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Rapid Sequence Induction and Intubation (RSII) For Anesthesia - UpToDate

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Rapid Sequence Induction and Intubation (RSII) For Anesthesia - UpToDate

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19/1/24, 6:22 Rapid sequence induction and intubation (RSII) for anesthesia - UpToDate

Official reprint from UpToDate®

Rapid sequence induction and intubation (RSII) for

anesthesia
AUTHOR: Lauren C Berkow, MD, FASA
SECTION EDITOR: Carin A Hagberg, MD, FASA
DEPUTY EDITOR: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2023.

This topic last updated: Jan 05, 2024.

INTRODUCTION

Rapid sequence induction and intubation (RSII) for anesthesia is a technique designed to
minimize the chance of pulmonary aspiration in patients who are at higher than normal risk.
The usual, nonrapid sequence of induction and intubation for anesthesia consists of
administration of an induction agent, proof of the ability to mask ventilate, administration of
a neuromuscular blocking agent (NMBA), and endotracheal intubation once paralysis is
achieved, usually approximately three minutes after induction. Since induction of anesthesia
results in loss of airway protective reflexes, pulmonary aspiration is a risk during the interval
between loss of consciousness and inflation of the cuff of the endotracheal tube.

The components of RSII are designed to protect the airway with a cuffed endotracheal tube
as quickly as possible after induction, while reducing the chance of passive or active
regurgitation. An essential goal of RSII is the achievement of adequate depth of anesthesia,
and, most often, paralysis, for laryngoscopy, to prevent coughing, straining, and active
vomiting with airway manipulation.

While RSII is a departure from the usual practice of induction of anesthesia, the equivalent
method of rapid airway control, often called "rapid sequence intubation" (RSI), is the most
commonly used method of controlling the airway in the emergency department.

This topic will discuss the components, techniques, and medications used for RSII for
anesthesia. Preoperative fasting guidelines, airway management for induction of anesthesia,
RSI in the emergency department, and medications used for induction of anesthesia are
discussed more fully separately.
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● (See "Airway management for induction of general anesthesia".)

● (See "Induction of general anesthesia: Overview".)

● (See "Preoperative fasting in adults".)

● (See "Rapid sequence intubation in adults for emergency medicine and critical care".)

INDICATIONS

General indications — RSII should be considered for the patient who is at increased risk of
aspiration with induction of anesthesia. This includes the patient with a full stomach,
gastrointestinal pathology, increased abdominal pressure, or pregnancy after 20 weeks
gestation ( table 1):

● Patients with a full stomach, which includes:

• Patients undergoing emergency surgery
• Patients who have sustained trauma, regardless of the interval since last oral intake
• Patients who have not fasted according to preoperative fasting guidelines (see
"Preoperative fasting in adults")

● Patients with gastrointestinal pathology, which includes:

• Gastroparesis or delayed gastric emptying (eg, due to diabetic autonomic
neuropathy, patients taking glucagon-like peptide-1 [GLP-1] receptor agonists)
• Small bowel obstruction
• Gastric outlet obstruction
• Esophageal stricture
• Gastroesophageal reflux disease (see 'Gastroesophageal reflux disease (GERD)'
below)

● Patients with increased intraabdominal pressure, which includes those with:

• Morbid obesity
• Ascites

● Pregnancy after 20 weeks gestation; earlier if symptoms of gastroesophageal reflux

(controversial) (see "Anesthesia for nonobstetric surgery during pregnancy", section on
'Preoperative aspiration mitigation')

Gastroesophageal reflux disease (GERD) — GERD is a common condition that may put
patients at risk for passive regurgitation and subsequent aspiration during induction of
anesthesia.

Patient selection — The decision to perform RSII for patients with GERD must be
individualized based on the degree of symptoms and the potential risk of RSII. Patients
should be questioned about symptoms of reflux during preoperative evaluation, including
the presence of heartburn, regurgitation, dysphagia, reflux symptoms at night, and the need
to sleep with the head of the bed elevated to avoid reflux. We consider RSII for the following
patients:

● Patients with current symptoms of active reflux (ie, regurgitation, heartburn, or the
need to sleep with the head of the bed elevated)

● Patients who had significant symptoms of active reflux prior to starting antacid
medication, such as proton pump inhibitor (PPI), histamine-2 receptor antagonist
(H2RA), or calcium carbonate

● Patients who believe that symptoms of reflux would recur if antacid therapy was
discontinued

● Patients with hiatal hernia or endoscopic evidence of GERD

We do not routinely perform RSII for patients who report heartburn only with spicy or acidic
foods.

Clinical manifestations, diagnosis, and management of GERD are discussed more fully
separately. (See "Clinical manifestations and diagnosis of gastroesophageal reflux disease in
children and adolescents" and "Medical management of gastroesophageal reflux disease in
adults".)

Preoperative antacids — Patients presenting for elective surgery who take antacid
medication, including PPIs and H2RAs, on a regular or as-needed basis should be instructed
to take their usual medication before surgery. PPIs are more effective at reducing gastric
volume and increasing pH if given in two doses, one the evening prior to surgery, and
another on the morning of surgery [1,2]. A single dose of oral ranitidine three hours prior to
induction of anesthesia has been shown to significantly reduce gastric volume and increase
pH of stomach contents. Ranitidine is no longer available in the United States. Alternatives
include famotidine, cimetidine, or a PPI. When administered orally, two doses of a PPI are
required for maximum efficacy (one the evening before and one the morning of surgery). A
meta-analysis of randomized trials that compared efficacy of H2RAs with PPIs found that a
single IV dose or two oral doses of PPIs were as effective as H2RAs administered by either
route [3].

Patients taking GLP-1 receptor agonists — Delayed gastric emptying is a potential side
effect of GLP-1 receptor agonists (eg, semaglutide, liraglutide), which are used to treat
diabetes and are increasingly used for weight loss. Patients who take these medications may

have residual gastric contents despite preoperative fasting [4-6] and may be at increased risk
of aspiration during induction of anesthesia.

In 2023, the American Society of Anesthesiologists (ASA) issued guidance on preoperative

management of patients taking GLP-1 agonists based on some case reports of aspiration
during anesthesia [4,5,7,8]. The ASA recommends holding the daily or weekly dose of GLP-1
agonists prior to elective surgery and, for patients who take the drug up until the day of
surgery, performing RSII. For patients with diabetes, glucose management may require
coordination with the prescribing clinician when the GLP-1 agonist is held.

Gastrointestinal side effects (nausea, vomiting, diarrhea) are common with GLP-1 agonists,
particularly early in treatment. (See "Glucagon-like peptide 1-based therapies for the
treatment of type 2 diabetes mellitus", section on 'Gastrointestinal' and "Obesity in adults:
Drug therapy", section on 'GLP-1 receptor agonists'.)

The literature on the effect of GLP-1 agonists on gastric emptying is inconclusive. Several
observational studies have found increased risk of residual gastric contents at the time of
upper gastrointestinal endoscopy in patients taking GLP-1 receptor agonists for diabetes or
for weight loss [4,5,9,10]. By contrast, several studies using paracetamol absorption to assess
gastric emptying found no effect of semaglutide after the first few hours after a dose [11-13].

In patients presenting for surgery who have not held their GLP-1 receptor agonists for one
week or more, gastric ultrasound can be considered to assess for the presence of gastric
contents and to guide the need for rapid sequence intubation (RSI). If gastric ultrasound is
not available or inconclusive, it is reasonable to perform RSII to minimize aspiration risk.

PREPARATION FOR ANESTHESIA

In addition to the preparation for routine induction of anesthesia, an assistant should be

present who understands RSII and is capable of correctly applying cricoid pressure to assist
in airway management.

Airway evaluation — Airway evaluation is an important step in making the decision to

perform an RSII. If a difficult airway is predicted, the risk of aspiration must be weighed
against the risk of difficult or failed airway management. This is because RSII usually includes
the administration of a neuromuscular blocking agent (NMBA) without proof that mask
ventilation will be possible once the patient is paralyzed. In all but the most urgent
situations, a quick airway examination and query about previous airway problems should be
possible. If difficult airway management is expected, a modified RSII, awake intubation, or
even an inhalation induction may be chosen as alternatives. The 2022 American Society of
Anesthesiologists (ASA) Difficult Airway Guidelines recommend an awake intubation strategy

when both difficult intubation and a significant risk of aspiration are present ( algorithm 1
and figure 1) [14]. (See "Airway management for induction of general anesthesia", section
on 'Prediction of the difficult airway' and 'Potential complications of RSII' below.)

Equipment — Preparation of equipment for RSII should be similar to that for routine
induction. An assortment of standard and alternative airway devices should be immediately
available, including small, medium, and large facemasks; several sizes and types of
laryngoscopes; oral and nasal airways; several sizes of supraglottic airway, and a bougie.
Alternative devices for laryngoscopy, including a video laryngoscope and flexible intubating
scope, as well as other emergency airway equipment, should be accessible quickly and
present in the operating room or anesthetizing location if difficult airway is suspected.
Working suction must always be close by during induction of anesthesia; for RSII, we usually
place the suction directly under the headrest for immediate access.

