Rocuronium 0.6-1.0 mg/kg IV OR Succinylcholine 1.0 mg/kg IV immediately after propofol 1, 4
• NEVER use atracurium for RSI—its 3-5 minute onset is incompatible with rapid sequence technique 1
• Note: If the patient is on magnesium sulfate for pre-eclampsia, consider reducing rocuronium dose due to potentiation 1

Step 4: Cricoid Pressure

• Apply cricoid pressure at 10 N initially, increase to 30 N after loss of consciousness, maintain until airway is secured 1
• Release cricoid pressure if intubation becomes difficult 1

Step 5: Intubation (45-60 seconds after neuromuscular blocker)

• Perform endotracheal intubation 45-60 seconds after rocuronium/succinylcholine 1
• Use videolaryngoscopy as first-line in this obese, short-neck patient 1
• Avoid positive-pressure ventilation during apnea unless "can't intubate, can't oxygenate" occurs 1

Step 6: Confirm Tube Placement BEFORE Surgery

• Confirm endotracheal tube placement with capnography and bilateral chest auscultation 1
• Surgical incision may commence ONLY after confirmed tube placement and stable ventilation 1

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Why the Sequence You Witnessed Was Dangerous

Atracurium Before Propofol = Awareness Risk

• Paralyzing the patient before achieving unconsciousness creates extremely high risk of intra-operative awareness 1
• This is one of the most serious anesthetic complications in obstetrics 1

Atracurium Instead of Rocuronium/Succinylcholine = Prolonged Apnea

• Atracurium has a 3-5 minute onset, leaving the patient apneic and unintubated for an unacceptably long period 1
• Obese pregnant patients desaturate rapidly—this patient would likely become severely hypoxemic before intubation conditions develop 2, 3

Surgical Incision Before Intubation = Aspiration Risk

• Performing surgical incision before securing the airway markedly increases risk of aspiration pneumonitis (Mendelson's syndrome) and maternal hypoxemia 1
• This can lead to fetal bradycardia, acidosis, and possible brain injury 1

Fentanyl 100 mcg During Pre-Oxygenation = Wrong Timing and Agent

• Fentanyl should not be given during pre-oxygenation—it provides no benefit at this stage 1
• In pre-eclampsia, remifentanil 0.5-1 µg/kg at induction (not fentanyl) is recommended to blunt hypertensive response 1

Local Anesthesia and Skin Prep During Induction = Distraction

• The OAA/DAS guidelines explicitly state the theatre team should keep noise to a minimum during induction to reduce distraction 2
• Surgical preparation should be completed BEFORE induction begins 2

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Correct Medication Timing for TXA and Citicoline

• Tranexamic acid (TXA) should be given AFTER delivery of the baby to reduce postpartum hemorrhage risk without fetal exposure 2
• Citicoline has no established role in routine cesarean section anesthesia and should not be part of the standard protocol

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Special Considerations for This High-Risk Patient

Obesity + Short Neck

• Extended pre-oxygenation (≥3 minutes) is essential because obese pregnant patients desaturate rapidly during apnea 2, 1
• Ramped positioning is mandatory—this is non-negotiable in obese patients with short necks 2, 1

Pre-eclampsia

• Magnesium sulfate potentiates neuromuscular blockers—reduce rocuronium dose if patient is receiving magnesium 1
• Remifentanil (not fentanyl) at induction blunts hypertensive response to laryngoscopy 1

Previous Spinal Surgery

• Regional anesthesia is contraindicated when spinal surgery history exists—general anesthesia with proper RSI is the recommended alternative 1

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Common Pitfalls to Avoid

• Never administer neuromuscular blocker before induction agent—this guarantees awareness 1
• Never use atracurium for RSI—only rocuronium or succinylcholine have appropriate onset times 1, 4
• Never allow surgical incision before confirmed endotracheal tube placement 1
• Never skip adequate pre-oxygenation in obese patients—they will desaturate within 1-2 minutes 2, 3
• Never perform RSI in supine position in obese patients—head-up/ramped positioning is mandatory 2, 1