"The 9 Ps" of the Rapid Sequence Induction.




    The Rapid Sequence Induction is a technique of inducing general anesthesia so as to reduce the risk of pulmonary aspiration of gastric contents.




I. Preparation.

  • A working laryngoscope and different types of blades. A video laryngoscope may be desirable.
  • ETTs of the desired size with smaller ETTs available. A stylet should be inserted prior to inducing anesthesia.
  • Device to confirm proper placement of ETT (e.g., capnograph)
  • Working suction
  • Gum elastic introducer (Bougie) or Eschmann stylet
  • Appropriately sized SGA (supraglottic airway device) for rescue.
  • Equipment for emergency tracheotomy/cricothyrotomy where appropriate
  • Functional IV access
  • Appropriate monitoring equipment

II. Patient Evaluation.

  • Evaluate the airway to rule out possible difficult ventilation or intubation.
  • Review possible contraindications to medications.

III. Preoxygenation.
Administer 100% oxygen for 3–5 minutes with a tight seal around
the mask.

 IV. Premedication.
This should be used judiciously because it may increase the risk of aspiration or delay awakening in the event that the patient cannot be intubated.

  • Midazolam: 0.02–0.05 mg/kg. Use with caution in patients with head injury or those who may need to be awakened rapidly.
  • Fentanyl: 3 mcg/kg IV 2–3 minutes prior
  • Lidocaine: 1.5 mg/kg IV 2–3 minutes prior
  • Consider aspiration prophylaxis such as sodium citrate.

V. Paralysis and Induction.
Rapidly administer an anesthetic followed by a neuromuscular blocking agent. Do not titrate medication to effect.
  • Choose an induction agent:
    • Etomidate: 0.3 mg/kg IV
    • Ketamine: 1–2 mg/kg IV
    • Propofol: 1–2 mg/kg IV
  • Choose a neuromuscular blocking agent:
    • Succinylcholine: 1–2 mg/kg
    • Rocuronium: 1–1.2 mg/kg

VI. Position and Protect the Patient.

  • Position the head and neck into the sniffing position by flexing the neck and extending the atlanto-occipital joint. Reposition the head if an adequate view of the glottic opening is not achieved.
  • If the patient is in a cervical spine collar, an assistant must maintain inline stabilization and the front of the collar must be removed.
  • Apply cricoid pressure (Sellick’s maneuver) before induction. Do not release the cricoid pressure until correct ETT position is confirmed
  • Wait for 45–60 seconds to allow full effect of the neuromuscular blockade.
  • If the patient will tolerate apnea, do not ventilate him or her at this time to prevent gaseous distention of the stomach.
VII. Pass the Endotracheal Tube. Visualize the tube going through the vocal cords.
VIII. Proof of Placement. Establish that the ETT is in the correct position by end-tidal capnography, bilateral breath sounds, chest rise, and fogging within the ETT.

IX. Postintubation Care.
  • Ventilate.
  • Secure the ETT.
  • Evacuate the stomach.
  • Administer postintubation sedation if out of the operating room (OR).
  • Maintain appropriate postintubation hemodynamics.
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