Premedication — Premedication may be administered prior to RSII to relieve anxiety, to

blunt or eliminate the physiologic response to airway management, and to reduce the
volume or increase the pH of stomach contents.

● Anxiolytics – For patients who are hemodynamically stable, a benzodiazepine (eg,

midazolam up to 1 to 2 mg IV) may be administered to reduce anxiety. This dose should
be titrated cautiously in older adults and when given simultaneously with narcotic
premedication, to avoid hypotension and loss of protective airway reflexes [15].

● Atropine – The administration of succinylcholine and airway manipulation can trigger a

vagal response, especially in children and neonates. We therefore suggest the use of
atropine with RSII for all children younger than one year and for children less than five
years of age who receive succinylcholine, though succinylcholine is rarely administered
to children in the operating room. (See "Rapid sequence intubation (RSI) in children for
emergency medicine: Approach", section on 'Pretreatment'.)

A vagal response to straightforward endotracheal intubation is much less common in

adults; as such, atropine is not routinely administered as a premedication before RSII
for adults. However, anticholinergic treatment may be required if bradycardia occurs
with difficult laryngoscopy and intubation, or as a result of intubation in patients with
preexisting bradycardia caused by medication or conduction system disease [16-18].

● Opioids – Opioids may be administered as part of premedication for analgesia and

sedation. They should be titrated to avoid respiratory depression and loss of protective
airway reflexes in patients at risk for aspiration, especially in older patients, and when
administered with benzodiazepines.

● Antacids – We suggest premedication with antacids prior to induction of anesthesia for

patients at high risk of aspiration to increase the pH of gastric contents so that, if
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aspiration does occur, it will result in less pulmonary damage. Several classes of antacid
medication are routinely used:

• Clear, nonparticulate oral antacid (eg, sodium citrate-citric acid, 30 mL orally

immediately prior to induction) increases pH of stomach contents [19].

• Histamine-2 receptor antagonist (H2RA) (eg, famotidine 20 mg IV, given 40 to 60

minutes prior to induction) reduces the volume and increases the pH of stomach
contents.

For pregnant patients and for those at high risk of aspiration, we routinely administer
clear, nonparticulate antacid prior to induction. For nonpregnant patients at high risk of
aspiration who have not received a proton pump inhibitor (PPI) or H2RA on the
morning of surgery, we also administer an H2RA 40 to 60 minutes prior to induction.

● Prokinetic agent – Intravenous (IV) metoclopramide increases lower esophageal

sphincter tone [20], induces peristalsis, and enhances stomach emptying, thereby
reducing gastric volume and the risk of regurgitation. Metoclopramide is particularly
useful in patients with gastroparesis undergoing general anesthesia. It is also
antiemetic and may help prevent postoperative nausea and vomiting. Rare adverse
effects of metoclopramide include extrapyramidal effects and tardive dyskinesia, which
are more common if administered quickly. We reserve metoclopramide for patients
with uncontrolled reflux and pregnant patients who are symptomatic with reflux. In this
setting, we administer metoclopramide 10 mg IV over one to two minutes.

Positioning — The patient's head should be positioned in the sniffing position to facilitate
intubation (atlanto-occipital extension with head elevation of 3 to 7 cm). Obese patients may
require a ramped position ( figure 2). (See "Airway management for induction of general
anesthesia", section on 'Patient positioning'.)

When RSII is planned, we prefer to position the operating table with the head up because
passive regurgitation and aspiration may be less likely if the larynx is above the level of the
lower esophageal sphincter. We flex the operating table at the level of the patient's hips to
elevate the back of the operating table, or tilt the table 20 degrees head up, making sure that
once that is done, the height of the patient's head is optimal for intubation. Should the
patient regurgitate prior to or during induction, the table should be quickly tipped head
down, the patient's head turned to the side, and the mouth suctioned to avoid aspiration.

The optimal positioning for RSII remains controversial with a lack of scientific evidence to
support a particular position. A simulation study in manikins found that the head-down
position with neck extension reduced aspiration but made laryngoscopy more difficult [21].

Clinical recommendations and clinical practice patterns favor the head-up position [22]. Two
2020 surveys of clinician practice demonstrated a strong preference for the head-up position
(60 to 70 percent) [23,24].

Preoxygenation — All patients presenting for general anesthesia should be preoxygenated

with 100 percent oxygen to increase oxygen reserve and provide additional time to secure
the airway. This is particularly important prior to RSII, since with this technique, mask
ventilation is not usually performed between induction and intubation. Preoxygenation is
administered for three minutes of normal tidal volume breathing, for eight deep breaths
over one minute, or until the fraction of expired oxygen is over 90 percent [25]. (See 'Mask
ventilation' below.)

The use of nasal cannula for passive apneic oxygenation during laryngoscopy can prolong
the time to desaturation in high-risk patients during airway management [26-28]. We
suggest the administration of oxygen by nasal cannula at 10 L in addition to facemask
oxygen for those patients who are at high risk for rapid oxygen desaturation during the
apneic period between induction and intubation, and for those at higher risk of difficult
intubation.

The 2022 ASA Difficult Airway Guidelines recommend properly positioning the patient,
administering supplemental oxygen before initiating management of the difficult airway and
continuing to deliver supplemental oxygen whenever feasible throughout the process of
difficult airway management, including extubation [14].

Methods for apneic oxygenation have become available that may be useful for
preoxygenation as well as passive oxygenation during RSII. The transnasal humidified rapid
insufflation ventilatory exchange (THRIVE) technique uses a device that provides humidified
high-flow nasal oxygen with continuous positive airway pressure (CPAP). THRIVE may
maintain a blood gas profile equivalent to face mask preoxygenation despite longer apnea
time [29,30]. (See "Preoxygenation and apneic oxygenation for airway management for
anesthesia".)

A number of studies have shown either more rapid or effective preoxygenation or increased
time to desaturation after apnea with the use of CPAP during preoxygenation [31-33]. CPAP
can be provided using a tight-fitting anesthesia face mask, and pressure support ventilation
provided with positive end-expiratory pressure (PEEP). Morbidly obese patients in particular
may benefit from CPAP preoxygenation. Low levels of inspiratory pressure should be used to
avoid gastric insufflation.

CRICOID PRESSURE DURING RSII

Although controversial, we routinely apply cricoid pressure (also known as Sellick's

maneuver) prior to and during RSII until confirmation of correct endotracheal tube
placement. Despite conflicting evidence regarding the effectiveness of cricoid pressure for
preventing regurgitation, clinical experience suggests that, in most situations, it is not
harmful and may be beneficial.

The most significant downside to the use of cricoid pressure is the possibility that it may
make laryngoscopy, supraglottic airway placement, or mask ventilation more difficult. We
routinely have an assistant apply cricoid pressure during RSII, but we communicate the need
to shift or release the pressure, as necessary, to facilitate tracheal intubation. Cricoid
pressure may have to be released if intubation proves difficult and/or mask ventilation,
supraglottic airway placement, or flexible fiberoptic bronchoscopy become necessary.
Indeed, the 2015 Difficult Airway Society guidelines from the United Kingdom recommend
that cricoid pressure be released if initial attempts at laryngoscopy are difficult [34]. Should
active vomiting occur, cricoid pressure should be released to avoid esophageal rupture.

We do not routinely use cricoid pressure during RSII for patients with acute cervical spinal
cord injury because it can move unstable cervical spine fractures. In trauma patients with
possible but unevaluated cervical spine injury, cricoid pressure should only be used along
with manual in line stabilization to stabilize the posterior cervical spine. (See "Anesthesia for
adults with acute spinal cord injury", section on 'Airway management strategy'.)

As originally described by Sellick in 1961, the cricoid cartilage ring is pressed backward by an
assistant against the underlying cervical vertebrae, occluding the lumen of the esophagus to
prevent regurgitation of stomach contents into the pharynx ( figure 3) [35]. Based on
cadaver and patient studies, pressure should be applied at 10 Newtons (approximately 2.5
lbs) while the patient is awake and increased to 30 Newtons after loss of consciousness.
Despite these recommendations, clinicians and assistants are not routinely trained to
standardize application of pressure [36-38].

While optimal external laryngeal manipulation (OELM) of the thyroid cartilage is often used
to improve the view of the vocal cords during laryngoscopy, cricoid pressure should not be
applied in an attempt to improve laryngeal view, as it may in fact make the view worse.

Cricoid pressure controversies — The need for, efficacy, anatomical basis, and optimal
technique for application of cricoid pressure have all been questioned, and literature is
inconclusive [39]. Some guidelines, including the American Heart Association Guidelines for
Cardiopulmonary Resuscitation, no longer recommend the routine use of cricoid pressure
[40].

