Introduction

Various studies analyzing lawsuits in anesthesiology and examining adverse events link failures in airway management to preventable death and permanent brain damage ^1-2. Despite proposals suggesting that injuries and deaths related to airway management should be considered “never events” ³, a historical observational study spanning 20 years found that 31% of preventable errors leading to unexpected deaths were due to failures in airway management, particularly in the timing of advanced management (4). Analyses of lawsuits for perioperative pulmonary aspiration conclude that the second leading cause, accounting for 33% of cases, was the failure to properly perform a Rapid Sequence Induction and Intubation (RSII) ⁵.

RSII was first proposed in 1970. The classic description included pre-oxygenation for two minutes, the use of thiopental and succinylcholine, the application of cricoid pressure, a period of nonventilation with a face mask, and finally, intubation using an endotracheal tube with a cuff ⁶. Over the years, each of these components has been scrutinized and elaborated upon, leading to changes in the original description. This necessitates a synthesis of available evidence. A narrative review is conducted for this purpose.

Methodology

Information Sources and Search Strategy

A non-systematic search was carried out on Medline, Embase, and CENTRAL databases, using the MeSH terms Rapid Sequence Induction and Intubation, Intratracheal Intubation, Ketamine, Etomidate, Propofol, Midazolam, Succinylcholine, Rocuronium, Emergency Medical Services, Emergency Medicine, and Airway Management. This was complemented by a search for references and other sources considered relevant by the authors.

Review

Definition

Rapid Sequence Induction and Intubation is a strategy based on the administration of full-dose neuromuscular relaxation and induction, aiming to minimize complications arising from bronchoaspiration, apnea, and autonomic response and to improve the conditions for advanced airway management. While the choice of the inducing agent and its dosage will depend on the patient’s clinical context, the use of full doses of drugs, especially of the neuromuscular relaxant, shortens the latency period of their effects and allows for quicker tracheal intubation.

Indications

RSII is indicated in scenarios involving the loss of airway protection or patency, the deterioration of ventilation or oxygenation, and cases where such losses are anticipated and there is a high risk of bronchoaspiration. Common indications include acute neurological disorders associated or not with trauma or poisoning, imminent ventilatory failure due to unresponsive obstructive disorders, and, in the perioperative setting, non-fasting patients requiring urgent surgical intervention ⁷.

Contraindications

The contraindications for RSII are relative. In patients with clear predictors of difficult airway (DA), the safest approach is awake orotracheal intubation, as conventional techniques are often not successful; thus, induction and relaxation are not recommended for these patients. If emergency action is required due to imminent ventilatory failure in patients with DA, a double setup is recommended. This strategy involves having, in addition to RSII, all the preparations on the table for maneuvers of an open translaryngeal technique like cricothyroidotomy ^8-9. On the other hand, RSII is not indicated in the case of loss of ventilation with airway collapse, that is, in situations of no ventilation and no oxygenation, where immediate cricothyroidotomy should be performed due to the high risk of permanent brain damage and death ^8,10. Finally, this strategy is not indicated in the scenario of crash intubation or crash airway, which applies to unresponsive patients with deteriorated or absent cardiopulmonary function (cardiopulmonary arrest) or nearing death, who cannot maintain ventilation and oxygenation themselves and are in an altered state of consciousness with loss of muscle contraction ¹¹.

General Overview and Steps

As a didactic strategy, the mnemonic of the “seven Ps” has been used, consisting of various points that help to remember the steps to follow in an RSII (see Figure 1).

Preparation

This step begins with knowledge acquisition, initially theoretical and later practical, through simulation and hands-on patient experience. It also involves identifying the needs for supplies and medications based on an understanding of the work service’s operation, even before interacting with the patient, to reduce complications and increase the likelihood of successful intubation on the first attempt. The equipment that should be prepared includes the following:

• Intravenous Therapy: Verified permeable venous access and required medications.

• Oxygen Therapy: Sources of oxygen, equipment for administering pre-oxygenation and positive pressure ventilation, for example, self-inflating bag with reservoir and oxygen connection, Ayre Rees or anesthesia machine with circuit and facial mask according to patient type.

• Focused Monitoring for Identifying Complications: In a multicenter study across 29 countries involving 3659 patients undergoing emergency intubation, 45.2% experienced at least one major peri-intubation adverse event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%) ¹². Tachycardia was reported in 32.7% and bradycardia in 5.2% of patients ¹³. Additionally, a first-attempt intubation success rate of only 84.1% (95% CI 80.1 87.4) was reported, esophageal intubation in 3.5%, the requirement of three or more intubation attempts in 0.8%, and the need for cricothyroidotomy in 0.3% of patients ¹⁴. Given the frequency of complications, routine non-invasive blood pressure monitoring, continuous pulse oximetry, cardioscopy, and capnography for intubation verification are suggested.

• Aspiration Equipment: Includes portable aspirators or medical gas network aspirators and the use of non-collapsible cannulas, such as the Yankauer cannula.

