Rapid sequence induction (RSI) Dr. S. Parthasarathy MD., DA., DNB, Dip. Diab. DCA, Dip. Software based statistics- PhD ( physiology), IDRA

Rapid sequence induction (RSI) is a method of achieving rapid control of the airway whilst minimising the risk of regurgitation and aspiration of gastric contents. What is the concept ?

Time between loss of protective airway reflexes to insertion of cuffed endotracheal tube to be kept minimum The scenario ?? Especially Unprepared patient with a risk of aspiration

What is the difference Sedate Mask ventilation sufficient – check Make them apneic Intubate Take that risk

What is the risk of aspiration ?? 1 in 2000 to 1 in 14000 It varies But the mortality – 1 in 72000 Obtunded patients – no RSI ?? Intubate

History Stept and Safar in 1970 Conscious or unconscious patient with full stomach Intracranial pathology and trauma 15 step process for two years

Seven P s of RSI Evolved now as Preparation Pre oxygenation Pretreatment Paralyses Positioning Prove placement Post intubation management

Preparation Equipment Drugs and support staff SOAPME Suction oxygen airway evaluation pharmacology, monitors , equipment for difficult airway

Preoxygenation 100 % oxygen for 3-5 minutes 4 vital capacity breaths Pregnancy , obesity, cardio respiratory disease Elderly and children desaturate earlier

Pretreatment Atropine - ? Use. Only the second dose of succinyl choline Opioids – the original drugs were long acting – but after fentanyl and analogues – OK One tenth the dose of NDPs – but the dose of scoline – 2 mg/kg minimal – penetrating eye injury – distressing few seconds because 3 minutes is the ideal pre time – for not that emergent cases Lignocaine 1 – 2 mg/kg – used prior to the advent of newer opioids

Paralyses with induction Safar started with predetermined dose of thio and scoline 150 and 100 respectively for a 70 kg patient Intravenous induction facilitates loss of consciousness in one arm–brain circulation time, minimizing the time from loss of consciousness to intubation. Ideally, the chosen induction agent should provide a rapid onset and a rapid recovery from anaesthesia with minimal cardiovascular and systemic side effects.

Paralyses - continued Thiopentone 3- 5 mg / kg – fast Propofol 1 mg/ kg but depression of reflexes better Midaz and ketamine for shocked patients and Etomidate for hemodynamic stability Acidic relaxants and alkaline thio – precipitate – loss of IV lines

1 is ok in non precurarized patients Dose of scoline 0.6 1 1.5 to 2 1 is ok in non precurarized patients

Non depolarizers Rocuronium comes nearer Crush injury , raised ICP or IOP , hyperkalemia 0.6 mg / kg – ok intubating conditions in 1 minute But 0.9 – 1.2 means – excellent – long acting but want to reverse in CICV, suggamadex

Priming and timing One tenth of the nondepolarizer is given prior three minutes to original dose Partial weakness problem Timing – means give the full dose just prior to thiopentone

Positioning Sniffing position

Sellick maneuver Separate slides in website From the internet for closed academic purpose only

Prove Confirm and prove placement of endotracheal tube in the correct position Visual Stethoscope Capnograph

Post intubation managemant Need for mechanical ventilation Monitoring Vital signs

Modified rapid sequence induction Trial of mask ventilation Use of nondepolarizers Proseal LMA Rapid sequence induction (RSI) or Rapid sequence airway

Name Rapid sequence induction (RSI) ? Actually Rapid sequence intubation ? !

Clinical implications Emergency surgical procedures Special – peritonitis Abdominal distension Opioids Trauma alcohol Pain Ryles tube insertion may not eliminate the risks

Pregnancy Physical and physiological changes – prone Elective LSCS is RSI ( 95 % anesthesiologists prefer) Thio and scoline obvious choice Rocuronium, difficult cricoid pressure , possible proseal ??

Morbid obesity and RSI Weight and drug dosage CVS and RS changes Fatty neck Comorbidities Prone for aspiration And go ahead with RSI

Neonates Inhalational agents or without it also Prone for arrhythmias , desaturation, intra ventricular hemorhage, vocal cord injuries and a longer time ?? RSI is acceptable when there are no facial or airway anomalies

So many !! inadvertent esophageal intubation, esophageal perforation, and trauma to the lips, gums, or tongue. Vocal folds edema, ulcerations of the arytenoids, ulcerations of the posterior glottis, and ulcerations of the main stem bronchus have been described in the literature

Thiopentone 3 -7 mg / kg but slow Succinyl choline 1.5 mg/ kg Atropine 0.1 mg Fentanyl – 1- 2 mic/kg Thiopentone 3 -7 mg / kg but slow Succinyl choline 1.5 mg/ kg IM RSI also described Lot of modifications No propofol

Outside the operation theatre – ER Can be done by non anesthesiologists also Can be done by technicians also Urgent – no 100 % oxygen also Only with sedatives Sedative facilitated intubation (SFI) – midaz and ketamine with atropine is used for that purpose

ICU Hypoxic acidotic and collapsed stage RSI decreased the morbidity by 50% Two operators Experienced staff

Preoxygenation – must 500 ml crystalloids – vasopressors Minimum diastolic – 35 mmHg preferable Newer short acting opioids Etomidate Scoline

Prehospital RSI Arrest Trauma Hypoxic Unstable patients Gagging , uncooperative patients made failure common Hence RSI

Extubation also important In patients for whom an RSI was indicated due to aspiration risk, emergence remains a high-risk time for further aspiration events. Awake patient with intact reflexes Left lateral head-down positioning may further reduce the chance of aspiration, at the expense of reduced access to the airway.

Complications of RSI Drugs Cricoid pressure Due to intubation or due to “cant do it”

CICV Release CP Insert LMA Keep CP again Try to ventilate Still no – means – take out CP and try

Difficult airway 2 % Hypoxia – 2% Hypotension – 0.7 % Hypertension - ? Arrhythmias -? Scoline and arrhythmias !!

Rupture of esophagus Clear cut vomiting during RSI, relax CP and suck 20 or 30 40 N pressure Possible but rare cricoid fractures Awareness – worst may be upto 50 % Think of high doses of Thio – 7 mg/kg in fit individuals

Summary What is it ? And the concept – name ? Preparation ,Pre oxygenation ,Pretreatment Paralyses, Positioning ,Prove placement Post intubation management Outside the OR Neonates Complications