A 2021 meta-analysis of five trials that assessed the impact of cricoid pressure on intubation
outcomes in the operating room setting found a slightly higher time to intubation and

incidence of hoarseness with the use of cricoid pressure, but no difference in first pass
success rate or laryngoscopic view [41]. Only two randomized controlled trials have
evaluated cricoid pressure for RSII with direct laryngoscopy [42]. In one of these trials the
primary outcome was the pressor response to endotracheal intubation; there was no
difference between patients who had cricoid pressure applied and those who did not [43].
The other trial, which evaluated aspiration and intubating conditions with and without
cricoid pressure, was a prospective, randomized, multicenter study of 3472 patients who
required RSII for increased risk of aspiration [44]. The incidence of aspiration was similar in
the two groups (0.6 percent with cricoid pressure versus 0.5 percent without). Median
intubation time was longer in patients who had cricoid pressure applied (27 versus 23
seconds), and there was higher incidence of Cormack Lehane grade 3 or 4 laryngeal views
with cricoid pressure (10 versus 5 percent) ( figure 4). (See "Direct laryngoscopy and
endotracheal intubation in adults", section on 'Glottic view scores'.)

● Evidence that cricoid pressure may reduce the incidence of aspiration of gastric
contents is scant and consists primarily of observational clinical studies and
experimental data from cadaver studies [45], including the following:

• Cadaver studies have shown that cricoid pressure prevents reflux of saline into the
pharynx at esophageal pressures up to 50 cmH2O [36,46-48].

• Several studies have shown that cricoid pressure prevents gastric insufflation during
mask ventilation in children and adults [49-51].

• An observational study performed in patients undergoing elective surgery reported

that cricoid pressure applied at 30 Newtons effectively occluded the upper
esophagus, as determined by the inability to pass gastric tubes of two different sizes
[52].

• There are case reports of regurgitation when cricoid pressure was released [35,53].

● Lack of efficacy of cricoid pressure and possible harm are suggested by several studies
and observations, as follows:

• The anatomical basis for the use of cricoid pressure has been questioned by
imaging studies. Both computed tomography (CT) and magnetic resonance imaging
(MRI) studies have shown that the esophagus is located lateral to the midline in
approximately 50 percent of patients [54,55]. The application of cricoid pressure
displaced the esophagus laterally in 90 percent of subjects [55], suggesting that the
esophagus would not be occluded by pressing the cartilage against cervical
vertebrae. In contrast, an MRI study showed that application of 2 to 4 kg of cricoid
pressure moved the cricoid cartilage and the hypopharynx as one unit, effectively
obliterating the lumen of the alimentary tract, even with lateral displacement [56].
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• Cricoid pressure at 20 Newtons has been shown to reduce lower esophageal

pressure in awake, un-anesthetized volunteers (presumably by reflex), with
restoration to baseline after release of pressure [57]. If applicable to anesthetized
patients, this effect could theoretically increase the chance of gastroesophageal
reflux, though it isn't clear whether this would increase the chance of reflux into the
pharynx. Another study of awake volunteers reported that application of cricoid
pressure did not promote gastroesophageal reflux [58].

• Several studies have reported a worsened Cormack Lehane grade view during
laryngoscopy, prolonged time to intubation, and/or airway obstruction with the use
of cricoid pressure [45,59-63].

NASOGASTRIC TUBE

For patients with bowel obstruction, ileus, and other gastrointestinal pathology, some
clinicians place a nasogastric tube to decompress the stomach prior to induction of
anesthesia. Nasogastric drainage or suction does not guarantee an empty stomach and may
not remove particulate matter. Such patients often present for anesthesia and surgery with a
nasogastric tube already in place. We generally leave the nasogastric tube in place during
RSII, connect it to suction to drain the stomach prior to induction, and then leave it open to
air as a vent for the stomach. The stomach is suctioned again prior to emergence. While
presence of a nasogastric tube may impair the function of the lower and upper esophageal
sphincters [64], two cadaver studies have shown that cricoid pressure effectively prevents
regurgitation of stomach contents with a nasogastric tube in place [37,46]. In addition, the
nasogastric tube can help identify the esophagus during laryngoscopy and therefore make
esophageal intubation less likely.

CHOICE OF MEDICATIONS

Since the aim of RSII is to place an endotracheal tube as quickly as possible after loss of
consciousness, all medications used should be rapid in onset, without significant
hemodynamic effects when given at the required doses, and should achieve optimal
intubating conditions. Depending on the planned surgical procedure, a short duration of
action or reversibility may be desirable as well. An important goal of RSII is the achievement
of an adequate depth of anesthesia and, in most cases, paralysis to prevent coughing,
gagging, straining, or vomiting during airway manipulation.

Induction agents

Dose and timing of induction agent — We typically titrate the anesthesia induction agent
to loss of consciousness prior to the administration of neuromuscular blocking agent
(NMBA). As RSII was originally described, a precalculated dose of an induction drug was
administered, immediately followed by an NMBA. This timing can result in either
underdosing, with the possibility of awareness or an undesirable sympathetic response to
intubation, or to overdosing, with the possibility of hypotension. An alternative method of
administration is to titrate the induction medication to loss of consciousness, recognizing
that total induction time may be slightly longer with a titration technique. There are no data
comparing the risk of aspiration, awareness, or hemodynamic consequence of RSII using the
titration versus bolus technique.

Choice of agent — Propofol is the induction agent we use most commonly for RSII, but the
choice, dose, and speed of administration of the induction agent should be individualized.
Patients presenting for emergency surgery may be hypovolemic or have other comorbidities
that increase the risk of hemodynamic instability with induction. Ketamine and etomidate
are alternatives to propofol for patients at increased risk of hypotension with induction. (See
"General anesthesia: Intravenous induction agents".)

Propofol — Propofol is the most commonly used medication for induction of anesthesia
and for RSII. Advantages for RSII include its rapid onset (30 to 45 seconds) and its ability to
suppress airway reflexes and produce apnea [65]. Duration of action of propofol is short (5 to
10 minutes), which is an advantage if airway management is difficult and the patient must be
awakened. However, the short duration of action means that repeat doses of propofol may
be required if airway management is prolonged. (See "General anesthesia: Intravenous
induction agents", section on 'Propofol'.)

Propofol can cause hypotension because of dose-dependent venodilation, arterial dilation,

and decrease in cardiac contractility [66]. The usual induction dose for RSII is 2 mg/kg, with
reduced doses for patients at increased risk of hypotension [65].

Etomidate — Etomidate is an imidazole drug that acts directly on the gamma-aminobutyric

acidA (GABAA) receptor complex, with a fast onset and short duration of action. Unlike
propofol, etomidate does not cause vasodilation or myocardial depression, an advantage for
patients who are at increased risk for hypotension [67]. For RSII, the induction dose of
etomidate is 0.2 to 0.4 mg/kg IV, with rapid onset (30 to 45 seconds) and duration of action of
5 to 15 minutes [68]. (See "General anesthesia: Intravenous induction agents", section on
'Etomidate'.)

Etomidate has been associated with adrenal suppression in the first 12 hours after a single
dose and may prevent a rise in cortisol in response to a surgical stimulus [67]. However, a
systematic review including six trials (772 patients) reported that a single induction dose of

etomidate for endotracheal intubation in critically ill patients was not associated with
increased mortality compared with other induction agents [69].

Ketamine — Ketamine is an NMDA receptor antagonist used for induction of anesthesia. It

is a mild direct myocardial depressant [70], but in patients with an intact autonomic nervous
system, it increases sympathetic tone, resulting in an increase in blood pressure, heart rate,
and cardiac output [71]. Thus, ketamine is an alternative to etomidate for patients at risk for
hypotension. However, sympathetic stimulation with administration of ketamine is
dependent upon the presence of adequate sympathetic reserve. In the patient who has
maximally activated the sympathetic response and depleted all reserve (eg, patients with
profound hypovolemic shock), ketamine administration may result in hypotension as a result
of myocardial depression. The RSII induction dose of ketamine is 1 to 2 mg/kg IV. (See
"General anesthesia: Intravenous induction agents", section on 'Ketamine'.)

Induction with ketamine for patients with traumatic brain injury is controversial. The concern
is that ketamine may increase cerebral blood flow and intracranial pressure (ICP), thereby
reducing cerebral perfusion. However, since it increases cardiac output and maintains mean
arterial pressure, cerebral perfusion may actually increase. We believe that ketamine is an
appropriate induction agent for RSII in patients with suspected ICP elevation and normal
blood pressure or hypotension. In patients with hypertension and suspected ICP elevation,
ketamine should be avoided because of its tendency to further elevate blood pressure.

Barbiturates — Prior to the introduction of propofol, thiopental was the most commonly
used agent for both routine induction of anesthesia and RSII. It is no longer available in the
United States, though it is still used in other parts of the world. Methohexital is another
barbiturate used for induction, with limited availability in the United States. With an
induction dose of thiopental, 3 to 5 mg/kg IV, the time to effect is less than 30 seconds, and
the duration of action is approximately 5 to 10 minutes. The induction dose of methohexital
is 1 to 3 mg/kg IV, with similar time to effect and duration of action [72]. (See "General
anesthesia: Intravenous induction agents", section on 'Methohexital'.)

Both barbiturates are myocardial depressants and venodilators, and can cause hypotension.
Doses should be reduced for older patients and for those at risk for hypotension. In addition,
thiopental releases histamine and should be avoided in patients with asthma or reactive
airway disease [73].