• Airway Management Devices: Laryngoscope with tested batteries, orotracheal tubes of different sizes, oroand nasopharyngeal cannulas, and equipment used in alternative techniques (second-generation supraglottic device, videolaryngoscopy, intubation adjuvants like Frova® and open cricothyroidotomy equipment [i.e., No. 10 scalpel blade, 6 mm tube, and Bougie]).

• Initial Patient Evaluation: Must be performed in all cases, both for the clinical state that leads to RSII indication and for airway evaluation.

Special situations requiring immediate consideration for a Difficult Airway (DA) include anatomical abnormalities (craniofacial malformations, tumors), post-radiation therapy changes in the head and neck, oral opening <2 cm, cervical immobility, history of DA, and the presence of two or more minor predictors ¹⁵.

In a quick physical examination, other clinical predictors that are associated with DA to varying extents should be sought: Class 3 upper lip bite test (positive LR 14, 95% CI 8.9 22), reduced hyomental distance (positive LR 6.4, 95% CI 4.1 10), subjective retrognathia or mandible <9 cm (positive LR 6, 95% CI 3.1 11), limited mandibular protrusion (positive LR 5.5, 95% CI 2.1 15), reduced cervical mobility (positive LR 4.2, 95% CI 1.9 9.5), reduced sternomental distance (positive LR 4.1, 95% CI 2.7 6.1), modified Mallampati ≥III (positive LR 4.1, 95% CI 3 5.6), and reduced thyromental distance (positive LR 3.3, 95% CI 2.4 4.4) ¹⁶. None of these offer sufficient diagnostic accuracy to rule out or confirm the presence of a DA as a sole predictor, so they should be applied collectively.

Position

This can be considered a preliminary step to preoxygenation, as it will aid in enhancing it as well as in patient ventilation (Figure 2).

Sniffing Position: Traditionally recommended as the optimal position for direct laryngoscopy in most patients, it theoretically allows alignment of the three axes (oral, pharyngeal, and laryngeal, as indicated in Figure 2) and improves glottic visualization ¹⁷. A better score on the intubation difficulty scale has been demonstrated (RR 1.28, 95% CI 1.15 1.42, p < 0.0001), so it remains relevant ¹⁸.

Ramp Position: Compared to the sniffing position in adult general populations, no statistically significant differences were found in terms of first-attempt success, intubation attempts, or glottic vision; thus, it is not conventionally recommended for all patients ¹⁹. However, when compared to the supine position, it clearly improves ventilation in obese patients in terms of exhaled tidal volume (mean ± SD 9.3 ± 2.7 vs. 7.6 ± 2.4 ml/kg; p <0.001). Furthermore, several clinical trials indicate that the ramp position in morbidly obese patients improves glottic visualization compared to the sniffing position ^20-21. In critically ill patients, this position has been associated with a higher likelihood of a Cormack-Lehane score of 1-2 (OR 2.05, 95% CI 1.26 3.32, p = 0.004) and a lower likelihood of a score of 3-4 (OR 0.49, 95% CI 0.3 0.79, p = 0.004) ¹⁹.

Neutral Position: Supported in patients with RSII in cervical trauma scenarios ²². It has been described that if video laryngoscopy is chosen as the technique, the neutral position may not have significant differences compared to the sniffing position in terms of intubation difficulty (p = 0.384). Although the neutral position was associated with less glottic opening, it was also not related to laryngoscopy time, intubation time, or first-attempt success rate ²³.

Preoxygenation

This is a technique of prior oxygen administration aimed at increasing oxygen reserves and extending safe apnea time ²⁴. It is indicated in all patients, especially those who are critically ill, urgent, pediatric, obese, and pregnant, given physiological conditions that reduce safe apnea time (functional residual capacity reduction, increased oxygen consumption, anemia, acidosis, cardiopulmonary disease) ²⁵.

The goal is to achieve an expired oxygen level of 0.9 or higher ²⁶. Various techniques exist to achieve this: tidal volume ventilation (TVV) for 3 to 5 minutes with fresh gas flow (FGF) >5 L/min or 8 deep breaths for one minute with FGF of 10 L/min ²⁵. Technical considerations include proper mask attachment and the use of 100% inspired oxygen fraction (FiO2). Transnasal Humidified RapidInsufflation Ventilatory Exchange (THRIVE) has also been suggested, which involves administering 100% FiO2 through a high-flow nasal cannula (HFNC) for 3 minutes at 60 L/min, appearing to be as effective as TVV for 3 minutes at 10 L/min ²⁷.

The original RSII protocol advised against the use of positive pressure ventilation (PPV) for fear of gastric inflation leading to pulmonary aspiration; however, this hypothesis has been debated. Those refuting it argue that providing ventilation just before attempting intubation is essential to avoid desaturation, especially in those with low functional residual capacity or high oxygen consumption, who may not optimally benefit from preoxygenation ²⁸. A network meta-analysis published in 2019 found that, in patients with acute respiratory failure, non-invasive mechanical ventilation with a face mask is associated with fewer adverse events (OR 0.43, 95% CI 0.21 0.87) and less desaturation (MD 5.53, 95% CI 2.71 8.34), as is the use of a high-flow nasal cannula ²⁹.

