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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 aspiratio...
Indications of RSI:
Patient with high risk of aspirations:
• Abdominal pathology (ileus, I/O)
• Delayed gastric emptying (...
The Six ‘P’s of RSI
• Preparation
• Pre-Oxygenation with 100% oxygen
• Pretreatment & Induction
• Paralysis + Cricoid pres...
PREPARATION
• Assess patient  Any features of difficult
intubation?
• IV Access  Adequate & Functioning
• Monitor
• Gath...
Pre-Oxygenation
Goals:
• Establish O2 reservoir
• Maximize time for intubation
• Prevent need for bag-mask ventilation
Met...
Pre-Treatment
Goals:
• Mitigate adverse physiologic reactions to
intubation
– Symphatetic “pressor response”
• Manipulatio...
LIDOCAINE:
• Dose: 1.5mg/kg (IV)
• To prevent ↑ ICP by:
> Prevent cough
> Blunting pressure response
- May reduce reactive...
INDUCTION
• Given as rapid IV push immediately before
paralysing agent
• Facilitate LOC in one-arm-brain circulation
time ...
INDUCTION
Paralysis/NMB Agent
Ideal:
• Rapid onset of action to minimize risk of
aspiration & hypoxia
• Rapid recovery to facilitate...
Suxamethonium:
• Rapid onset & offset of action
Rocuronium:
• Rapid onset but duration of action much
longer than sux
- Wa...
Techniques
Cricoid Pressure:
• The oesophagus is occluded by extension of
the neck & application of pressure over the
cric...
Placement of tube
Tube position is confirmed by:
• Direct visualization of ET tube between the
vocal cord
• Auscultation: ...
POST INTUBATION CARE
• ECG
• SPO2
• NIBP/Art-line
• Capnograph
• Naso/Orogastric tube
• CXR
• ABG Post intubation
• Mainta...
Terminating anaesthesia
• During transition from deep anaesthesia to
full conciousness & vice versa risk of
aspiration is ...
Complications of RSI
• Failed to intubate & failed to ventilate
• Risk of anaphylaxis
• Cricoid pressure:
– Failure to occ...
Rapid sequence intubation
Rapid sequence intubation
Rapid sequence intubation
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Rapid sequence intubation

RAPID SEQUENCE INTUBATION

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Rapid sequence intubation

  1. 1. RAPID SEQUENCE INTUBATION (RSI) Dr Khairunnisa Binti Azman Dept of Anaesthesiology TGH
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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)
  7. 7. 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”
  8. 8. 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)
  9. 9. 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.
  10. 10. INDUCTION
  11. 11. 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
  12. 12. 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
  13. 13. 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.
  14. 14. Placement of tube Tube position is confirmed by: • Direct visualization of ET tube between the vocal cord • Auscultation: equal air entry • Capnometer: EtCO2
  15. 15. POST INTUBATION CARE • ECG • SPO2 • NIBP/Art-line • Capnograph • Naso/Orogastric tube • CXR • ABG Post intubation • Maintainace of sedation & NMB
  16. 16. 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
  17. 17. Complications of RSI • Failed to intubate & failed to ventilate • Risk of anaphylaxis • Cricoid pressure: – Failure to occlude the oesophagus – Distortion of larynxdisrupt view – Oesophageal rupture during active vomiting

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