Opioids — Short-acting opioids (eg, fentanyl 1 to 3 mcg/kg IV three minutes prior to

induction) is usually administered to reduce the sympathetic nervous system response to
intubation. Remifentanil, an ultrashort-acting opioid, can be administered to profoundly
suppress airway reflexes for intubation when the administration of NMBA is undesirable or
contraindicated. (See 'Remifentanil intubation' below and "Induction of general anesthesia:
Overview", section on 'Induction with endotracheal intubation'.)
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Lidocaine — Lidocaine (eg, 1 to 1.5 mg/kg IV given two minutes prior to intubation) is
administered to blunt the sympathetic response to laryngoscopy and suppress the cough
reflex [74-77]. Lidocaine pretreatment may prevent or decrease the transient rise in
intracranial pressure with laryngoscopy and intubation, though studies of this effect have
reached contradictory conclusions. Hypotension may occur with administration of higher
doses of intravenous lidocaine [78]. (See "Pretreatment medications for rapid sequence
intubation in adults for emergency medicine and critical care", section on 'Lidocaine' and
"Induction of general anesthesia: Overview", section on 'Induction with endotracheal
intubation'.)

Neuromuscular blocking agents (NMBAs) — NMBAs are administered for RSII to achieve
optimal intubating conditions and to prevent coughing, gagging, straining, and vomiting as
a result of airway manipulation.

Succinylcholine — Unless contraindicated, for most cases we suggest the use of

succinylcholine (1 to 1.5 mg/kg) rather than nondepolarizing NMBAs for RSII because it
provides excellent intubating conditions within 30 to 60 seconds [79]. Paralysis is achieved
once fasciculations have stopped, at which point intubation can be performed. If a
defasciculating dose of a nondepolarizing NMBA is administered in addition, the dose of
succinylcholine must be increased to 1.5 to 2 mg/kg IV to overcome the antagonism between
nondepolarizing and depolarizing NMBAs. (See "Clinical use of neuromuscular blocking
agents in anesthesia", section on 'Drug interactions'.)

Succinylcholine causes muscle fasciculations in most patients, which tend to be more severe
in younger and more muscular patients. Administration of succinylcholine can increase
intragastric pressure, primarily as a result of fasciculation of abdominal musculature, though
this effect is variable [80]. A study of thiopental/succinylcholine induction in young,
unpremedicated male patients reported increases in intragastric pressure as high as 30
cmH2O over baseline. The increase was prevented by administration of a defasciculating
dose of nondepolarizing NMBA (eg, vecuronium, rocuronium, cisatracurium). The potential
increase in intragastric pressure may be of particular concern in patients with reduced
competence of the lower esophageal sphincter, such as those with abdominal distention,
hiatal hernia, pregnancy, and gastroesophageal reflux. (See 'Defasciculation' below.)

When masseter muscle spasm occurs after succinylcholine, administration of a

nondepolarizing NMDA may or may not successfully resolve the spasm [81]. If endotracheal
intubation is not possible, mask ventilation should be attempted, and preparations for a
surgical airway should be made. Rarely, masseter muscle spasm progresses to spasm in
extremities and may herald malignant hyperthermia. Isolated masseter spasm usually
resolves over approximately 20 minutes [82]. Succinylcholine is discussed more fully

separately. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on

'Succinylcholine'.)

Defasciculation — We do not routinely administer a defasciculating dose of

nondepolarizing NMBA before succinylcholine, though other clinicians do. A small dose of
nondepolarizing NMBA has been shown to reduce the fasciculations, myalgias, and the
increase in intragastric pressure that result from administration of succinylcholine [80,83].
The defasciculating dose should be 10 percent of the ED95 for the chosen drug (ie, 2 mg
rocuronium IV, 1.5 mg cisatracurium IV, or 0.3 mg vecuronium IV) given two to three minutes
prior to induction. (The ED95 is the median dose of NMBA which results in 95 percent twitch
depression, and is typically much lower than the intubating dose) ( table 2). (See "Clinical
use of neuromuscular blocking agents in anesthesia", section on 'Endotracheal intubation'.)

Higher doses may result in signs of paralysis, including diplopia and difficulty breathing or
swallowing, and should be avoided. If a defasciculating dose is administered, the dose of
succinylcholine must be increased to 1.5 to 2 mg/kg IV to overcome the antagonism between
nondepolarizing and depolarizing NMBAs [84]. Without fasciculations as a marker for
paralysis, a peripheral nerve stimulator may be used to confirm adequate relaxation for
intubation.

A number of other drugs have been studied as pretreatment to prevent fasciculations and
myalgias, with variable results. A meta-analysis of randomized trials concluded that
succinylcholine-induced fasciculations are best prevented with pretreatment with NMBAs,
lidocaine, or magnesium [83].

Alternatives to succinylcholine

Nondepolarizing NMBAs — All nondepolarizing NMBAs have a slower time to onset

and longer duration of action than succinylcholine. When the use of succinylcholine is
contraindicated, high doses of nondepolarizing NMBA can be administered to speed the
onset of paralysis. However, the clinical duration of paralysis will be much longer with the
use of these higher doses. This may be problematic when shorter surgery is planned or
when nerve monitoring will be used during surgery. In addition, if airway management
proves difficult, prolonged paralysis eliminates the option of awakening the patient to allow
spontaneous ventilation.

If rocuronium or vecuronium is used for RSII, even high doses can be reversed relatively
quickly with sugammadex. Importantly, sugammadex may not reverse the effects of muscle
relaxation quickly enough to consider it a "rescue" medication in the cannot intubate, cannot
ventilate scenario, especially in the setting of other depressant medications [85].
Sugammadex is discussed more fully separately. (See "Clinical use of neuromuscular blocking
agents in anesthesia", section on 'Sugammadex'.)

● Rocuronium – When administered for RSII, rocuronium is the nondepolarizing NMBA

that allows the fastest onset of action and the best intubating conditions, with the least
side effects. A relatively high dose of rocuronium is required for RSII. In a meta-analysis
of 50 trials that compared the use of succinylcholine with rocuronium for RSII,
succinylcholine >1mg/kg IV provided superior intubating conditions compared with
rocuronium 0.6 to 0.7 mg/kg IV, but there was no difference in intubating conditions
when rocuronium 0.9 to 1.0 mg/kg IV was administered [86].

The onset and duration of neuromuscular block depends on the dose. After induction
of anesthesia with thiopental, rocuronium 0.9 to 1.2 mg/kg IV achieves maximal
neuromuscular block in 55 to 75 seconds, with clinical duration (recovery of twitch to 25
percent of control) of 53 to 73 minutes [87]. In contrast, succinylcholine 1.5 mg/kg IV
achieves maximal block in 45 to 60 seconds, with a clinical duration of 6 to 10 minutes
[88].)

● Others – While less desirable than rocuronium, cisatracurium and vecuronium are two
other commonly used nondepolarizing NMBAs that can be used for RSII. As compared
with rocuronium, the onset of paralysis with each of these is slower. Rapid onset of
paralysis can be achieved by administration of a high dose, which results in prolonged
duration of action, or by using a priming dose, that is, a small dose (10 percent of the
intubating dose), of NMBA two to four minutes prior to the intubating dose of the drug.

Since the priming dose of NMBA may cause signs of paralysis, including diplopia, blurry
vision, difficulty swallowing, and risk of aspiration [89], we do not routinely administer a
priming dose of NMBA. Recommended doses of vecuronium and cisatracurium for RSII
are as follows:

• Vecuronium – 0.1 mg/kg IV (approximately 2 x ED95) results in a time to maximum

block of 2.4 minutes with a clinical duration (recovery of twitch to 25 percent of
control) of 44 minutes [90]. In one study, a vecuronium dose of 0.2 mg/kg (4 x ED95)
resulted in peak effect in 120 ± 17 seconds and time to recovery of 25 percent of
control twitch height of 68 ± 8 minutes [91]. Like rocuronium, vecuronium can be
reversed with sugammadex.

• Cisatracurium – 0.4 mg/kg IV (approximately 8 x ED95) results in a time to maximum

block of 1.9 minutes with a clinical duration (recovery of twitch to 25 percent of
control) of 91 minutes [92].

If a nondepolarizing NMBA is used (instead of succinylcholine or for defasciculation),

fasciculations do not occur as a marker of paralysis. A peripheral nerve stimulator can
be used to confirm adequate paralysis and optimum intubating conditions prior to
laryngoscopy. (See 'Succinylcholine' above.)

Remifentanil intubation — Remifentanil is an ultrashort-acting opioid that can be

used for RSII as an alternative to succinylcholine. A high-dose remifentanil intubation may be
useful for intubation when the prolonged duration of action of nondepolarizing NMBAs is
undesirable, and sugammadex is unavailable. A high-dose remifentanil intubation involves
administration of propofol (2 to 2.5 mg/kg IV) followed by remifentanil (3 to 5 mcg/kg IV) [93-
95]. We give ephedrine (10 mg IV) along with the propofol for this type of induction to avoid
the profound bradycardia and hypotension that may result from these doses of remifentanil
and propofol. Propofol 2 mg/kg IV has been shown to provide better intubating conditions
than thiopental 6 mg/kg IV or etomidate 0.3 mg/kg IV when given for induction with
remifentanil 3 mcg/kg IV without NMBAs [96].

