RAPID SEQUENCE INTUBATION

1. RAPID SEQUENCE
INTUBATION (RSI)
Dr Khairunnisa Binti Azman
Dept of Anaesthesiology TGH

2. DEFINITION
• An established method of inducing
anaesthesia with precalculated drug in
patient who are at risk of aspiration of gastric
contents into the lungs with application of
cricoid pressure
• Aim: To intubate the trachea as quickly &
safely as possible
• Employed daily especially during emergency
surgery

3. Indications of RSI:
Patient with high risk of aspirations:
• Abdominal pathology (ileus, I/O)
• Delayed gastric emptying (Pain, trauma, opioids,
alcohol, vagotomy)
• Incompetent lower esophageal spchinter, hiatus
hernia, GERD
• Altered concious level  Impaired laryngeal reflex
• Neurological/neuromuscular ds
• Pregnancy
• Difficult airway

4. The Six ‘P’s of RSI
• Preparation
• Pre-Oxygenation with 100% oxygen
• Pretreatment & Induction
• Paralysis + Cricoid pressure
• Placement of the tube
• Post intubation management & stratergy of
failed intubation

5. PREPARATION
• Assess patient  Any features of difficult
intubation?
• IV Access  Adequate & Functioning
• Monitor
• Gather:
– Equipment for intubation
– Post intubation medication
– Patient history
– Supplies for surgical airway

6. Pre-Oxygenation
Goals:
• Establish O2 reservoir
• Maximize time for intubation
• Prevent need for bag-mask ventilation
Methods:
• 3-5 minutes of 100% O2 via face mask
• 5 Tidal capacity (5 Breaths)

7. Pre-Treatment
Goals:
• Mitigate adverse physiologic reactions to
intubation
– Symphatetic “pressor response”
• Manipulation of airway, ↑ HR/BP,
– Bronchospasm
– Increased ICP
– Muscle Fasciculation
• Begins 2-3 minutes PRIOR to induction/Paralysis
– Not routinely Practised
– “LOAD”

8. LIDOCAINE:
• Dose: 1.5mg/kg (IV)
• To prevent ↑ ICP by:
> Prevent cough
> Blunting pressure response
- May reduce reactive bronchospasm
in asthma
OPIOID:
• IV Fentanyl 3mcg/kg
• Provides analgesia & reduces anxiety
• Lessen pressor response:
> Limits ↑ ICP
> More effective than lidocaine
ATROPINE:
• Dose: 0.02mg/kg
• To prevent bradycardia caused by
airway manipulation &
Succinylcholine
• Usually used in paediatric
DEFASCICULATING AGENT:
• Fasciculations occur in >90% of patients
given succinylcholine
> Muscle pain
> Increase intragastric pressure emesis
> Increase ICP
• Preventions:
> Higher dose of Scholine (1.5mg/kg)

9. INDUCTION
• Given as rapid IV push immediately before
paralysing agent
• Facilitate LOC in one-arm-brain circulation
time  minimize the time from LOC to
intubation
• Should provide a rapid onset & a rapid
recovery from anaesthesia with minimal CVS
& Systemic side effect.

10. INDUCTION

11. Paralysis/NMB Agent
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

12. Suxamethonium:
• Rapid onset & offset of action
Rocuronium:
• Rapid onset but duration of action much
longer than sux
- Wait for relaxation
- Do not bag unless hypoxic
- Insuflate air into the stomach & increase risk of
vomiting/aspiration

13. Techniques
Cricoid Pressure:
• The oesophagus is occluded by extension of
the neck & application of pressure over the
cricoid cartilage againsts the body of 5th
cervical vertebra to obliterate oesophageal
lumen
• Applied an assisstant with thumb & finger at
either side of cricoid cartilage
– Maintain until after intubation & cuff inflation.

15. Placement of tube
Tube position is confirmed by:
• Direct visualization of ET tube between the
vocal cord
• Auscultation: equal air entry
• Capnometer: EtCO2

16. POST INTUBATION CARE
• ECG
• SPO2
• NIBP/Art-line
• Capnograph
• Naso/Orogastric tube
• CXR
• ABG Post intubation
• Maintainace of sedation & NMB

18. Terminating anaesthesia
• During transition from deep anaesthesia to
full conciousness & vice versa risk of
aspiration is greatest
• Patient should be completely awake
• Performing purposeful movement &
responding to command
– Confirms patient can protect their own airway uo
removal of the cuffed tube
• Left lateral position
– Protect airway during regurgitation

19. Complications of RSI
• Failed to intubate & failed to ventilate
• Risk of anaphylaxis
• Cricoid pressure:
– Failure to occlude the oesophagus
– Distortion of larynxdisrupt view
– Oesophageal rupture during active vomiting