Pharmacological approach to rapid sequence induction/intubation: a contemporary perspective

Purpose of review: This review examines the evolution of the pharmacological approach to rapid sequence induction/intubation (RSII) over the past 55 years, highlighting recent advances and contemporary perspectives on managing full-stomach patients requiring airway control. Recent findings: While aspiration remains a significant concern during RSII (occurring in 3-6% of cases), recent data suggests that desaturation, hypoxemia, and hemodynamic instability pose even greater risks, particularly in critically ill patients. Modern RSII approaches have evolved significantly from Safar's original protocol. Cricoid pressure is increasingly questioned, with evidence suggesting it may be unnecessary except when active regurgitation is observed. Gentle ventilation postinduction appears safe and beneficial when desaturation risk is high. Regarding pharmacology, succinylcholine has largely been replaced by rocuronium, while ketamine and etomidate are preferred over propofol for hemodynamically unstable patients. glucagon-like peptide 1 agonists may increase residual gastric content but have not definitively been linked to increased aspiration rates. First-pass success (currently ~84%) is crucial, as complications increase exponentially with multiple attempts. Summary: Contemporary RSII should balance aspiration prevention with avoiding hypoxemia and hemodynamic collapse. This requires thorough patient assessment, appropriate drug selection, optimal positioning, and effective teamwork. The priority should be making the first intubation attempt the best possible attempt, with preintubation optimization and consideration of human factors.