Rapid Sequence Induction

Question 1

What is rapid sequence induction

Answer 1

1. Induce anaesthesia
2. Paralyse patient
3. Give rapid induction agent (Suxamethonium  depolarising muscle relaxant)
4. Don’t ventilate the lungs
5. Place ETT within 30 – 60 seconds
6. Inflate cuff

Question 2

Indications for rapid sequence induction

Answer 2

• Full stomach  to prevent aspiration of stomach contents into the lungs

Question 3

Describe an ordinary induction process

Answer 3

1. Anaesthetize patient  slow injection of titrated induction agent (Propofol)
2. Administer non-depolarizing NMB (Rocuronium)
3. Wait until NMB works  2 to 3 minutes
4. Ventilate the lungs with facemask in interim  IPPV (“bag the patient”)
5. Intubate the trachea
6. Confirm tracheal placement of ETT

Question 4

Now compare with rapid sequence induction the process steps

Answer 4

1. Prepare operating room  equipment, drugs, suction
2. Prepare patient  drip, airway evaluation, position
3. Pre-oxygenate & apply cricoid pressure by dedicated, educated assistant
4. Anaesthetize patient  rapid injection with pre-calculated dose of induction agent (consequence of potential haemodynamic instability)
5. Administer depolarizing NMB  Suxamethonium
6. Wait until NMB works  30 to 45 seconds
7. Do not ventilate the lungs with facemask in interim  allow apnoea
8. Intubate the trachea with cuffed ETT & immediately inflate the cuff
9. Confirm tracheal placement of ETT

do not do RSI in patient with difficult airway!

Question 5

Equipment for RSI

Answer 5

• Anaesthesia machine  source of oxygen & IPPV
• Alternative oxygen source
• Suction
• Laryngoscope x2
• EET x2
• Introducer

Question 6

Preparation for RSI what do you need?

Answer 6

1. Airway evaluation  do not do RSI in patient with difficult airway! NB
2. Equipment
3. Assistant for cricoid pressure
4. Drugs / IV access
   - Induction agent
   - Succinylcholine
   - Pre-calculated dosages no titration

Question 7

If Suxamethonium is contraindicated:

Answer 7

Rocuronium 1 mg/kg > intubate within 1 minute (but paralysed for at least 1 hour)

Question 8

Phase 1 of RSI

Answer 8

1. Preparation
2. Pre-oxygenate to end-point  end-tidal PaO2 > 90 – 95% confirms lungs are filled with adequate oxygen reserve (NB during apnoea!)
3. Assistant identifies cricoid ring

Question 9

Phase 2 RSI

Answer 9

1. Induction > rapid injection of induction agent & Suxamethonium
2. Cricoid pressure is applied & oxygen mask is maintained
3. No facemask ventilation is applied

Question 10

Phase 3 RSI

Answer 10

1. Laryngoscopy after 45 seconds
2. Confirm intubation
3. Release cricoid pressure

Question 11

Cricoid pressure:
Method:

Answer 11

• Identify cricoid while patient is awake, then push on ring of cartilage to compress oesophagus posteriorly against the vertebrae  and then hopefully the patient cannot regurgitate
  o Cricoid ring is pressed against C6 to occlude oesophagus
• Induction agent
• press as hard as you would to make the bridge of your nose sore