Some patients have a high risk of pulmonary aspiration when under anesthesia and require a technique called rapid sequence intubation (sometimes referred to as rapid sequence induction). It helps prevent aspiration by reducing the interval of time between loss of consciousness and inflation of the endotracheal tube cuff. Without the right equipment, rapid sequence intubation becomes impossible. Here’s what you need to have on hand to properly perform this technique.
Medications
Before administering anesthesia, you must give medication to induce sedation and prevent pain. It’s wise to have several options on hand in case a patient has allergies or a history of medical conditions that contraindicate a specific drug. Include in your kit:
- Fentanyl, and alternative sedatives such as sufentanil, lidocaine, alfentanil
- Dexamethasone
- Atropine, especially if you regularly treat pediatric patients
- Muscle relaxants such as vecuronium and rocuronium
- Esmolol, a beta blocker that can reduce the risk of hypertension
You’ll also need anesthesia induction agents. The right agent or combination depends on the ideal length of anesthesia and an assessment of patient health, because each anesthetic poses some risks. The most commonly used options include:
- Etomidate, which can induce unconsciousness in 30 seconds that lasts for about 10 minutes.
- Ketamine, which has a similarly rapid onset and an effect that lasts about 10 minutes without a second dose.
- Propofol, which lasts about 15 minutes and induces unconsciousness in less than a minute.
Most providers also use a paralytic agent to prevent dangerous movements. These agents can prevent coughing and reflexive airway movements that may further endanger patients with a higher-than-average risk of aspiration. Some options include:
- Rocuronium
- Mivacurium
- Pancuronium
- Cisatracurium
While anesthetics wear off, you will need an agent to reverse long-acting paralytics. The best option is usually sugammadex.
Airway Management Equipment
Anesthesia inhibits the body’s respiratory response, necessitating airway management to prevent aspiration, hypoxia, and serious injury. Rapid sequence intubation requires endotracheal intubation. The equipment you’ll need includes:
- Laryngoscope
- Light source for the laryngoscope
- Suction machine
- Endotracheal tube
- Stylet to make tube insertion easier
- Syringe to inflate the balloon
- Suction catheters in various sizes
- Carbon dioxide monitor
- Both oral and nasal airways
- Nasal cannula
- Bag-valve mask
- Back-up battery for any portable suction unit
This equipment should be well organized and accessible in a ready-made kit, so that you never have to delay treatment because you can’t find a catheter. You must also clean your equipment every time you use it, so that you’re never rushing to disinfect it when a patient needs prompt care. Be sure to charge the battery for any portable equipment after each use.
The Right Training
Rapid induction often means you’re working with a vulnerable patient who may have multiple comorbidities. It can be high stress even for experienced providers, and entirely daunting for novices. Ongoing training—including in less-than-ideal scenarios with patients who have difficult airways—is critical to the safe and successful use of rapid sequence induction.
Portable emergency suction is a key tool in any toolkit. It allows you to promptly intervene to stop aspiration and more effectively control the airway in both emergency and surgical scenarios. In most situations, you’ll be using wall-mounted suction for rapid sequence intubation. In a true emergency, during an equipment shortage, or in settings such as surgicenters or dental facilities, you may use portable suction. This approach to suction allows you to tend to more patients and reduces limitations on where you induce anesthesia.
For help selecting the right emergency suction device for your agency or organization, download our free e-book, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.
Editor's Note: This blog was originally posted on June 2021. It has since been updated with new content.