Observational studies have found high success rates with remifentanil intubation using the
doses described above [93-95]. In a randomized trial that compared intubation with a
hypnotic (propofol in almost all cases) along with remifentanil 3 to 4 mcg/kg IV versus an
NMBA (succinylcholine 1 mg/kg IV or rocuronium 1 mg/kg IV), successful first attempt at
intubation was higher when an NMBA was administered (93.5 versus 88.5 percent, adjusted
difference 4.9 percent, 95% CI 1.6-8.2 percent) [97].

Doses of propofol and remifentanil should be reduced for the elderly and for other patients
who are at risk for hypotension with induction. (See "General anesthesia: Intravenous
induction agents", section on 'Dosing considerations'.)

MASK VENTILATION

Ventilation by mask is traditionally not performed prior to intubation during RSII, to avoid
inflating the stomach and thereby increasing the chance of regurgitation. Without the
application of cricoid pressure, bag-mask ventilation with inflation pressure over 20 cmH2O
can result in inflation and, potentially, distention of the stomach [51]. However, a number of
studies have shown that cricoid pressure prevents gastric insufflation during mask
ventilation in children and adults without airway obstruction and, in adults, with airway
pressures up to 60 cmH2O [49-51].

Patients without decreased oxygen reserve or increased oxygen consumption should not
desaturate during RSII without mask ventilation. For patients expected to desaturate rapidly
with apnea (eg, those with decreased functional residual capacity because of obesity or
increased intraabdominal pressure; those with sepsis or fever), gentle, low-pressure mask
ventilation with cricoid pressure is not likely to inflate or distend the stomach.

Modified RSII — There is no standard definition of "modified RSII," but most commonly it
refers to the combination of cricoid pressure and mask ventilation during induction and
intubation [98]. The modification of RSII may be either the addition of mask ventilation to an

otherwise traditional RSII, or the application of cricoid pressure to a routine induction and
intubation. Common scenarios in which modified RSII may be chosen include the following:

● When airway evaluation suggests that intubation may be difficult for a patient who is at
high risk of aspiration, gentle mask ventilation may be attempted prior to
administration of a neuromuscular blocking agent (NMBA) to prove that ventilation will
be possible if intubation is difficult or prolonged. In this situation, one very low-
pressure breath may be all that is required.

● Mask ventilation may be performed for patients who are likely to desaturate with
apnea, despite preoxygenation. In this situation, several low-pressure breaths (<20
cmH2O) may be required while waiting for paralysis.

● For the patient who may be at unclear but potentially higher risk of regurgitation and
aspiration, cricoid pressure may be applied during routine induction. Examples include
patients with asymptomatic hiatal hernia, morbid obesity without symptoms of
gastroesophageal reflux disease, and patients who have fasted appropriately but who
are receiving opioids.

CHOICE OF LARYNGOSCOPE

As the goal of RSII is to intubate as rapidly as possible, the anesthesia clinician should use
the laryngoscope and blade most likely to succeed on the first attempt. In most cases, this
will be a standard laryngoscope used for direct laryngoscopy with a Macintosh or miller
blade. However, when a difficult airway is expected, a video laryngoscope may be a better
choice, assuming the clinician is facile with its use. (See "Airway management for induction of
general anesthesia", section on 'Prediction of the difficult airway' and "Video laryngoscopes
and optical stylets for airway management for anesthesia in adults", section on 'VL versus
DL'.)

No matter which laryngoscope is chosen for RSII, a backup plan and the necessary
equipment must be immediately available and at the bedside if difficult airway management
is expected. All anesthesia clinicians should be familiar with a difficult airway algorithm
( algorithm 1). (See "Airway management for induction of general anesthesia", section on
'Preparation for induction of anesthesia'.)

For RSII, we place a stylette in the endotracheal tube to add rigidity, to facilitate placement
through the vocal cords, and to increase the chance of success on the first attempt at
laryngoscopy. It is important to recognize that increasing the rigidity of the endotracheal
tube can also potentially increase the risk of injury to the vocal cords or trachea. Once the tip

of the tube is placed through the vocal cords, the stylette should be removed to avoid
trauma to the anterior trachea and the tube advanced under direct vision.

POTENTIAL COMPLICATIONS OF RSII

The decision to perform RSII, to modify the induction sequence, or to perform a standard
sequence induction must take into account the individualized potential risks of each choice.
Potential complications of RSII include difficulty with intubation, hypoxia, hypotension, active
regurgitation, and aspiration.

Difficult or failed airway — Difficult intubation is always a possibility during induction of

anesthesia. If the preoperative airway evaluation suggests potential difficulty with
intubation, an awake or, if necessary, inhalation induction may be chosen instead of RSII.
Difficult intubation is not always predictable [99]. Thus, equipment, personnel, and a backup
plan for airway management must always be ready when RSII is performed. Anesthesia
clinicians should be familiar with a difficult airway algorithm ( algorithm 1 and figure 1).
(See "Management of the difficult airway for general anesthesia in adults" and "Management
of the failed airway during anesthesia".)

Hypoxia — The most common risk of RSII is hypoxia, a potential result of oxygen
desaturation during the period of apnea prior to intubation. Patients with poor oxygen
reserves, such as obese patients, pregnant patients, and patients with pulmonary disease,
may be at higher risk for arterial desaturation, despite preoxygenation. Low-pressure mask
ventilation during RSII may prevent hypoxia and desaturation for such patients. (See
'Modified RSII' above.)

Passive apneic oxygenation using high-flow oxygen through a nasal cannula and continuous
positive airway pressure preoxygenation are strategies that may increase the time to apneic
oxygen desaturation during RSII. (See 'Preoxygenation' above.)

Hypotension — Hypotension is common after RSII, especially for those patients who present
for emergency surgery with hemodynamic instability. Dysrhythmias and cardiac arrest can
also occur in critically ill patients with poor cardiovascular reserve. The selection of induction
agent, rate of administration, and the dose administered should be based on the patient's
clinical condition and comorbidities. (See 'Induction agents' above.)

Regurgitation — Regurgitation may occur during RSII, despite the maneuvers designed to
prevent it. If the patient regurgitates, the head of the operating table should be quickly
tipped down to allow material to drain away from the larynx. The head should be turned to
the side and the oropharynx suctioned prior to intubation. The trachea should be suctioned

prior to administration of a positive pressure breath. If active vomiting occurs, cricoid

pressure should be released to avoid esophageal rupture [100].

Aspiration — Regurgitation and aspiration can occur during RSII, even when protocols are
followed as suggested. The incidence of aspiration during emergency surgical procedures is
approximately 0.15 percent [101].

The sequelae depend on the volume and type of material aspirated and the patient's
comorbidities. Aspiration of small amounts of oral secretions may result in minor
complications, such as cough or tracheal irritation, while aspiration of large-volume,
particulate, or acidic material can result in infection, airway obstruction, acute respiratory
distress syndrome, and death. Evaluation and management of aspiration pneumonia is
discussed more fully separately. (See "Aspiration pneumonia in adults".)

EMERGENCE FROM ANESTHESIA

Patients at high risk of aspiration during induction of anesthesia are also at high risk of
aspiration during emergence from anesthesia. In most cases, an orogastric tube should be
passed during the anesthetic and suctioned and removed immediately prior to emergence.
Patients should remain intubated with the endotracheal tube cuff inflated until responding
to commands and until airway reflexes return. Patients should be transported to the
recovery area with the head of the bed elevated to reduce the chance of reflux.

AIRWAY MANAGEMENT FOR PATIENTS WITH COVID-19

In patients with COVID-19 there may be a high risk of spread of the virus during
laryngoscopy and other airway management procedures. Techniques for improving patient
care and minimizing infectious risks to care providers and spread of the virus during
emergency intubation are summarized in the following table. Other aspects of airway
management in patients with COVID-19 are discussed separately. (See "Overview of infection
control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg,
COVID-19)'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Airway management
in adults" and "Society guideline links: COVID-19 – Index of guideline topics".)

SUMMARY AND RECOMMENDATIONS

● Indications – Rapid sequence induction and intubation (RSII) is routinely performed for
patients at high risk of aspiration during the induction of general anesthesia. The risk of
aspiration should be balanced against the risk of difficult intubation, hypoxia during
apnea, and hypotension with RSII. (See 'General indications' above.)

● Preparation

• For patients who are at high risk of aspiration, we suggest the administration of
antacid medication before induction to increase the pH of gastric contents (Grade
2C). For pregnant patients and for those at high risk of aspiration, we routinely
administer clear, nonparticulate antacid prior to induction (eg, sodium citrate-citric
acid, 30 mL by mouth). For nonpregnant patients at high risk of aspiration who have
not received a proton pump inhibitor or histamine-2 receptor antagonist (H2RA) on
the morning of surgery, we also administer an H2RA 40 to 60 minutes prior to
induction (eg, famotidine 20 mg IV). (See 'Premedication' above.)