Apneic oxygenation can complement preoxygenation and is described through various methods: nasopharyngeal cannula, THRIVE, or simple nasal cannula (NODESAT [nasal oxygen during efforts securing a tube]). In the latter, oxygen is administered through a cannula at 3 L/min before conventional preoxygenation and induction, then maintained at 5-15 L/min ³⁰. A recent clinical trial found no differences between these techniques in obese patients (safe apnea of 601 (268-900) vs. 537 (399-808) seconds, p = 0.698 in the HFNC group), suggesting that simple nasal cannulas, being more readily available, are likely to be more cost-effective ³¹.

Preoptimization

Previously, the term “premedication” was used for this step. Physiological disorders reduce the patient’s tolerance to repeated or prolonged attempts at laryngoscopy, and as a result, hypoxemia and hemodynamic deterioration are common complications. In this regard, various strategies have been proposed to optimize the patient’s physiological state before and during anesthetic induction. This is done with three main objectives: to reduce the dose of induction drugs, to decrease adverse drug events, and to preoptimize hemodynamic status (see Table 1).

The use of combined strategies (preoxygenation, the presence of two operators, RSI, cricoid pressure, capnography, protective ventilation, fluid loading, early preparation and administration of sedation, and the use of vasopressors) has been shown to decrease life-threatening events (21% vs. 34%, p = 0.03) and other complications (9% vs. 21%, p = 0.01) ⁵⁶.

Paralysis and Induction

Neuromuscular Relaxant

Neuromuscular relaxants (NMR) are a critical pillar for the success of intubation. They have been shown to increase the incidence of first-attempt success in critically ill patients (OR 2.37, 95% CI 1.36-4.88). Similar results have been found in the subgroup of patients intubated with videolaryngoscopy (OR 2.50, 95% CI 1.43-4.37, p<0.001) ⁵⁷. Avoiding the use of NMR significantly increases difficult laryngoscopy (RR 13.27, 95% CI 8.19-21.49; p<0.00001) and airway injuries (RR 1.37, 95% CI 1.09-1.74; p=0.008) and increases the risk of tracheostomy among emergency patients (OR 2.59, 95% CI 1.06-6.34; p=0.04) ⁵⁹.

Two medications are supported by evidence for use in the RSI scenario: succinylcholine, a depolarizing NMR used at doses of 1-2 mg/kg with an onset of action of 30-60 seconds and an approximate duration of 10 minutes; and rocuronium, a non-depolarizing NMR used at a dose of 1.2 mg/kg with a similar onset and a prolonged duration of about 160 minutes. In a Cochrane meta-analysis, succinylcholine was found to generally provide better intubation conditions than rocuronium (RR 0.86, 95% CI 0.80-0.92; n=2690), but when compared with a 1.2 mg/kg dose of rocuronium, no statistical difference was found in intubation conditions. Succinylcholine was considered clinically superior due to its shorter duration of action ⁶⁰.

It is crucial to consider the contraindications and adverse effects of both drugs. Succinylcholine is contraindicated in patients at risk of hyperkalemia, prolonged bed rest, rhabdomyolysis, burns after 24-48 hours, muscular dystrophy, or a family history of malignant hyperthermia ⁶¹. While rocuronium does not have these contraindications and appears to have a safer clinical profile ⁶², it is one of the drugs most commonly associated with anaphylaxis in anesthesia ⁶³.

Induction Agent

The choice of the induction agent is a point of great contention in the literature; however, safety during laryngoscopy is ensured with adequate preparation in the preceding steps. As previously mentioned, full doses are indicated to ensure appropriate latency times.

The ideal induction agent should have a rapid onset of action, maintain optimal hemodynamics, and avoid secondary damage due to adverse effects ⁶⁴. All these factors, in addition to the availability and experience of the operator, must be considered when choosing the induction agent (see Table 2).

The potential of using a combination of lower doses of different induction agents to potentiate their effects and minimize adverse events exists. For instance, the combination of ketamine and propofol, known as “ketofol,” has been used. However, its utility has not shown a significant difference in post-intubation hemodynamic stability when compared to etomidate in critically ill patients ⁷³.

Tube Positioning

After achieving the appropriate anesthetic depth and paralysis, the next step is to position the tube through the glottis. There are multiple strategies available for this phase ^9,74,75, and it is crucial to optimize the first attempt as much as possible. Studies suggest that the risk of an adverse event during emergency tracheal intubation increases significantly with the number of attempts (with an incidence of 14.2%, 47.2%, 63.6%, and 70.6% for one, two, three, and four attempts, respectively; adjusted OR for 2 or more attempts is 7.52, 95% CI 5.86 9.63) ⁷⁶. It is also essential to have multiple fallback options available, including rescue devices like second-generation laryngeal masks.

