RAPID SEQUENCE INTUBATION (RSI)

Dr Khairunnisa Binti Azman

Dept of Anaesthesiology TGH

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

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

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

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

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)

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”

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)

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.

INDUCTION

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

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

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.

Placement of tube

Tube position is confirmed by:

• Direct visualization of ET tube between the vocal cord

• Auscultation: equal air entry

• Capnometer: EtCO2

POST INTUBATION CARE

• ECG

• SPO2

• NIBP/Art-line

• Capnograph

• Naso/Orogastric tube

• CXR

• ABG Post intubation

• Maintainace of sedation & NMB

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

Complications of RSI

• Failed to intubate & failed to ventilate

• Risk of anaphylaxis

• Cricoid pressure:

– Failure to occlude the oesophagus

– Distortion of larynxdisrupt view

– Oesophageal rupture during active vomiting