• An assistant who is familiar with correct application of cricoid pressure and with
assistance with airway management should be present for RSII. A back-up plan for
airway management should be determined prior to induction, and the anesthesia
clinician should be familiar with a difficult airway management algorithm
( algorithm 1). (See 'Cricoid pressure during RSII' above.)

● Goals and components of RSII – An essential goal of RSII is to achieve adequate depth
of anesthesia and, most often, paralysis for laryngoscopy, to prevent coughing,
straining, and active vomiting with airway manipulation.

Components of RSII are designed to protect the airway with a cuffed endotracheal tube
as quickly as possible after induction of anesthesia, while preventing passive or active
regurgitation of stomach contents. They include:

• Preoxygenation (see 'Preoxygenation' above)

• Application of cricoid pressure ( figure 3) (see 'Cricoid pressure during RSII' above)
• Administration of an anesthesia induction agent, followed immediately by
administration of succinylcholine (see 'Choice of medications' above)
• Avoidance of mask ventilation prior to endotracheal intubation (see 'Mask
ventilation' above)
• Endotracheal intubation with inflation of the endotracheal tube cuff as quickly as
possible (see 'Choice of laryngoscope' above)

Not all of these components will be appropriate for every patient.

● Cricoid pressure – We suggest the application of cricoid pressure during RSII (Grade
2C). Despite conflicting evidence regarding the effectiveness of cricoid pressure for
preventing regurgitation, clinical experience suggests that, in most situations, it is not
harmful and may be beneficial. We shift or release pressure if laryngoscopy proves
difficult, and release cricoid pressure if active vomiting occurs. We avoid cricoid
pressure in patients with acute cervical spinal cord injury. (See 'Cricoid pressure during
RSII' above.)

● Induction of anesthesia

• We typically titrate the anesthesia induction agent to loss of consciousness prior to

the administration of a neuromuscular blocking agent (NMBA). We prefer propofol
for hemodynamically stable patients. Ketamine and etomidate are alternatives for
hemodynamically unstable patients. (See 'Induction agents' above.)

• For most cases, we suggest the use of succinylcholine (1 to 1.5 mg/kg) rather than
nondepolarizing NMBAs for RSII (Grade 2C). If a defasciculating dose of a
nondepolarizing NMBA is administered in addition, the dose of succinylcholine must
be increased to 1.5 to 2 mg/kg IV to overcome the antagonism between
nondepolarizing and depolarizing NMBAs. (See 'Succinylcholine' above.)

• If succinylcholine is contraindicated, rocuronium can provide rapid onset of paralysis

but results in prolonged duration of action, which may be undesirable. High-dose
remifentanil induction is an alternative to RSII with an NMBA. (See 'Alternatives to
succinylcholine' above.)

● Modified RSII – RSII may be modified to include low-pressure mask ventilation to prove
the ability to ventilate prior to paralysis or to prevent hypoxia for patients with reduced
oxygen reserve. (See 'Modified RSII' above.)

● Emergence from anesthesia – Patients at high risk of aspiration during induction of

anesthesia are also at high risk of aspiration during emergence from anesthesia. Prior
to emergence, the stomach should be emptied using an orogastric or nasogastric tube.
(See 'Emergence from anesthesia' above.)

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Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S444.

41. Hung KC, Hung CT, Poon YY, et al. The effect of cricoid pressure on tracheal intubation in
adult patients: a systematic review and meta-analysis. Can J Anaesth 2021; 68:137.

42. Algie CM, Mahar RK, Tan HB, et al. Effectiveness and risks of cricoid pressure during
rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev
2015; :CD011656.
43. Mills P, Poole T, Curran J. Cricoid pressure and the pressor response to tracheal
intubation. Anaesthesia 1988; 43:788.
44. Birenbaum A, Hajage D, Roche S, et al. Effect of Cricoid Pressure Compared With a Sham
Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical
Trial. JAMA Surg 2019; 154:9.
45. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence
tracheal intubations: a risk-benefit analysis. Ann Emerg Med 2007; 50:653.
46. Salem MR, Joseph NJ, Heyman HJ, et al. Cricoid compression is effective in obliterating
the esophageal lumen in the presence of a nasogastric tube. Anesthesiology 1985;
63:443.
47. Fanning GL. The efficacy of cricoid pressure in preventing regurgitation of gastric
contents. Anesthesiology 1970; 32:553.

48. Salem MR, Wong AY, Fizzotti GF. Efficacy of cricoid pressure in preventing aspiration of
gastric contents in paediatric patients. Br J Anaesth 1972; 44:401.

49. Salem MR, Wong AY, Mani M, Sellick BA. Efficacy of cricoid pressure in preventing gastric
inflation during bag-mask ventilation in pediatric patients. Anesthesiology 1974; 40:96.
50. Moynihan RJ, Brock-Utne JG, Archer JH, et al. The effect of cricoid pressure on preventing
gastric insufflation in infants and children. Anesthesiology 1993; 78:652.
51. Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid
sequence induction. Br J Anaesth 1987; 59:315.
52. Zeidan AM, Salem MR, Mazoit JX, et al. The effectiveness of cricoid pressure for
occluding the esophageal entrance in anesthetized and paralyzed patients: an
experimental and observational glidescope study. Anesth Analg 2014; 118:580.
53. Neelakanta G. Cricoid pressure is effective in preventing esophageal regurgitation.
Anesthesiology 2003; 99:242.
54. Smith KJ, Ladak S, Choi PT, Dobranowski J. The cricoid cartilage and the esophagus are
not aligned in close to half of adult patients. Can J Anaesth 2002; 49:503.
55. Smith KJ, Dobranowski J, Yip G, et al. Cricoid pressure displaces the esophagus: an
observational study using magnetic resonance imaging. Anesthesiology 2003; 99:60.

56. Rice MJ, Mancuso AA, Gibbs C, et al. Cricoid pressure results in compression of the
postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg 2009;
109:1546.
57. Tournadre JP, Chassard D, Berrada KR, Boulétreau P. Cricoid cartilage pressure decreases
lower esophageal sphincter tone. Anesthesiology 1997; 86:7.
58. Skinner HJ, Bedforth NM, Girling KJ, Mahajan RP. Effect of cricoid pressure on gastro-
oesophageal reflux in awake subjects. Anaesthesia 1999; 54:798.

59. Harris T, Ellis DY, Foster L, Lockey D. Cricoid pressure and laryngeal manipulation in 402
pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid
safe intubation? Resuscitation 2010; 81:810.
60. El-Orbany M, Connolly LA. Rapid sequence induction and intubation: current
controversy. Anesth Analg 2010; 110:1318.
61. Vanner RG, Clarke P, Moore WJ, Raftery S. The effect of cricoid pressure and neck
support on the view at laryngoscopy. Anaesthesia 1997; 52:896.
62. Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy.
Anaesthesia 2005; 60:41.

63. Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence
INduction of Anesthesia. JAMA Surg 2018.
64. Manning BJ, Winter DC, McGreal G, et al. Nasogastric intubation causes
gastroesophageal reflux in patients undergoing elective laparotomy. Surgery 2001;
130:788.
65. Langley MS, Heel RC. Propofol. A review of its pharmacodynamic and pharmacokinetic
properties and use as an intravenous anaesthetic. Drugs 1988; 35:334.
66. Scheffer GJ, Ten Voorde BJ, Karemaker JM, et al. Effects of thiopentone, etomidate and
propofol on beat-to-beat cardiovascular signals in man. Anaesthesia 1993; 48:849.
67. Schenarts CL, Burton JH, Riker RR. Adrenocortical dysfunction following etomidate
induction in emergency department patients. Acad Emerg Med 2001; 8:1.
68. Cherfan AJ, Arabi YM, Al-Dorzi HM, Kenny LP. Advantages and disadvantages of
etomidate use for intubation of patients with sepsis. Pharmacotherapy 2012; 32:475.
69. Bruder EA, Ball IM, Ridi S, et al. Single induction dose of etomidate versus other
induction agents for endotracheal intubation in critically ill patients. Cochrane Database
Syst Rev 2015; 1:CD010225.

70. Pagel PS, Kampine JP, Schmeling WT, Warltier DC. Ketamine depresses myocardial
contractility as evaluated by the preload recruitable stroke work relationship in
chronically instrumented dogs with autonomic nervous system blockade.
Anesthesiology 1992; 76:564.

71. Tweed WA, Minuck M, Mymin D. Circulatory responses to ketamine anesthesia.

Anesthesiology 1972; 37:613.
72. Russo H, Bressolle F. Pharmacodynamics and pharmacokinetics of thiopental. Clin
Pharmacokinet 1998; 35:95.
73. Eames WO, Rooke GA, Wu RS, Bishop MJ. Comparison of the effects of etomidate,
propofol, and thiopental on respiratory resistance after tracheal intubation.
Anesthesiology 1996; 84:1307.

74. Aouad MT, Sayyid SS, Zalaket MI, Baraka AS. Intravenous lidocaine as adjuvant to
sevoflurane anesthesia for endotracheal intubation in children. Anesth Analg 2003;
96:1325.
75. Davidson JA, Gillespie JA. Tracheal intubation after induction of anaesthesia with
propofol, alfentanil and i.v. lignocaine. Br J Anaesth 1993; 70:163.

