Overview
Definition:
Rapid Sequence Induction (RSI) is a critical anesthetic technique used to facilitate rapid loss of consciousness and paralysis, minimizing the risk of pulmonary aspiration of gastric contents during endotracheal intubation
It involves the concurrent administration of an induction agent and a neuromuscular blocking agent, without pre-oxygenation or positive pressure ventilation, followed immediately by laryngoscopy and intubation
A surgical perspective focuses on the surgeon's role, preparedness, and understanding of the RSI process to ensure patient safety and facilitate timely surgical intervention.
Epidemiology:
Aspiration during anesthesia, though rare, carries significant morbidity and mortality
RSI is indicated in patients with increased risk of aspiration, such as those with a full stomach, gastrointestinal obstruction, pregnancy, morbid obesity, or diminished airway reflexes
Its incidence is tied to the prevalence of these risk factors and the frequency of emergent surgical procedures.
Clinical Significance:
From a surgical standpoint, understanding and participating in RSI is paramount for patient safety
Surgeons are often present during RSI and must be prepared to assist, manage airway complications, or proceed with surgery if intubation is successful
A well-executed RSI by the anesthesia team reduces the risk of intraoperative complications, allowing for smoother surgical workflow and improved patient outcomes
Delays or complications in RSI can significantly impact the surgical plan and patient safety.
Indications For Rsi
Surgical Indications:
Emergent surgery with a potentially full stomach
patients with gastrointestinal obstruction or ileus
procedures requiring rapid airway control due to patient instability or nature of the surgery
patients with diminished gag or cough reflexes (e.g., head injury, altered mental status)
difficult airway anticipated and rapid control needed.
Anesthetic Considerations:
Risk of pulmonary aspiration of gastric contents
need for rapid sequence of events
patient factors increasing aspiration risk (e.g., pregnancy, obesity, diabetes with gastroparesis, hiatal hernia)
conditions where positive pressure ventilation could worsen gastric insufflation.
Pre Existing Conditions:
Gastroesophageal reflux disease (GERD)
bowel obstruction
trauma patients with potential for increased intracranial pressure
diabetic patients with autonomic neuropathy
patients with altered consciousness from intoxication or neurological events.
Preoperative Preparation Surgical Role
Surgeon Readiness:
Confirm patient identification, procedure, and consent
Understand the anesthesia plan, including RSI indication and anticipated challenges
Ensure appropriate surgical positioning is planned and achievable
Have all necessary surgical instruments and equipment readily available and checked.
Anesthesia Team Collaboration:
Communicate with the anesthesiologist about the surgical procedure, expected duration, potential for blood loss, and any specific surgical positioning requirements that might affect airway access
Confirm the anesthesiologist has their RSI medications, airway equipment, and backup plans ready.
Patient Assessment Surgical Input:
While the anesthesiologist performs the primary airway assessment, the surgeon should be aware of any anatomical challenges evident from surgical history or imaging that might impact intubation or surgical access
Provide input on potential difficulties in positioning for surgery that could also affect airway management.
Equipment Availability:
Ensure that all necessary surgical equipment, including specialized retractors, lights, and patient positioning devices, are available and functional
Confirm that the operating room is set up for immediate surgical commencement once intubation is confirmed.
Rsi Checklist Components Surgical Focus
Patient Identification And Procedure Confirmation:
Crucial for both teams
Double-check patient name, surgical site, and procedure before any intervention
Surgical team confirms operative site marking and patient positioning.
Airway Equipment Availability:
Anesthesiologist is responsible for laryngoscopes (various sizes), endotracheal tubes (ETTs) of appropriate sizes, stylets, suction, and backup airway devices (e.g., LMA, bougie)
Surgeon should be aware of these to anticipate potential issues or assist if needed.
Medication Preparation And Verification:
Induction agents (e.g., etomidate, propofol, ketamine) and neuromuscular blockers (e.g., succinylcholine, rocuronium) are prepared and verified by anesthesia
Surgeon needs to know the drugs being used to understand potential physiological effects.
Cricoid Pressure Application:
Application of Sellick's maneuver (cricoid pressure) is a key component of RSI to occlude the esophagus and prevent regurgitation
The surgeon or an assistant may be asked to apply this pressure
Proper technique and duration are vital.
Successful Intubation Confirmation:
Confirmation of correct ETT placement by auscultation (bilateral breath sounds, absence of epigastric sounds), capnography (gold standard), chest rise, and condensation in the ETT
Surgeon should visually confirm endotracheal tube passage during laryngoscopy if participating.
Surgical Considerations During Rsi
Positioning For Access:
Patient positioning (e.g., ramped position for difficult airways) should be optimized for both intubation and subsequent surgical access
Surgeon must ensure positioning does not compromise airway management.
Assistance During Intubation:
Surgeons may be called upon to assist the anesthesiologist, particularly in difficult airway scenarios, by providing manual stabilization of the head, external laryngeal manipulation, or using surgical airway equipment if emergent
This requires clear communication and understanding of roles.
Timing Of Surgical Incision:
The surgical incision should only be made after successful endotracheal intubation and confirmation of adequate ventilation, unless a surgical airway is being established emergently
Delays in intubation may necessitate delaying the surgical start.
Managing Airway Emergencies Surgical Role:
In a failed intubation scenario, the surgeon must be prepared for the possibility of a surgical airway (e.g., cricothyroidotomy, tracheostomy)
Understanding the indications and techniques for these procedures is crucial.
Patient Hemodynamics And Neuromuscular Blockade:
The surgeon should be aware of the physiological effects of induction agents and neuromuscular blockers on blood pressure, heart rate, and muscle relaxation, as these can impact surgical field visualization and patient stability.
Post Rsi Considerations And Complications
Confirmation Of Tube Placement:
Ongoing verification of ETT position is critical throughout the surgery
Dislodgement or malposition can lead to hypoxemia or aspiration
Surgeon should alert anesthesia to any concerns about tube position or patency.
Airway Trauma:
Potential for pharyngeal, laryngeal, or tracheal injury from laryngoscopy or ETT insertion
Surgeons should report any observed trauma to the anesthesiologist.
Aspiration Pneumonitis:
Despite RSI, aspiration can still occur
Surgeons should be vigilant for signs of aspiration and communicate with anesthesia regarding any suspicious events or findings, such as emesis or gastric contents in the airway.
Surgical Site Preparation And Draping:
Once intubation is confirmed, the surgical team proceeds with sterile preparation and draping, ensuring the ETT and anesthesia equipment are adequately protected and do not interfere with surgical access.
Cricoid Pressure Cessation:
Cricoid pressure is typically released once the ETT is secured and inflated, or when positive pressure ventilation is established
The anesthesiologist typically signals this, but the surgeon should be aware.
Key Points
Exam Focus:
RSI is a critical safety measure to prevent aspiration
The checklist ensures all steps are performed sequentially and safely
Surgeons play a vital role in patient positioning, assisting with airway maneuvers, and managing surgical emergencies that may arise from RSI complications.
Clinical Pearls:
Always confirm endotracheal tube placement with capnography as the gold standard
Surgeon's presence and readiness to assist are crucial
Understand the drugs used in RSI and their effects
Be prepared for the unexpected, including difficult airways and failed intubations.
Common Mistakes:
Failure to confirm tube placement
improper application or premature release of cricoid pressure
delayed laryngoscopy/intubation
inadequate preparation of airway equipment or medications
failure to communicate effectively between surgical and anesthesia teams
Surgeons must avoid initiating surgical steps before confirming successful intubation.