Anesthesia

1. RAPID SEQUENCE INDUCTION
AND INTUBATION (RSII)
DR RAMAN GHIMIRE

2. RSII
Rapid sequence induction and intubation (RSII) for anesthesia is
a technique designed to minimize the chance of pulmonary
aspiration in patients who are at higher than normal risk.
• Pre-filling the patient's lungs with a high concentration
of oxygen
• Rapid-onset sedative or hypnotic and NMBA that induce
prompt unconsciousness and paralysis
• Applying cricoid pressure
• Inserting an endotracheal tube with minimal delay
• Avoiding use of BVM ventillation

3. CLASSICAL RSI
RSI was originally described in 1961 by Sellick1 as:
• Emptying of the stomach via a gastric tube which is then
removed
• Pre-oxygenation
• Positioning the patient supine with a head-down tilt
• weight-based doses of an induction agent
• Induction of anaesthesia with a barbiturate (e.g. thiopentone)
or volatile,
• Rapid-acting muscle relaxant (e.g. suxamethonium)
• Application of cricoid pressure
• Laryngoscopy and intubation of the trachea with a cuffed
tube immediately following fasciculations
• Avoidance of BVM ventilation

4. MODIFIED RSII
• Omitting the placement of an OG/NG tube
• Supine or ramped positioning
• Titrating the dose of induction agent to loss of consciousness
• Use of propofol, ketamine, midazolam or etomidate to induce
anaesthesia
• Use of high-dose rocuronium as a NMBA
• Omitting cricoid pressure
• BVM before intubation ( <20 cmH2O)

5. General indications
Patients with a full stomach:
 Patients undergoing emergency surgery
 Patients who have sustained trauma, regardless of the interval since
last oral intake
 Patients who have not fasted according to preoperative fasting
guidelines
Patients with gastrointestinal pathology:
 Gastroparesis
 Small bowel obstruction
 Gastric outlet obstruction
 Esophageal stricture
 GERD
Patients with increased intraabdominal pressure,
 Morbid obesity
 Ascites
 Pregnancy after 20 weeks gestation

6. CONTRAINDICATIONS
Absolute :
• Total upper airway obstruction
• Total loss of facial/oropharyngeal landmarks
(requires a surgical airway)
Relative:
• Anticipated "difficult" airway
(BVM , Awake intubation ,VAL ,difficult airway adjuncts )
• The "crash" airway: unconscious + apneoic
( BVM + intubation )

7. STEPS OF RSII

8. PREPARATION
@ STOP MAID
Airway assessment :
L : Look externally
E : Evaluate the 3-3-2 rule
M : Mallampati classification
O : Obstruction
N : Neck mobility

9. PREOXYGENATION
Replace nitrogen that forms the majority of the functional residual
capacity with oxygen
“Nitrogen washout oxygen wash in”
Goals:
• To increase oxygen reserve and provide additional time to secure
the airway
• To prevent the need of mask ventilation
Methods:
• 3-5 minutes of 100% O2 via tight fitting face mask ( non rebreather )
• 8 deep breaths over 1min
(Maintains SPO2 least 90% for up to 8 minutes)
• Apneic oxygnation : oxygen via NC :10 L/min during laryngoscopy
• CPAP :Morbidly obese patients

10. PREMEDICATION
Goals:
• To relieve anxiety
• To reduce the volume or increase the pH of stomach contents
• To blunt or eliminate the physiologic response to airway management
 ↑ HR/BP
 Bronchospasm
 Increased ICP
 Muscle Fasciculation
• Anxiolytics : benzodiazepine (eg, midazolam up to 1 to 2 mg IV)
• Antacids :Clear, nonparticulate oral antacid eg, sodium citrate-citric acid
• Histamine-2 receptor antagonist : Ranitidine 50 mg IV /famotidine20 mg IV
• Prokinetic agent : Inj Metoclopramide 10mg iv
 increases lower esophageal sphincter tone
 induces peristalsis, and enhances stomach emptying.
 antiemetic :prevent PONV

11. Lidocaine :1 -1.5 mg/kg IV
 to blunt the sympathetic response
to laryngoscopy
 suppress the cough reflex
Opioids : Fentanyl :1- 3mcg/kg IV
Remifentanyl :0.5-1
mcg/kg/min
 analgesia and sedation
 blunt pressor response
Atropine: 0.02mg/kg
Neonates and Children <5 years
Not routinely used in adult
Blunts vagal response caused
by succinylcholine and laryngoscopy
 Limits secretions
Defasciculation
Succinylcholine causes
 fasciculations
 myalgias
 increase in intragastric pressure
defasciculating dose : 10 % of induction
dose of NonDepolarizing NMBA
0.01 mg/kg for vecuronium
@LOAD