The choice between videolaryngoscopy or direct laryngoscopy as a first-line option is a point of contention. Several factors, including the operator’s familiarity with each choice, influence this decision. Recent meta-analyses from the Cochrane collaboration suggest that first-line videolaryngoscopy decreases the likelihood of failed intubation (RR 0.41, 95% CI 0.26 to 0.65) and hypoxia (RR 0.72, 95% CI 0.52 to 0.99). Moreover, hyperangulated videolaryngoscopy blades significantly decrease failed intubation in anticipated difficult airway scenarios (RR 0.29, 95% CI 0.17 to 0.48) ⁷⁷.

Recent studies have assessed the use of flexible stylets and bougies, concluding that both improve the percentage of first-attempt intubations in emergency and critical care scenarios and should be considered for routine use ^78-80.

Several strategies exist for confirming the correct positioning of the endotracheal tube. The ASA’s Difficult Airway Algorithm recommends the use of capnography and, in cases of uncertainty, resorting to other options like flexible bronchoscopy, ultrasound, or X-ray ^9,81.

Post-intubation

After the placement and confirmation of the endotracheal tube, taking appropriate measures to ensure the patient’s stability is advised. This includes proper tube fixation, the use of sedoanalgesia, continuation of hemodynamic resuscitation, and safe ventilation practices.

Securing the endotracheal tube is essential to avoid accidental extubation, a catastrophic complication for patients requiring secure airway management. Fixation can be achieved through commercial devices or adhesive tapes. Regardless of the method used, two vectors of force should be ensured for added safety ⁸² (see Figure 3).

Infusion or intermittent administration of sedoanalgesia is often necessary, as intubation is an uncomfortable and painful procedure that can induce anxiety and agitation in the patient ⁸³. It is advisable to use the minimum effective dose to control symptoms. A protocol emphasizing analgesia can reduce the overuse of hypnotic agents ⁸⁴. Early administration is crucial to avoid conscious paralysis, an event that can lead to post-traumatic stress ^85-86.

The transition from physiological to positive pressure ventilation has significant hemodynamic implications due to decreased venous return. Moreover, the effects of the drugs used can either potentiate or worsen the hemodynamic status. Up to 24% of patients experience post-intubation hypotension, which is associated with increased mortality, and up to 3% experience cardiac arrest ¹². Thus, it is vital to closely monitor and continue goal-directed resuscitation measures if needed to avoid hypoperfusion.

During transport, it is recommended to use a mechanical ventilator according to availability. Ideally, protective ventilation parameters should be used, which are associated with lower morbidity and mortality, even in patients without adult respiratory distress syndrome (ARDS) ⁸⁷. Early initiation of these strategies is associated with better adherence later on ⁸⁸. This strategy includes using a tidal volume of 6-8 ml/kg of ideal body weight and routine use of positive end-expiratory pressure (PEEP) between 5 and 8 cmH2O, with adjustments to the respiratory rate and FiO2 based on oxygen saturation and CO2 arterial pressure.

Conclusions

Recent advances in Rapid Sequence Induction and Intubation (RSII) highlight the importance of preparation, ramp positioning in special patients, routine preoxygenation coupled with apneic oxygenation, preoptimization before tracheal intubation, neuromuscular relaxation as a treatment cornerstone, rescue techniques for failed intubation, and post-intubation care.

It is imperative for physicians in emergency services, critical care, and anesthesiology to master each of these key points in proper RSII to reduce morbidity and mortality.

References

Cook TM, Woodall N, Harper J, Benger J, Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth [Internet]. 2011;106(5):632-42. https://doi.org/10.1093/bja/aer059

Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology [Internet]. 2019;131(4):818-829. https://doi.org/10.1097/ALN.0000000000002815

Domino KB. Death and brain damage from difficult airway management: a “never event”. Can J Anaesth [Internet]. 2021;68(2):169-174. https://doi.org/10.1007/s12630-020-01847-6

LaGrone LN, McIntyre L, Riggle A, Robinson BRH, Maier RV, Bulger E, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg [Internet]. 2020;89(6):1046-1053. https://doi.org/10.1097/TA.0000000000002902

Eltorai AS. Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors. J Eval Clin Pract [Internet]. 2019;25(5):739-743. https://doi.org/10.1111/jep.13086

Avery P, Morton S, Raitt J, Lossius HM, Lockey D. Rapid sequence induction: where did the consensus go? Scand J Trauma Resusc Emerg Med [Internet]. 2021;29(1):64. https://doi.org/10.1186/s13049-021-00883-5

Brown CA 3rd, Bair AE, Pallin DJ, Walls RM, NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med [Internet]. 2015;65(4):363-370.e1. https://doi.org/10.1016/j.annemergmed.2014.10.036

Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth [Internet]. 2021;68(9):1373-1404. https://doi.org/10.1007/s12630-021-02007-0

Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology [Internet]. 2022;136(1):31-81. https://doi.org/10.1097/ALN.0000000000004002

Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth [Internet]. 2021 Sep;68(9):1405-1436. https://doi.org/10.1007/s12630-021-02008-z

