Rapid Sequence Induction (RSI) in Emergency Care

Introduction

Rapid sequence induction (RSI) is also known as the Rapid sequence intubation which is the special procedure of the endotracheal intubation that is performed when health professionals find out that a patient is at the high risk of the pulmonary aspiration (Wahlen et al. 2019). The RSI is performed by health professionals in the emergency ward in order to prevent the aspiration of gastric content into the pulmonary tract as well as into the lungs. In case of the bowel obstruction in the 45-year-old man, there is some structural and functional changes in the small and large intestine that generate obstructions to the excretion of undigested food and the stool from the body (Birenbaum et al. 2019). People with impaired gastric activity like the 45 years man in the case study need RSI in emergency ward before performing the surgery to prevent the chances the pulmonary aspiration. The RSI leads to the rapid control of the airways in patients thereby minimising the risk of the regurgitation of the gastric contents into lung. Here an intravenous induction of suitable anaesthesia is performed with the cricoid pressure which is followed by placing the endotracheal tube into oesophagus. This process leads to the state of unconsciousness of patients with temporary neuromuscular paralysis (Klucka et al. 2020). Through causing this neuromuscular paralysis health professional achieves the successful intubation without the interposing mechanical ventilation thereby facilitating the reduction of chances of the gastric aspiration.

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In case of the 45 years old man who undergoes a surgery for the bowel obstruction, there is high chances of the gastric aspiration. In this context, use of RSI is high priority for this patient as there is an airway risk (Roshan et al. 2021). While using the anaesthesia during the emergency surgical intervention, it is important for this patient to perform the RSI for eliminating the chances of the preserved airways reflexes. Whie performing this process health professional must consider some biological and physical factors in patient such as whether the patient has allergy, and susceptibility to hyperkalaemia and malignant hyperthermia

Common side effects of RSI are increased heart rate, urinary retention, flushing mouth, dry mouth. Patient can also face consequences of RSI such as hypoxemia if the anaesthetic nurse fails to maintain the right dose and the times during administration of neuromuscular block agents (Yoshida et al. 2018). In case of the man of 45 years the anaesthetic nurses must choose the right hypnotic agents with proper dose that can enables body to resist the chances of hypoxemia during the process of RSI.

Under NICE (2018), anaesthetic nurses must have high level of expertise and clear understanding about how to perform the RSI safely (Birenbaum et al. 2019). During the process of intubation, anaesthetic nurse must use the high level of expertise to perform the process systematically to ensure that there are no chances any injuries in the larynx or oesophagus. Lack of skill of the health professionals and anaesthetic nurse can develop side effects of RSI which is associated with improper insertion of the laryngeal tube. Potential consequences of RSI can range from injuries in the airways to hypoxemia due to improper insertion of the orotracheal tube.

Part two:

Anesthetists must consider the risk factors that are associated with the pulmonary aspiration during the airways management at the time of administering anesthesia (Eichelsbacher et al. 2018). Evidence suggests that aspiration during anesthesia leads to several death due to the failure of ventilate and incubate during the process of anesthesia administration. Pulmonary aspiration can be defined as the inhalation of the gastric or oropharyngeal content into respiratory tract, specially into the larynx and lung thereby causing severe obstructions in the normal airflow through the airways. Thet clinical intervention suggest if patients inhale solid matters into the respiratory tract, it can cause hypoxia (lack of oxygen supply to the lung) (Beck et al. 2020). The aspiration of the different gastric juice to the lung and the other respiratory tract can cause exacerbating condition of the pneumonia associated with symptoms of hypoxia, dyspnea, patchy collapse and bronchial wheeze. Moreover, there are high chances of the morbidity with complex health condition and the high rate of mortality in patients with increasing exposure of the respiratory tract to the highly acidic gastric juices and solid matter.

