"RSI"-Is it Rapid Sequence Induction or Rapid Sequence Intubation?

Backgrounds: Since its first definition and publication on 1970, Rapid Sequence Induction / Intubation (RSI) technique has been accepted globally as the “standard” for doing rapid intubation after induction of anesthesia for patients with high risk of aspiration, especially in emergency situation. However, this technique is not so much a “standard” as there are numerous variations on its practice based on national surveys. Anesthesia providers have their own opinions on the practice of RSI components which need to be discussed to assess their advantages and disadvantages, while there has been no review article which discussed these controversies in the last ten years. Objectives: To review the technique differences within RSI protocols. Methods: Online databases were searched, including MEDLINE and COCHRANE for each step in the original RSI protocol using keywords such as: “rapid sequence induction” or “rapid sequence intubation” or “RSI” and “controversies” or “head position” or “cricoid pressure” or “neuromuscular blocking agent” or “NMBA” or positive pressure ventilation” or “PPV”; and so on. Articles were then sorted out based on relevancy. Results and conclusion: Supported by new evidence, RSI practices may differ in: the positioning of patient, choices of induction agent, application of cricoid pressure, choices of neuromuscular blocking agent, and the use of positive pressure ventilation. A more updated and standardized guideline should be established by referring and evaluating to these controversies.

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Rapid Sequence Intubation with Remifentanil During COVID-19 Pandemic

Anesthesia and Clinical Research ◽

10.31487/j.acr.2021.01.01 ◽

2021 ◽

pp. 1-2

Author(s):

Sergio Bevilacqua ◽

PierLuigi Stefano

Keyword(s):

Low Dose ◽

Rapid Sequence Induction ◽

Rapid Sequence Intubation ◽

Surgical Patient ◽

High Dose ◽

Muscle Paralysis ◽

Intubation Technique ◽

Rapid Induction ◽

Rapid Sequence ◽

Sequence Induction

We greatly appreciate the interest that De Melo MS, et al. showed on the use of remifentanil in a rapid sequence intubation technique that we recently proposed for patients undergoing surgery during the current SARS-CoV-2 pandemic [1, 2]. The authors also reported the response that Tang and Wang wrote to comment on that paper [3]. Given the interest aroused by our article, we think it would be worth making some clarifications. In brief, in order to limit aerosolization, we proposed to systematically perform rapid induction and intubation in the surgical patient after he had reached a state of deep analgesia with a continuous infusion of high-dose remifentanil (0.2-0.3 g/kg/min) [2]. Although in the title of the article this method is labeled as a rapid sequence induction, in the text, we explain how this technique, far from being standard rapid sequence intubation, was a rather longer technique in which the patient, although in a state of profound analgesia and sedation induced by remifentanil, breathed spontaneously and at last on command, until hypnosis, and muscle paralysis was rapidly induced with a low dose of propofol (<0.5 mg/kg) or midazolam (0.05-0.1 mg/kg) and a full dose of rocuronium (1 mg/kg) [2].

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Systematic Application of Rapid Sequence Intubation With Remifentanil During COVID-19 Pandemic

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253220941369 ◽

2020 ◽

pp. 108925322094136 ◽

Cited By ~ 1

Author(s):

Sergio Bevilacqua ◽

Vanessa Bottari ◽

Ilaria Galeotti

Keyword(s):

Health Care Professionals ◽

Gold Standard ◽

Rapid Sequence Induction ◽

Orotracheal Intubation ◽

Rapid Sequence Intubation ◽

Hemodynamic Stability ◽

Rapid Induction ◽

Rapid Sequence ◽

Cardiovascular Patients ◽

Sequence Induction

In this letter, the authors wonder about the need to apply some of the precautions that have been repeatedly suggested during the recent COVID-19 (coronavirus disease 19) pandemic not only to suspected or documented cases of infection but also to all the new cases entering the hospital. In this regard, orotracheal intubation has been universally recognized as a maneuver with a high risk of viral transmission. On the other hand, rapid sequence induction, which represents the gold standard for limiting the risk of transmission for health care professionals, implies side effects that can be potentially harmful for patients with impaired hemodynamics. In this regard, the authors report a particular type of rapid induction that they are performing in a systematic way during the recent pandemic in cardiac surgery patients. This is performed after the patient reaches a deep analgesic plan, thanks to the unique characteristics of the opioid remifentanil. This type of induction, already tested in vasculopathic patients who underwent carotid surgery, is characterized by great hemodynamic stability and is very advantageous, in the writer’s experience, when rapid sequence induction has to be systematically applied to cardiovascular patients, especially if you only want to protect operators.