Sun F, Wang Y, Ma S, Zhu H, Yu X, Xu J; Chinese Collaboration Group for Emergency Airway Management. Clinical consensus of emergency airway management. J Thorac Dis [Internet]. 2017;9(11):4599-4606. https://doi.org/10.21037/jtd.2017.10.79

Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA [Internet]. 2021;325(12):1164-1172. https://doi.org/10.1001/jama.2021.1727

Allene MD, Melekie TB, Ashagrie HE. Evidence based use of modified rapid sequence induction at a low income country: A systematic review. Int J Surg Open [Internet]. 2020;25:17-23. https://doi.org/10.1016/j.ijso.2020.06.005

Park L, Zeng I, Brainard A. Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Emerg Med Australas [Internet]. 2017;29(1):40-47. https://doi.org/10.1111/1742-6723.12704

Guzmán J, Montalván C, Coloma R, Kunze S. Recomendaciones de la Sociedad de Anestesiología de Chile para el manejo de la vía aérea difícil. Rev Chil Anest [Internet]. 2012;41:166-178. Disponible en: https://revistachilenadeanestesia.cl/PII/revchilanestv41n3.02.pdf

Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, Pinto R, Simel DL, et al. Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA [Internet]. 2019;321(5):493-503. https://doi.org/10.1001/jama.2018.21413

Greenland KB, Eley V, Edwards MJ, Allen P, Irwin MG. The origins of the sniffing position and the Three Axes Alignment Theory for direct laryngoscopy. Anaesth Intensive Care [Internet]. 2008;36 Suppl 1:23-7. https://doi.org/10.1177/0310057X0803601s05

Akihisa Y, Hoshijima H, Maruyama K, Koyama Y, Andoh T. Effects of sniffing position for tracheal intuation: a meta-analysis of randomized controlled trials. Am J Emerg Med [Internet]. 2015;33(11):1606-11. https://doi.org/10.1016/j.ajem.2015.06.049

Okada Y, Nakayama Y, Hashimoto K, Koike K, Watanabe N. Ramped versus sniffing position for tracheal intubation: A systematic review and meta-analysis. Am J Emerg Med [Internet]. 2021;44:250-256. https://doi.org/10.1016/j.ajem.2020.03.058

Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg [Internet]. 2004;14(9):1171-5. https://doi.org/10.1381/0960892042386869

Lee BJ, Kang JM, Kim DO. Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth [Internet]. 2007;99(4):581-6. https://doi.org/10.1093/bja/aem095

Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci [Internet]. 2014;4(1):50-6. https://doi.org/10.4103/2229-5151.128013

Mendonca C, Ungureanu N, Nowicka A, Kumar P. A randomised clinical trial comparing the ‘sniffing’ and neutral position using channelled (KingVision® ) and non-channelled (C-MAC®) videolaryngoscopes. Anaesthesia [Internet]. 2018;73(7):847-855. https://doi.org/10.1111/anae.14289

Azam-Danish M. Preoxygenation and Anesthesia: A Detailed Review. Cureus [Internet]. 2021;13(2):e13240. https://doi.org/10.7759/cureus.13240

Hagberg CA, Benumof J. Benumof and Hagberg’s airway management. 15th ed. Philadelphia: Elsevier; 2013.

Eichelsbacher C, Ilper H, Noppens R, Hinkelbein J, Loop T. Rapid sequence induction and intubation in patients with risk of aspiration: Recommendations for action for practical management of anesthesia. Anaesthesist [Internet]. 2018;67(8):568-583. https://doi.org/10.1007/s00101-018-0460-3

Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia [Internet]. 2015;70(3):323-9. https://doi.org/10.1111/anae.12923

Kriswidyatomo P, Paramitha MP. Rapid sequence induction/intubation controversies. Hong Kong Journal of Emergency Medicine [Internet]. 2021;28(5):314-319. https://doi.org/10.1177/1024907920910835

Fong KM, Au SY, Ng GWY. Preoxygenation before intubation in adult patients with acute hypoxemic respiratory failure: a network meta-analysis of randomized trials. Crit Care [Internet]. 2019;23(1):319. https://doi.org/10.1186/s13054-019-2596-1

Gleason JM, Christian BR, Barton ED. Nasal Cannula Apneic Oxygenation Prevents Desaturation During Endotracheal Intubation: An Integrative Literature Review. West J Emerg Med [Internet]. 2018;19(2):403411. https://doi.org/10.5811/westjem.2017.12.34699

Hamp T, Prager G, Baron-Stefaniak J, Müller J, Bichler C, Plöchl W. Duration of safe apnea in patients with morbid obesity during passive oxygenation using high-flow nasal insufflation versus regular flow nasal insufflation, a randomized trial. Surg Obes Relat Dis [Internet]. 2021;17(2):347-355. https://doi.org/10.1016/j.soard.2020.09.027

Tian S, Zhang D, Zhou W, Tan C, Shan Q, Ma R, et al. Median Effective Dose of Lidocaine for the Prevention of Pain Caused by the Injection of Propofol Formulated with Mediumand Long-Chain Triglycerides Based on Lean Body Weight. Pain Med [Internet]. 2021;22(6):1246-1252. https://doi.org/10.1093/pm/pnaa316