76. Jakobsen CJ, Ahlburg P, Holdgård HO, et al. Comparison of intravenous and topical
lidocaine as a suppressant of coughing after bronchoscopy during general anesthesia.
Acta Anaesthesiol Scand 1991; 35:238.
77. Yukioka H, Hayashi M, Terai T, Fujimori M. Intravenous lidocaine as a suppressant of
coughing during tracheal intubation in elderly patients. Anesth Analg 1993; 77:309.
78. Grover VK, Reddy GM, Kak VK, Singh S. Intracranial pressure changes with different
doses of lignocaine under general anaesthesia. Neurol India 1999; 47:118.
79. Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid
sequence induction intubation. Cochrane Database Syst Rev 2008; :CD002788.

80. Miller RD, Way WL. Inhibition of succinylcholine-induced increased intragastric pressure
by nondepolarizing muscle relaxants and lidocaine. Anesthesiology 1971; 34:185.
81. Gill M, Graeme K, Guenterberg K. Masseter spasm after succinylcholine administration. J
Emerg Med 2005; 29:167.
82. Schwartz L, Rockoff MA, Koka BV. Masseter spasm with anesthesia: incidence and
implications. Anesthesiology 1984; 61:772.
83. Schreiber JU, Lysakowski C, Fuchs-Buder T, Tramèr MR. Prevention of succinylcholine-
induced fasciculation and myalgia: a meta-analysis of randomized trials. Anesthesiology
2005; 103:877.
84. Szalados JE, Donati F, Bevan DR. Effect of d-tubocurarine pretreatment on
succinylcholine twitch augmentation and neuromuscular blockade. Anesth Analg 1990;
71:55.
85. Naguib M, Brewer L, LaPierre C, et al. The Myth of Rescue Reversal in "Can't Intubate,
Can't Ventilate" Scenarios. Anesth Analg 2016; 123:82.

86. Tran, D, Newton, et al. Rocuronium vs. succinylcholine for rapid sequence intubation: a
Cochrane systematic review. Anaesthesia 2017; 72:765.
87. Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and
vecuronium for rapid-sequence induction of anesthesia in adult patients.
Anesthesiology 1993; 79:913.
88. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for
excellent endotracheal intubating conditions. Anesth Analg 2006; 102:151.

89. Engbaek J, Howardy-Hansen P, Ording H, Viby-Mogensen J. Precurarization with

vecuronium and pancuronium in awake, healthy volunteers: the influence on
neuromuscular transmission and pulmonary function. Acta Anaesthesiol Scand 1985;
29:117.
90. Agoston S, Salt P, Newton D, et al. The neuromuscular blocking action of ORG NC 45, a
new pancuronium derivative, in anaesthetized patients. A pilot study. Br J Anaesth 1980;
52 Suppl 1:53S.

91. Tullock WC, Diana P, Cook DR, et al. Neuromuscular and cardiovascular effects of high-
dose vecuronium. Anesth Analg 1990; 70:86.
92. Belmont MR, Lien CA, Quessy S, et al. The clinical neuromuscular pharmacology of
51W89 in patients receiving nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology
1995; 82:1139.
93. Bouvet L, Stoian A, Rimmelé T, et al. Optimal remifentanil dosage for providing excellent
intubating conditions when co-administered with a single standard dose of propofol.
Anaesthesia 2009; 64:719.
94. Trabold F, Casetta M, Duranteau J, et al. Propofol and remifentanil for intubation without
muscle relaxant: the effect of the order of injection. Acta Anaesthesiol Scand 2004;
48:35.
95. Klemola UM, Mennander S, Saarnivaara L. Tracheal intubation without the use of muscle
relaxants: remifentanil or alfentanil in combination with propofol. Acta Anaesthesiol
Scand 2000; 44:465.
96. Erhan E, Ugur G, Gunusen I, et al. Propofol - not thiopental or etomidate - with
remifentanil provides adequate intubating conditions in the absence of neuromuscular
blockade. Can J Anaesth 2003; 50:108.
97. Grillot N, Lebuffe G, Huet O, et al. Effect of Remifentanil vs Neuromuscular Blockers
During Rapid Sequence Intubation on Successful Intubation Without Major
Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial. JAMA
2023; 329:28.
98. Ehrenfeld JM, Cassedy EA, Forbes VE, et al. Modified rapid sequence induction and
intubation: a survey of United States current practice. Anesth Analg 2012; 115:95.

99. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J
Anaesth 2012; 109 Suppl 1:i68.
100. Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia
1991; 46:40.
101. Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid
sequence induction. Can J Anaesth 2007; 54:748.
Topic 94214 Version 41.0

GRAPHICS

Conditions that increase risk of aspiration during induction of anesthesia

Full stomach – nonfasted, emergency surgery or trauma

Pregnancy after 12 to 20 weeks gestation (gestational age for increased risk is controversial)

Symptomatic gastroesophageal reflux

Diabetic or other gastroparesis

Hiatal hernia

Gastric outlet obstruction

Esophageal pathology

Bowel obstruction

Increased intra-abdominal pressure – ascites, abdominal mass

Graphic 98506 Version 8.0

ASA difficult airway algorithm: Adults

ASA: American Society of Anesthesiologists; CO2: carbon dioxide.

* The airway manager's choice of airway strategy and techniques should be based on their previous
experience; available resources, including equipment, availability and competency of help; and the
context in which airway management will occur.

¶ Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive
ventilation during preoxygenation.

Δ Awake intubation techniques include flexible bronchoscope, videolaryngoscopy, direct

laryngoscopy, combined techniques, and retrograde wire-aided intubation.

◊ Invasive airway techniques include surgical cricothyrotomy, needle cricothyrotomy with a pressure-
regulated device, large-bore cannula cricothyrotomy, or surgical tracheostomy. Elective invasive
airway techniques include the above and retrograde wire-guided intubation and percutaneous
tracheostomy. Also consider rigid bronchoscopy and extracorporeal membrane oxygenation.

§ Other options include, but are not limited to, alternative awake technique, awake elective invasive
airway, alternative anesthetic techniques, induction of anesthesia (if unstable or cannot be
postponed) with preparations for emergency invasive airway, and postponing the case without
attempting the above options.

¥ Consideration of size, design, positioning, and first versus second generation supraglottic airways
may improve the ability to ventilate.

‡ Includes postponing the case or postponing the intubation and returning with appropriate
resources (eg, personnel, equipment, patient preparation, awake intubation).

† Alternative difficult intubation approaches include but are not limited to video-assisted
laryngoscopy, alternative laryngoscope blades, combined techniques, intubating supraglottic airway
(with or without flexible bronchoscopic guidance), flexible bronchoscopy, introducer, and lighted stylet
or light wand. Adjuncts that may be employed during intubation attempts include tracheal tube
introducers, rigid stylets, intubating stylets, or tube changers and external laryngeal manipulation.

** Other options include, but are not limited to, proceeding with procedure utilizing face mask or
supraglottic airway ventilation. Pursuit of these options usually implies that ventilation will not be
problematic.

From: Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for
Management of the Difficult Airway. Anesthesiology 2021. DOI: 10.1097/ALN.0000000000004002. Copyright © 2021 American
Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this
material is prohibited.

Graphic 134460 Version 1.0

Difficult airway infographic: Adult patients

This figure provides three tools to aid in airway management for the patient with a planned,
anticipated difficult, or unanticipated difficult airway.

Part 1 is a decision tool that incorporates relevant elements of evaluation and is intended to assist
in the decision to enter the awake airway management pathway or the airway management with
the induction of anesthesia pathway of the ASA difficult airway algorithm.

Part 2 is an awake intubation algorithm.

Part 3 is a strategy for managing patients with induction of anesthesia when an unanticipated
difficulty with ventilation (as determined by capnography) with a planned airway technique is
encountered.

ECMO: extracorporeal membrane oxygenation.

* The airway manager's assessment and choice of techniques should be based on their previous
experience; available resources, including equipment, availability, and competency of help; and the
context in which airway management will occur.

¶ Review airway strategy: Consider anatomical/physiologic airway difficulty risk, aspiration risk,
infection risk, other exposure risk, equipment and monitoring check, role assignment, and backup
and rescue plans. Awake techniques include flexible intubation scope, videolaryngoscopy, direct
laryngoscopy, supraglottic airway, combined devices, and retrograde wire-aided.

Δ Invasive airways include surgical cricothyroidotomy, needle cricothyroidotomy with a pressure-

regulated device, large-bore cannula cricothyroidotomy, or surgical tracheostomy. Elective invasive
airways include the above, retrograde wire-guided intubation, and percutaneous tracheostomy. Other
options include rigid bronchoscopy and ECMO.

◊ Invasive airway is performed by an individual trained in invasive airway techniques, whenever

possible.

§ Adequate ventilation by any means (eg, face mask, supraglottic airway, tracheal intubation) should
be confirmed by capnography, when possible.

¥ Follow-up care includes postextubation care (ie, steroids, racemic epinephrine), counseling,
documentation, team debriefing, and encouraging patient difficult airway registry.

‡ Postpone the case/intubation and return with appropriate resources (eg, personnel, equipment,
patient preparation, awake intubation).