In terms of preventing the risk of aspiration during anesthesia, anesthetists need to follow important strategies. Being an anesthesia nurse, I ensure that the anesthetist must have skill and knowledge in using the systematic process of anesthesia. The anesthetists will must ensure the reduced gastric volume in the patient before anesthetize the patient (Koh et al. 2018). In this context the antitheist will check the preoperative fasting, prokinetic premedication and the nasogastric aspiration in the patient which can ensure that there is reduced gastric volume. The anesthetist must avoid the regional anesthesia which has high chances of the pulmonary aspiration. The patient can be administered with the antacid, proton pimp inhibitor and H2 histamine antagonists which will interact with the gastric juices and other gastric content thereby reducing the ph of these content (Kappert et al. 2021). The reduced ph in the gastric juices and content can reduce the chances or pneumonia, chest pain and wheezing during anesthesia. Anesthetist must use the airways protectants such as tracheal intubation, which will restrict the entry of the gastric content into the pulmonary pathways thereby eliminating the chances of hypoxia and dyspnea due to the pulmonary aspiration. As an anesthesia nurse I will check that whether anesthetist use the right cricoid pressure and systematic rapid sequence induction for improving the overall air flow inside the airways during the anesthesia (Smith et al. 2018). I will also check the anesthetist use some additional safety strategies while anaesthetize the patient such as the he or she will have a highly skilled assistant all the times to assist him to take the right anesthesia dose and right process. The anesthetist will must choose the right medicines for anesthetizing the patient. By injecting the right dose intravenously, the anesthetist will ensure that the systematic process of anesthesia is performed with proper safety which can lead to safe extubation of the patient (Kappert et al. 2021). The anesthetist must have enough knowledge to deal with any serious health issues that can suddenly occur during the anesthesia. For example, in some cases during anesthesia the patient can have increased intra-abdominal pressures and delayed gastric reduction which needed to be considers by the anesthetist while injecting the anesthesia medicines.

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Reference-list:

Beck, C. E., Rudolph, D., Mahn, C., Etspüler, A., Korf, M., Lüthke, M., ... & Sümpelmann, R. (2020). Impact of clear fluid fasting on pulmonary aspiration in children undergoing general anesthesia: Results of the German prospective multicenter observational (NiKs) study. Pediatric Anesthesia, 30(8), 892-899.

Birenbaum, A., Hajage, D., Roche, S., Ntouba, A., Eurin, M., Cuvillon, P., ... & Riou, B. (2019). Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia: the IRIS randomized clinical trial. JAMA surgery, 154(1), 9-17.

Eichelsbacher, C., Ilper, H., Noppens, R., Hinkelbein, J., & Loop, T. (2018). Rapid sequence induction and intubation in patients with risk of aspiration: Recommendations for action for practical management of anesthesia. Der Anaesthesist, 67(8), 568-583.

Kappert, K. D. R., Connesson, N., Elahi, S. A., Boonstra, S., Balm, A. J. M., van der Heijden, F., & Payan, Y. (2021). In-vivo tongue stiffness measured by aspiration: Resting vs general anesthesia. Journal of biomechanics, 114, 110147.

Klucka, J., Kosinova, M., Zacharowski, K., De Hert, S., Kratochvil, M., Toukalkova, M., ... & Stourac, P. (2020). Rapid sequence induction: An international survey. European journal of anaesthesiology, 37(6), 435.

Koh, G. H., Kim, S. H., Son, H. J., Jo, J. Y., Choi, S. S., Park, S. U., ... & Ku, S. W. (2018). Pulmonary aspiration during intubation in a high-risk patient: A video clip and clinical implications. Journal of dental anesthesia and pain medicine, 18(2), 111.

Roshan, R., Dhanapal, S. G., Joshua, V., Madhiyazhagan, M., Amirtharaj, J., Priya, G., & Abhilash, K. P. (2021). Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 25(2), 140.

Smith, J. S., Sheley, M., & Chigerwe, M. (2018). Aspiration pneumonia in two tibetan yak bulls (bos grunniens) as a complication of ketamine-xylazine-butorphanol anesthesia for recumbent castration. Journal of Zoo and Wildlife Medicine, 49(1), 242-246.

Wahlen, B. M., El-Menyar, A., Asim, M., & Al-Thani, H. (2019). Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers. World journal of emergency medicine, 10(1), 19.

Yoshida, K., Isosu, T., Noji, Y., Hasegawa, M., Iseki, Y., Oishi, R., ... & Murakawa, M. (2018). Usefulness of oxygen reserve index (ORi™), a new parameter of oxygenation reserve potential, for rapid sequence induction of general anesthesia. Journal of clinical monitoring and computing, 32(4), 687-691.


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