Wasinwong W, Termthong S, Plansangkate P, Tanasansuttiporn J, Kosem R, Chaofan S. A comparison of ondansetron and lidocaine in reducing injection pain of propofol: a randomized controlled study. BMC Anesthesiol [Internet]. 2022;22(1):109. https://doi.org/10.1186/s12871-022-01650-4

Fathy S, Hasanin A, Mostafa M, Ramzy E, Sarhan K, Almenesey T, et al. The benefit of adding lidocaine to ketamine during rapid sequence endotracheal intubation in patients with septic shock: A randomised controlled trial. Anaesth Crit Care Pain Med [Internet]. 2021;40(1):100731. https://doi.org/10.1016/j.accpm.2020.06.017

Mendonça FT, Silva SLD, Nilton TM, Alves IRR. Effects of lidocaine and esmolol on hemodynamic response to tracheal intubation: a randomized clinical trial. Braz J Anesthesiol [Internet]. 2022;72(1):95-102. https://doi.org/10.1016/j.bjane.2021.01.014

Seangrung R, Pasutharnchat K, Injampa S, Kumdang S, Komonhirun R. Comparison of the hemodynamic response of dexmedetomidine versus additional intravenous lidocaine with propofol during tracheal intubation: a randomized controlled study. BMC Anesthesiol [Internet]. 2021;21(1):265. https://doi.org/10.1186/s12871-021-01484-6

Hashemian AM, Zamani-Moghadam-Doloo H, Saadatfar M, Moallem R, Moradifar M, Faramarzi R, et al. Effects of intravenous administration of fentanyl and lidocaine on hemodynamic responses following endotracheal intubation. Am J Emerg Med [Internet]. 2018;36(2):197-201. https://doi.org/10.1016/j.ajem.2017.07.069

Garba SU, Mohammed AD. The effects of midazolam pretreatment on the induction dose of propofol in Nigerian Adults. Niger J Basic Clin Sci [Internet]. 2017;14(1):34-40. https://doi.org/10.4103/0331-8540.204083

You AH, Kim JY, Kim DH, Suh J, Han DW. Effect of remifentanil and midazolam on ED95 of propofol for loss of consciousness in elderly patients: A randomized, clinical trial. Medicine (Baltimore) [Internet]. 2019;98(16):e15132. https://doi.org/10.1097/MD.0000000000015132

Pouraghaei M, Moharamzadeh P, Soleimanpour H, Rahmani F, Safari S, Mahmoodpoor A, et al. Comparison between the effects of alfentanil, fentanyl and sufentanil on hemodynamic indices during rapid sequence intubation in the emergency department. Anesth Pain Med [Internet]. 2014;4(1):e14618. https://doi.org/10.5812/aapm.14618

Takahashi J, Goto T, Okamoto H, Hagiwara Y, Watase H, Shiga T, et al. Association of fentanyl use in rapid sequence intubation with post-intubation hypotension. Am J Emerg Med [Internet]. 2018;36(11):2044-2049. https://doi.org/10.1016/j.ajem.2018.03.026

Ferguson I, Bliss J, Aneman A. Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review. Acta Anaesthesiol Scand [Internet]. 2019;63(5):587-593. https://doi.org/10.1111/aas.13314

Ferguson I, Buttfield A, Burns B, Reid C, Shepherd S, Milligan J, et al. Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial. Acad Emerg Med [Internet]. 2022;29(6):719-728. https://doi.org/10.1111/acem.14446

Mahiswar AP, Dubey PK, Ranjan A. Comparison between dexmedetomidine and fentanyl bolus in attenuating the stress response to laryngoscopy and tracheal intubation: a randomized double-blind trial. Braz J Anesthesiol [Internet]. 2022;72(1):103-109. https://doi.org/10.1016/j.bjane.2021.02.060

Wilmott AR, Thompson GC, Lang E, Powelson S, Wakai A, Vandermeer B, et al. Atropine therapy versus no atropine therapy for the prevention of adverse events in paediatric patients undergoing intubation. Cochrane Database Syst Rev [Internet]. 2018;2018(1):CD010898. https://doi.org/10.1002/14651858.CD010898.pub2

Fukano N, Suzuki T, Ishikawa K, Mizutani H, Saeki S, Ogawa S. A randomized trial to identify optimal precurarizing dose of rocuronium to avoid precurarization-induced neuromuscular block. J Anesth [Internet]. 2011;25(2):200-4. https://doi.org/10.1007/s00540-010-1086-z

Kim KN, Kim KS, Choi HI, Jeong JS, Lee HJ. Optimal precurarizing dose of rocuronium to decrease fasciculation and myalgia following succinylcholine administration. Korean J Anesthesiol [Internet]. 2014;66(6):451-6. https://doi.org/10.4097/kjae.2014.66.6.451

