Guidelines Quality and Patient Safety GI and Nutrition

Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

Nicole M. Acquisto, PharmD, FCCM; Michael J. Murray, MD, PhD, MCCM; Jarrod M. Mosier, MD, FCCM

Published: 9/13/2023

Acquisto NM, Mosier JM, Bittner EA, et al. Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient. Crit Care Med. 2023 Oct;51(10):1411-1430. doi: 10.1097/CCM.0000000000006000.

Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

Citation: Acquisto NM, Mosier JM, Bittner EA, et al. Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient. Crit Care Med. 2023 Oct;51(10):1411-1430. doi: 10.1097/CCM.0000000000006000.

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RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI).

OBJECTIVES: Develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI

DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel’s inception in 2018 through 2020 and face to face at the 2020 Critical Care Congress. The guidelines panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine. Consultation with a methodologist and librarian was available. A formal conflict-of-interest policy was followed and enforced throughout the guidelines development process.

METHODS: Panelists created population, intervention, comparison, and outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guidelines. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of “strong” or “conditional” were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable, suggestions when evidence was equivocal, and best practice statements when the benefits of the intervention outweighed the risks but direct evidence to support the intervention did not exist.

RESULTS: From the original 35 proposed PICO questions, 10 were selected. The guidelines panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence.

CONCLUSIONS: Using GRADE principles, the multiprofessional panel found substantial agreement on the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

KEY WORDS: etomidate, hypnotics and sedatives, intubation, intratracheal, ketamine, neuromuscular blocking agents, propofol, rapid sequence induction and intubation, rocuronium, succinylcholine

Guideline Type: Clinical

Category: Quality and Patient Safety, GI and Nutrition,

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We suggest use of the head and torso inclined (semi-Fowler) position during RSI.
Quality of Evidence: Very low

Positioning Conditional Semi-Fowler position

We suggest preoxygenation with HFNO when laryngoscopy is expected to be challenging.
Quality of Evidence: Low

Preoxygenation Conditional Preoxygenation

We suggest preoxygenation with NIPPV in patients with severe hypoxemia (PaO₂/FIO₂ < 150).
Quality of Evidence: Low

Preoxygenation Conditional Preoxygenation

We suggest using medication-assisted preoxygenation to improve preoxygenation in patients undergoing RSI who are not able to tolerate a face mask, NIPPV, or HFNO because of agitation, delirium, or combative behavior.
Quality of Evidence: Very low

Med-Assisted Preoxygenation Conditional Preoxygenation

We suggest there is no difference between etomidate and other induction agents administered for RSI with respect to mortality or the incidence of hypotension or vasopressor use in the peri-intubation period and through hospital discharge.
Quality of Evidence: Moderate

Induction Agent Selection Conditional Induction agent

We suggest against administering corticosteroids following RSI with etomidate for the purpose of counteracting etomidate-induced adrenal suppression.
Quality of Evidence: Low

Etomidate, Corticosteroid Use Conditional Corticosteroids, Etomidate

We recommend administering an NMBA when a sedative-hypnotic induction agent is used for intubation.
Quality of Evidence: Low

NMBA Use Strong NMBA

We suggest administering either rocuronium or succinylcholine for RSI when there are no known contraindications to succinylcholine.
Quality of Evidence: Low

NMBA Selection Conditional Rocuronium, succinylcholine

We advise NG tube decompression when the benefit outweighs the risk in patients who are undergoing RSI and are at high risk of regurgitation of gastric contents.

NG Tube Decompression None NG tube decompression

There is insufficient evidence to make a recommendation that there is a difference in the incidence of further hypotension or cardiac arrest between the administration of peri-intubation vasopressors or IV fluids for hypotensive critically ill patients undergoing RSI.

Peri-Intubation Vasopressors Insufficient evidence Peri-intubation vasopressors

We advise administering a sedative-hypnotic induction agent when an NMBA is used for intubation.

Induction Agent Use None Induction agent

HFNO = high-flow nasal oxygen, NG = nasogastric, NIPPV = noninvasive positive pressure ventilation, NMBA = neuromuscular-blocking agent, RSI = rapid sequence intubation.

Nicole M. Acquisto, PharmD, FCCM

Nicole M. Acquisto, PharmD, FCCM, is a clinical research pharmacist in the Department of Pharmacy and Associate Profession in the Department of Emergency Medicine at University of Rochester Medical Center in New York, NY. She served as chair for the committee that developed the guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.

Michael J. Murray, MD, PhD, MCCM

Michael J. Murray, MD, PhD, MCCM, is an anesthesiologist at the University Medical Center in Phoenix, Arizona, USA. He served as cochair for the committee that developed the guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.

Jarrod M. Mosier, MD, FCCM

Jarrod M. Mosier, MD, FCCM, is the director of emergency medicine/medical critical care at University of Arizona College of Medicine in Tucson, Arizona, USA. He served as co-vice chair for the committee that developed the guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.

A complete list of the guidelines authors and contributors is available within the published manuscript.