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Introduction of a Rapid Sequence Induction Checklist and its effect on Compliance to Guidelines and Complications

Acta Anaesthesiologica Scandinavica ◽

10.1111/aas.13947 ◽

2021 ◽

Author(s):

Jakob Zeuchner ◽

Jonas Graf ◽

Louise Elander ◽

Jessica Frisk ◽

Mats Fredrikson ◽

...

Keyword(s):

Rapid Sequence Induction ◽

Rapid Sequence ◽

Sequence Induction

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Rapid sequence induction: where did the consensus go?

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-021-00883-5 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Pascale Avery ◽

Sarah Morton ◽

James Raitt ◽

Hans Morten Lossius ◽

David Lockey

Keyword(s):

Cricoid Pressure ◽

Rapid Sequence Induction ◽

Hospital Environment ◽

Training Technique ◽

Rapid Sequence ◽

Gastric Aspiration ◽

Sequence Induction ◽

The Uk ◽

Key Aspects ◽

Risk Of Aspiration

Abstract Background Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. Conclusion The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

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COVID-19: Intensivmedizinische Aspekte und Langzeitfolgen

Aktuelle Kardiologie ◽

10.1055/a-1314-9342 ◽

2020 ◽

Author(s):

Raphael Romano Bruno ◽

Georg Wolff ◽

Malte Kelm ◽

Christian Jung

Keyword(s):

Rapid Sequence Induction ◽

High Flow ◽

Ältere Personen ◽

Rapid Sequence ◽

Sind Eine ◽

Sequence Induction ◽

Thrombembolische Komplikationen ◽

Invasive Beatmung

ZusammenfassungEtwa 14% der COVID-19-Patienten weisen einen schwereren und ca. 5% einen kritischen Krankheitsverlauf auf. Besonders gefährdet sind ältere Personen, männliches Geschlecht, Raucher und stark adipöse Menschen. Wird der Patient invasiv oder nichtinvasiv beatmet, so steigt die Mortalität auf 53% respektive 50% an. In der Regel beträgt die Dauer vom Beginn der Symptome bis zur Aufnahme auf die Intensivstation 10 Tage. Die mittlere Verweildauer auf der Intensivstation beträgt 9 Tage. Für die Priorisierung sind die klinische Erfolgsaussicht einer intensivmedizinischen Behandlung sowie der Wunsch des Patienten maßgebend. Zentrale Kriterien für die Aufnahme auf die Intensivstation sind eine Hypoxämie (SpO2 < 90% unter 2 – 4 Liter Sauerstoff/min bei nicht vorbestehender Therapie), Dyspnoe, eine erhöhte Atemfrequenz (> 25 – 30/min) und ein systolischer Blutdruck ≤ 100 mmHg. Der Schutz des Personals genießt bei allen Maßnahmen Vorrang. Alle aerosolgenerierenden Prozeduren sollten nur mit großer Vorsicht erfolgen. Wird unter High Flow keine adäquate Oxygenierung erreicht (SpO2 ≥ 90% oder ein paO2 > 55 mmHg), sollte über eine Eskalation nachgedacht werden (NIV, invasive Beatmung). Die Patienten sollten lungenprotektiv beatmet werden. Die Intubation sollte als Rapid Sequence Induction erfolgen. Eine ECMO kann erwogen werden. Thrombembolische Komplikationen sind sehr häufig. Antibiotika sollten nicht routinemäßig gegeben werden. Die aktuell beste Datenlage liegt für Dexamethason vor. Remdesivir kann die Rekonvaleszenz beschleunigen. Langzeitfolgen nach COVID-19 sind sehr häufig. Kardiale, pulmonale und neurologische Probleme stehen dabei im Vordergrund.

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