Farhat K, Waheed A, Pasha AK, Tariq M. Effects of rocuronium pretreatment on muscle enzyme levels following succinylcholine. Pak J Pharm Sci [Internet]. 2013;26(5):939-42. Disponible en: https://pubmed.ncbi.nlm.nih.gov/24035949/

Senapati LK, Battini KP, Padhi PP, Samanta P. Effect of Non-depolarizing Muscle Relaxants Rocuronium Versus Vecuronium in the Assessment of Post-Succinylcholine Complications in Surgeries Under General Anesthesia: A Randomized Double-Blind Study at a Tertiary Care Hospital. Cureus [Internet]. 2021;13(11):e19793. https://doi.org/10.7759/cureus.19793

Sane S, Aghdashi MM, Haki BK, Gholamveisi B, Rajabzadeh M, Golabi P. The Effect of Pregabalin on the Prevention of Succinylcholine-Induced Fasciculation and Myalgia. J Perianesth Nurs [Internet]. 2020;35(3):255-259. https://doi.org/10.1016/j.jopan.2019.11.005

Khan FA, Ullah H. Pharmacological agents for preventing morbidity associated with the haemodynamic response to tracheal intubation. Cochrane Database Syst Rev [Internet]. 2013;(7):CD004087. https://doi.org/10.1002/14651858.CD004087.pub2

Zatloukal J, Pouska J, Benes J. Perioperative goal directed therapy-current view. J Emerg Crit Care Med [Internet]. 2019;3:49. https://doi.org/10.21037/jeccm.2019.09.03

Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM; Society for Airway Management’s Special Projects Committee. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg [Internet]. 2021;132(2):395-405. https://doi.org/10.1213/ane.0000000000005233

Pollard S, Edwin SB, Alaniz C. Vasopressor and Inotropic Management Of Patients With Septic Shock. P T [Internet]. 2015;40(7):438-50. Disponible: https://pubmed.ncbi.nlm.nih.gov/26185405/

Alshahrani MS, Alatigue R. Association Between Early Administration of Norepinephrine in Septic Shock and Survival. Open Access Emerg Med [Internet]. 2021;13:143-150. https://doi.org/10.2147/OAEM.S298315

Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med [Internet]. 2010;36(2):248-55. https://doi.org/10.1007/s00134-009-1717-8

Mosier JM, Sakles JC, Stolz U, Hypes CD, Chopra H, Malo J, et al. Neuromuscular blockade improves firstattempt success for intubation in the intensive care unit. A propensity matched analysis. Ann Am Thorac Soc [Internet]. 2015;12(5):734-41. https://doi.org/10.1513/AnnalsATS.201411-517OC

Lundstrøm LH, Duez CHV, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, et al. Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review. Br J Anaesth [Internet]. 2018;120(6):1381-1393. https://doi.org/10.1016/j.bja.2017.11.106

Fujinaga J, Suzuki E, Kuriyama A, Onodera M, Doi H. Urgent intubation without neuromuscular blocking agents and the risk of tracheostomy. Intern Emerg Med [Internet]. 2020;15(1):127-134. https://doi.org/10.1007/s11739-019-02214-0

Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev [Internet]. 2008;16(2):CD002788. https://doi.org/10.1002/14651858.CD002788.pub2

Muñoz-Martínez T, Garrido-Santos I, Arévalo-Cerón R, Rojas-Viguera L, Cantera-Fernández T, Pérez-González R, et al. Prevalencia de contraindicaciones a Succinilcolina en unidades de cuidados intensivos. Med Intensiva [Internet]. 2015;39(2):90-6. https://doi.org/10.1016/j.medin.2014.07.002

De-Carvalho CC, da-Silva DM, de Athayde-Regueira SLP, de-Souza ABS, Rego CO, Ramos IB, et al. Comparison between rocuronium and succinylcholine for rapid sequence induction: A systematic review and network meta-analysis of randomized clinical trials. J Clin Anesth [Internet]. 2021;72:110265. https://doi.org/10.1016/j.jclinane.2021.110265

Harper NJN, Cook TM, Garcez T, Farmer L, Floss K, Marinho S, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth [Internet]. 2018;121(1):159-171. https://doi.org/10.1016/j.bja.2018.04.014

George B, Joachim N. Evolving Techniques in RSI: Can the Choice of Induction Agent Matter in Securing a Definitive Airway in Emergency Settings? Indian J Crit Care Med [Internet]. 2022;26(1):15-17. https://doi. org/10.5005/jp-journals-10071-24100

Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth [Internet]. 2016;117 Suppl 1:i60-i68. https://doi.org/10.1093/bja/aew061

Gregers MCT, Mikkelsin S, Lindvig KP, Brochner AC. Ketamine as an Anesthetic for Patients with Acute Brain Injury: A Systematic Review. Neurocrit Care [Internet]. 2020;33(1):273-282. https://doi.org/10.1007/s12028-020-00975-7

