Rapid Sequence Induction

Question 1

What are NPO orders for rapid sequence induction?

Answer 1

NPO Orders: 2-4-6-8

• Patients must not consume clear fluids within 2 hours of surgery
• Pediatric patients must not consume breast milk within 4 hours of surgery
• Pediatric patients must not consume formula within 6 hours of surgery; patients must not consume a
  “tea and toast” diet within 6 hours of surgery
• Patients must not consume non-clear fluids and food within 8 hours of surgery

Question 2

What are the categories for aspiration risk factors?

Answer 2

• Full stomach
• Decrease LOC
• Impaired airway reflexes
• Abnormal anatomy
• Decrease GE competence
• Increased intragastric pressure
• Delayed gastric emptying

Question 3

For a full stomach as a category for aspiration risk factors, what can this arise from?

Answer 3

Non-fasted, trauma

Question 4

With decreased LOC as a category for aspiration risk factors, what can lead to a decreased LOC?

Answer 4

• Drug/EtOH overdose,
• Anesthesia,
• Head injury,
• CNS
• Pathology,
• Trauma

Question 5

With impaired airway reflexes as a category for aspiration risk factors, what can lead to impaired airway reflexes?

Answer 5

• Prolonged intubation,
• Local airway anesthesia,
• Decreased LOC,
• Myopathy,
• CVA

Question 6

With abnormal anatomy being a category for aspiration risk factors, what can lead to abnormal anatomy?

Answer 6

• Zenker’s diverticulum,

- Esophageal stricture

Question 7

With decreased GE competence being a category for aspiration risk factors, what can cause decrease GE competence?

Answer 7

• NG tube,
• elderly,
• pregnancy,
• hiatus hernia,
• obesity

Question 8

With increased intragastric pressure being a category for aspiration risk factors, what can cause increased intragastric pressure?

Answer 8

• Pregnancy,
• obesity,
• bowel obstruction,
• large abdominal tumor, -
  ascites

Question 9

With delayed gastric emptying being a category for aspiration risk factors, what can cause delayed gastric emptying?

Answer 9

• Narcotics,
• anticholinergics,
• fear,
• pain,
• labor,
• trauma,
• pregnancy,
• renal failure,
• DM

Question 10

What are predisposing risk factors for aspiration?

Answer 10

• Preoperative fasting
• H2 antagonists (decreases acid production)
• Antacids (decreases acidity)
• Metoclopramide (increases GI motility)
• Antiemetics
• NG tube prior to induction
• Cricoid pressure on induction
• Awake extubation in recovery position
• Regional or local anesthetic

Question 11

What is the technique for rapid sequence intubation?

Answer 11

1. Preoxygenation for at least 3 minutes
2. Application of cricoid pressure with loss of consciousness (i.e., Sellick Manuever)
3. Administration of IV anesthestics and a muscle relaxant
4. Endotracheal intubation
5. Confirmation of ETT placement and release of cricoid pressure

Question 12

For rapid sequence induction, what if you don’t have time to preoxygenate for at least 3 minutes?

Answer 12

• If time is limited, four large breaths of 100% O2 will replace > 95% of the nitrogen in the
  patient’s lung with oxygen

Question 13

For the Sellick maneuver, how much pressure would we use and how would we do it?

Answer 13

Use thumb and index finger to apply 10 lbs of posterior pressure
on the cricoid ring to occlude the esophagus

Question 14

What is 10 lbs of pressure equivalent to?

Answer 14

10 lbs of pressure is equivalent
to applying pressure upon the
bridge of your nose until it
becomes uncomfortable

Question 15

What is the drawback of using the Sellick maneuver?

Answer 15

Note: this maneuver may make visualizing the larynx for

intubation difficult

Question 16

What should we not confuse the Sellick maneuver with?

Answer 16

o Do not confuse this maneuver with the BURP maneuver

Question 17

For rapid sequence induction, what medications would we use?

Answer 17

• Propofol
• Etomidate
• Ketamine
• Succinylcholine
• Recouronium

Question 18

For using propofol for rapid sequence induction, what would the dose be, what kind of onset should we expect, the duration of the drug, and the side effect we will most notably see?

Answer 18

1. Dose: 1-2.5 mg/kg (I think Dr. Roman said around 2 mg/kg)
2. Onset: ABCT
3. Duration: 10 min
4. Side effect: Decreases BP

Question 19

For using Etomidate for rapid sequence induction, what would the dose be, what kind of onset should we expect, the duration of the drug, and the side effect we will most notably see?

Answer 19

1. Dose: 0.2-0.3 mg/kg\
2. Onset: ABCT
3. Duration: 10 min
4. Side effect: Limited effect on BP

Question 20

For using Ketamine for rapid sequence induction, what would the dose be, what kind of onset should we expect, the duration of the drug, and the side effect we will most notably see?

Answer 20

1. Dose: 1-2 mg/kg
2. Onset: ABCT
3. Duration: 10 min
4. Side effect: Increases BP and HR

Question 21

For using Succinylcholine for rapid sequence induction, what would the dose be, what kind of onset should we expect, the duration of the drug, and the side effect we will most notably see?

Answer 21

1. Dose: 1-2 mg/kg
2. Onset: 60 sec
3. Duration: 7-10 min
4. Side effect: Hyperkalemia

Question 22

For using Recouronium for rapid sequence induction, what would the dose be, what kind of onset should we expect, the duration of the drug, and the side effect we will most notably see?

Answer 22

1. Dose: 0.3-0.6 mg/kg
2. Onset: 90 sec
3. Duration: 45 min
4. Side effect: High dose required for RSI