12. INDUCTION
Goal:
• Facilitate LOC in one-arm-brain circulation time
• Minimize the time from LOC to intubation

13. PARALYSIS
Ideal:
• Rapid onset of action to minimize risk of aspiration & hypoxia
• Rapid recovery to facilitate the return of ventilation if
intubation fails
• Minimal haemodynamic & systemic effect
Suxamethonium Rocuronium Cisatracurium
Dose 1-2mg/kg 1-1.2mg/kg 0.2mg/kg
Onset 45-60 sec 60-75 sec 2-3 min
Duration 8-10min 30-60 min 55-65min
Other Caution: hyperkalemia
CKD, burn , NM disease
Sugammadex :
reversal of NMB

14. POSITIONING
• Sniffing position
(neck flexion ,head extension with head elevation of 3 to 7 cm).
• Obese patients may require a ramped position
• 20 degrees head up to prevent passive regurgitation
Ear --- sternal notch in straight line
Ramp position

15. CRICOID PRESSURE DURING RSII
(Sellick's maneuver)

16. • Cricoid cartilage ring is pressed backward by an assistant
against the underlying cervical vertebrae
• Occludes the lumen of the esophagus & prevent regurgitation
of stomach contents
• Force : 10 Newtons :awake & upto 30 Newtons : LOC
• Released if intubation proves difficult and/or mask ventilation
C/I :
C-spine injury
ant. neck trauma
active vomitting
FB neck

17. Controversies
• The application of cricoid pressure displaced the esophagus
laterally in 90 percent of subjects
• Worsened Cormack Lehane grade view during laryngoscopy
• No difference in the incidence of aspiration
• Reduced lower oesophageal sphincter tone and therefore
increasing reflux risk
• Median intubation time was longer in patients who had
cricoid pressure applied
In most situations, “it is not harmful and may be beneficial”.

18. PLACEMENT (INTUBATION)
• Cuffed tube of appropriate size
• Cricoid pressure continued ,released if view is obscured
• Placement of tube is confirmed ,and fixed
• Cricoid pressure released after inflation of ET tube’s cuff
•

19. Confirmation of placement of ET tube:
• Direct visualization of ETT passing through vocal cords
• Chest rise/fall with each ventilation (bilateral)
• Five-point auscultation
• ET CO2 measurement
• Monitor O2 saturation
• Condensation of tube
• Radiological : CXR , USG

20. POST INTUBATION CARE
• Monitoring: ECG ,SPO2 ,NIBP ,Capnograph
• Initiate mechanical ventilation
• NG/OG tube
• CXR
• ABG Post intubation
• Maintenance of sedation & NMB
EMERGENCE FROM ANESTHESIA
• High risk of aspiration during emergence from anesthesia
• NG/OG suctioned and removed immediately prior to
emergence
• Postpone extubation until airway reflexes return.
• Transported to recovery room with head of the bed elevated

21. POTENTIAL COMPLICATIONS OF RSII
• Difficult or failed airway
• Hypoxia ; Obese patients, pregnant patients, and patients with
pulmonary disease
• Hypotension
• Regurgitation and Aspiration

22. MCQs
1. Agents of choice for RSII in 20yrs /M undergoing Em
laparotomy for hollow viscus perforation .(intake of last
meal 3hrs back)
BP: 90/60,K/C/O Beckers muscular dystrophy
A. Remifentanyl, Vecuronium
B. Propofol ,Rocuronium
C. Ketamine ,succinylcholine
D. Ketamine ,Rocuronium
ANS : D
Ketamine : Increases BP
Succinylcholine avoided in muscular dystrophy risk of
hyperkalemia

23. MCQs
2. Which of the following is NOT TRUE regarding Sellick's
maneuver?
A. Cricoid pressure.
B. Component of RSII
C. Prevents regurgitation and aspiration
D. Improves quality of laryngoscopic view
ANS: D
• Cricoid pressure worsens Cormack Lehane grade view during
laryngoscopy
• "BURP" manoeuvre improves laryngoscopic view
(Backwards Upwards Rightwards Pressure on thyroid cartilage )

24. ModifiedCormack-Lehaneclassification
views obtained by direct laryngoscopy based on the structures seen

25. MCQs
3. Best method to confirm ET tube placement is
A. Chest rise
B. Capnograph
C. O2 saturation
D. Condensation of tube
ANS: B

26. REFERENCES
• Uptodate
• PubMed : Cricoid pressure and the pressor response to tracheal
intubation.Mills P, Poole T, Curran J Anaesthesia. 1988;43(9):788
• Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid
Sequence Induction of Anesthesia: The IRIS Randomized Clinical
Trial.Birenbaum A, Hajage D, Roche S, Ntouba A, Eurin M, Cuvillon P, Rohn A,
Compere V, Benhamou D, Biais M, Menut R, Benachi S, Lenfant F, Riou
B JAMA Surg. 2018
• Preoxygenation, reoxygenation, and delayed sequence intubation in the
emergency department.J Emerg Med. 2011; 40(6):661-7(ISSN: 0736-4679)
• Should the routine use of atropine before succinylcholine in children be
reconsidered?Can J Anaesth. 1995; 42(8):724-9 (ISSN: 0832-610X)

27. THANK YOU
# 10 years challenge