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

2. 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 ?

3. 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

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

5. 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

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

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

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

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

10. 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

11. 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.

12. 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

13. 1 is ok in non precurarized patients
Dose of scoline
0.6 1
1.5 to 2
1 is ok in non precurarized patients

14. 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

15. 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

16. Positioning
Sniffing position

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

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

19. Post intubation managemant
Need for mechanical ventilation
Monitoring
Vital signs

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

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

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

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

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

26. 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

27. 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

28. 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

29. 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

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

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

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

33. 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.

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

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

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

37. Rupture of esophagus Clear cut vomiting during RSI, relax CP and suck
20 or 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

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