Gelissen H, Epema A, Henning R, Krinjen H, Hennis P, Hertog A. Inotropic effects of propofol, thiopental, midazolam, etomidate, and ketamine on isolated human atrial muscle. Anesthesiology [Internet]. 1996;84(2):397-403. https://doi.org/10.1097/00000542-199602000-00019

Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA [Internet]. 2021;325(12):1164-1172. https://doi.org/10.1001/jama.2021.1727

Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med [Internet]. 2022;26(1):108-113. https://doi.org/10.5005/jp-journals-10071-24086

Gu WJ, Wang F, Tang L, Liu JC. Single-dose etomidate does not increase mortality in patients with sepsis: a systematic review and meta-analysis of randomized controlled trials and observational studies. Chest [Internet]. 2015;147(2):335-346. https://doi.org/10.1378/chest.14-1012

Matchett G, Gasanova I, Riccio C, Nasir D, Sunna M, Bravenec B, et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med [Internet]. 2022;48(1):78-91. https://doi.org/10.1007/s00134-021-06577-x

Hino H, Matsuura T, Kihara Y, Tsujikawa S, Mori T, Nishikawa K. Comparison between hemodynamic effects of propofol and thiopental during general anesthesia induction with remifentanil infusion: a double-blind, age-stratified, randomized study. J Anesth [Internet]. 2019;33(4):509-515. https://doi.org/10.1007/s00540-019-02657-x

Smischney NJ, Nicholson WT, Brown DR, Gallo De Moraes A, Hoskote SS, Pickering B, et al. Ketamine/ propofol admixture vs etomidate for intubation in the critically ill: KEEP PACE Randomized clinical trial. J Trauma Acute Care Surg [Internet]. 2019;87(4):883-891. https://doi.org/10.1097/TA.0000000000002448

Frerk C, Mitchell V, McNarry A, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth [Internet]. 2015;115(6):827-848. https://doi.org/10.1093/bja/aev371

Chrimes N. The Vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. Br J Anaesth [Internet]. 2016;117(S1):i20-i27. https://doi.org/10.1093/bja/aew175

Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med [Internet]. 2013;20(1):71-8. https://doi.org/10.1111/acem.12055

Hansel J, Rogers A, Lewis S, Cook T, Smith A. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev [Internet]. 2022;4(4):CD011136. https://doi.org/10.1002/14651858.CD011136.pub3

Driver B, Prekker M, Klein L, Reardon R, Miner J, Fagerstrom E, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA [Internet]. 2018;319(21):2179-2189. https://doi.org/10.1001/jama.2018.6496

Driver B, Semler M, Self W, Ginde A, Trent S, Gandotra S, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA [Internet]. 2021;326(24):2488-2497. https://doi.org/10.1001/jama.2021.22002

Jaber S, Rollé A, Godet T, Terzi N, Riu B, Asfar P, et al. Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med [Internet]. 2021;47(6):653-664. https://doi.org/10.1007/s00134-021-06417-y

Arulkumaran N, McLaren CS, Arulkumaran K, Philips BJ, Cecconi M. An analysis of emergency tracheal intubations in critically ill patients by critical care trainees. J Intensive Care Soc [Internet]. 2018;19(3):180-187. https://doi.org/10.1177/1751143717749686

Komasawa N, Fujiwara S, Miyazaki S, Ohchi F, Minami T. Shifts in endotracheal tube position due to chest compressions: a simulation comparison by fixation method. J Emerg Med [Internet]. 2015;48(2):241-246. https://doi.org/10.1016/j.jemermed.2014.06.064

Noel C, Mallemat H. Sedation and Analgesia for Mechanically Ventilated Patients in the Emergency Department. Emerg Med Clin North Am [Internet]. 2019;37(3):545-556. https://doi.org/10.1016/j.emc.2019.04.004

Park G, Lane M, Rogers S, Basset P. A comparison of hypnotic and analgesic based sedation in a general intensive care unit. Br J Anaesth [Internet]. 2007;98(1):76-82. https://doi.org/10.1093/bja/ael320

Pappal R, Roberts B, Mohr N, Ablorddeppey E, Wessman B, Drewry A, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med [Internet]. 2021;77(5):532-544. https://doi.org/10.1016/j.annemergmed.2020.10.012

Edmunds K, Byczkowski T, Frey M, Boyd S, Caruso M, Zhang Y, et al. Risk factors for inadequate sedation after endotracheal intubation in the pediatric emergency department. Am J Emerg Med [Internet]. 2022 Jun;56:15-20. https://doi.org/10.1016/j.ajem.2022.03.002

Fernando S, Fan E, Rochwerg B, Burns K, Brochard L, Cook D, et al. Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the ED. Chest [Internet]. 2021 Feb;159(2):606-618. https://doi.org/10.1016/j.chest.2020.09.100

Roginski M, Burney C, Husson E, Harper K, Atchinson P, Munson J. Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care. Air Med J [Internet]. 2022;41(1):96-102. https://doi.org/10.1016/j.amj.2021.10.005

Author notes

Author for correspondence: Valeria Martínez Hurtado; aleria.martinez@udea.edu.co

Conflict of interest declaration