† In an unstable situation or when airway management is mandatory after a failed awake intubation,
a switch to the airway management with the induction of anesthesia pathway may be entered with
preparations for an emergency invasive airway.

** Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive
ventilation during preoxygenation.

¶¶ Alternative device examples: supraglottic airway, direct laryngoscope, videolaryngoscope, flexible

intubation scope.

ΔΔ Limit attempts ¥¥ , alternate and optimize ‡‡ techniques, avoid task fixation.

◊◊ First versus second generation supraglottic airway with intubation capability for initial or rescue
supraglottic airway.

§§ Videolaryngoscopy as an option for initial or rescue tracheal intubation.

¥¥ The intent of limiting attempts at tracheal intubation and supraglottic airway insertion is to reduce
the risk of bleeding, edema, and other types of trauma that may increase the difficulty of mask
ventilation and/or subsequent attempts to secure a definitive airway. Persistent attempts at any
airway intervention, including ineffective mask ventilation, may delay obtaining an emergency
invasive airway. A reasonable approach may be to limit attempts with any technique class (ie, face
mask, supraglottic airway, tracheal tube) to three, with one additional attempt by a clinician with
higher skills.

‡‡ Optimize: suction, relaxants, repositioning. Face mask: oral/nasal airway, two-hand mask grip.
Supraglottic airway: size, design, repositioning, first versus second generation. Tracheal tube:
introducer, rigid stylet, hyperangulated videolaryngoscopy, blade size, external laryngeal
manipulation. Consider other causes of inadequate ventilation (including but not limited to
laryngospasm and bronchospasm).

Graphic 135096 Version 1.0

Ramp position illustration

In the ramp position, the patient's head and torso are elevated such that the external auditory meatus
and the sternal notch are horizontally aligned (black line). This position allows for a better view of the
glottis in patients with obesity and should be used unless there are contraindications (eg, possible
cervical spine injury).

Graphic 95285 Version 5.0

Cricoid pressure (Sellick maneuver)

Cricoid pressure (Sellick maneuver). Posterior displacement of the airway cartilages occludes the
compliant esophagus. In infants and young children, the tracheal cartilage is also very compliant, and
excessive force while applying cricoid pressure may impair airway patency.

Reproduced with permission from: King C, Rappaport LD. Emergent endotracheal intubation. In: Textbook of Pediatric
Emergency Procedures, 2nd ed, King C, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. Copyright © 2008
Lippincott Williams & Wilkins. www.lww.com.

Graphic 71800 Version 13.0

Cormack-Lehane and Modified Cormack-Lehane grading systems for

laryngoscopy

The Cormack-Lehane scale [1] describes the best view of the glottis during laryngoscopy, with grades
defined by the structures that can be seen, as follows:
Grade 1 – Most of the glottis
Grade 2 – Only the posterior extremity of the glottis
Grade 3 – Only the epiglottis
Grade 4 – Neither the glottis nor the epiglottis

Difficult laryngoscopy is usually defined as a grade 3 or 4 view.

A modified version [2] of the Cormack-Lehane grading system divides Grade 2 into Grade 2a and 2b:
Grade 2a – Only part of the vocal cords is visible
Grade 2b – Only the arytenoids or the very posterior origin of the cords are visible

A further modification [3] divides Grade 3 as follows:

Grade 3a - Epiglottis can be seen and lifted (eg, with a bougie)
Grade 3b - Epiglottis can be seen but not lifted

Reference:

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19/1/24, 6:22 Rapid sequence induction and intubation (RSII) for anesthesia - UpToDate
1. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:1105.
2. Yentis SM, Lee DJ. Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 1998;
53:1041.
3. Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000; 55:274.

Graphic 141367 Version 2.0

Properties of neuromuscular blocking agents

Agent Vecuronium Rocuronium Pancuronium * Mivacurium ¶ A

Type (structure) Non- Non- Non-depolarizing Non-depolarizing N

depolarizing depolarizing

Type (duration) Intermediate Intermediate Long Short In

Potency – ED95 0.04 0.3 0.07 0.08 0

(mg/kg)

Intubating dose 0.1 to 0.2 Δ 0.6 to 1 (1.2 0.08 to 0.12 0.2 0

(mg/kg) with RSII
dose) ◊

Onset time (min) 3 to 4 1 to 2 2 to 3 3 to 4 3

Time to 25% 20 to 35 30 to 50 (60 to 60 to 120 15 to 20 20

recovery (min) 80 with RSII
dose)

Elimination half-life (min)

Normal 50 to 60 60 to 100 100 to 130 2 to 2.5 2

organ
function

Renal Mild increase 100 to 300 Increased ×2 3 to 4 2

impairment

Hepatic Significant 120 to 400 Increased ×2 3 to 6 2

impairment increase

Intermittent 0.01 0.1 0.02 0.1 0

maintenance
dose (mg/kg) ¥

Starting infusion 1 to 2 5 to 12 Not 5 to 8 4

dose recommended
(mcg/kg/min) ‡

Elimination Renal 10 to Renal 30%; Renal 40 to 70%; Plasma R

route/metabolism 50%; hepatic 70% hepatic 20% cholinesterase (70% H
hepatic 30 to of succinylcholine es
50% rate) 60

Active 3-desacetyl- 17-desacetyl- 3-OH- No active metabolites N

metabolites vecuronium rocuronium pancuronium; 17- m
(minimal) OH-pancuronium

Side effects Vagal Minimal Vagal block Histamine release H

blockade with (tachycardia), re
large doses catecholamine la
release ac
p

Contraindications None None Short surgical Pseudocholinesterase H

(other than procedures (<60 deficiency u
specific allergy) min); not d
recommended re
for continuous
infusion

Comments Not for Pain on Significant Reversal by O

prolonged ICU injection; accumulation, cholinesterase in
administration easily prone to residual inhibitors; mixture of e
(myopathy); reversible by block (3-OH 3 isomers (cis-cis
reversible by sugammadex; metabolite has minimal);
sugammadex; elimination 50% activity of edrophonium for
elimination half-life pancuronium) antagonism more
half-life halved prolonged in effective during deep
in late ICU patient; block
pregnancy; 3- 17-desacetyl
desacetyl metabolite has
metabolite 20% activity
has 60% of the
parent
compound
potency

The data in this table are averages obtained from published literature and do not account for other
influences such as the use of volatile anesthetics or muscle temperature. For further information refer
to UpToDate content on clinical use of neuromuscular blocking agents.

ED95: effective dose to achieve 95% depression of baseline muscle contraction; ICU: intensive care
unit; K + : potassium; MH: malignant hyperthermia; N/A: data not available; NMBA: neuromuscular
blocking agents; RSII: rapid sequence induction and intubation; ST: single twitch.

* Pancuronium is no longer available in the United States, Canada, or Europe. It is available in several
countries around the world.

¶ Mivacurium is no longer available in the United States or Canada. It is available in many other
countries.

Δ Vecuronium at a dose of 0.1 to 0.2 mg/kg may be used for RSII in patients for whom succinylcholine
is contraindicated and rocuronium is unavailable; onset of paralysis will be delayed compared with
those preferred agents.

◊ Some experts use a higher dose, 1.5 mg/kg IV, of rocuronium for rapid sequence induction in the
emergency department. Refer to UpToDate content on rapid sequence in duction for emergency
intubation.

§ Cisatracurium at a dose of 0.4 mg/kg may be used for RSII in patients for whom succinylcholine is
contraindicated and rocuronium is unavailable; onset of paralysis will be delayed compared with
those preferred agents.

¥ Intermittent dosing titrated to endpoints such as ventilator synchrony may be preferred to

continuous infusions in the ICU. Higher intermittent maintenance doses may be used in the ICU to
provide a longer duration of action and to avoid continuous infusion.

‡ The starting infusion dose presumes that an intubating dose or a similar loading dose has been
given prior to starting the infusion. The infusion dose should be adjusted thereafter based on
monitoring.

Adapted from: Brull SJ. Neuromuscular blocking agents. In: Clinical Anesthesia, 8th ed, Barash PG, Cullen BF, Stoelting RK, et al
(Eds), Wolters Kluwer, Philadelphia 2017.

Graphic 114271 Version 8.0

Contributor Disclosures
Lauren C Berkow, MD, FASA Consultant/Advisory Boards: Masimo [Monitoring]; Member of Ai
Endoscopic International Medical Advisory Network [no monies received; provide input on
development of a robotic assisted intubation device]; Teleflex [Airway management]. All of the relevant
financial relationships listed have been mitigated. Carin A Hagberg, MD, FASA Grant/Research/Clinical
Trial Support: Ambu [Airway management]; Fisher & Paykel Health Limited [Airway management]; Karl
Storz Endoscopy [Airway management]; Teleflex [Airway management]; Vivid Lane [Digital and
behavioral tele-health]; Vyaire Medical [Airway management, respiratory diagnostics, ventilation and
operative care consumables]. Other Financial Interest: Elsevier [Honoraria]. All of the relevant financial
relationships listed have been mitigated. Marianna Crowley, MD No relevant financial relationship(s)
with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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