Modified rapid sequence induction and intubation: a survey of United States current practice

Anesth Analg. 2012 Jul;115(1):95-101. doi: 10.1213/ANE.0b013e31822dac35. Epub 2011 Oct 24.


Background: Rapid sequence induction and intubation (RSII) is a technique commonly used to resist regurgitation of gastric contents and protect the airway. A modification of this technique is implemented in certain clinical circumstances. However, there is currently no standard definition for a modified RSII. Therefore, we surveyed clinicians at academic centers across the United States to establish a working definition of a modified RSII as well as the clinical scenarios in which it is being used.

Methods: A survey was created that queried the use and definition of modified RSII, and validated with test respondents. We then mailed the survey to all 131 anesthesia residency training programs across the United States. Logistic regression models were created to estimate the percentage of affirmative responses among respondents that performed modified RSII procedures and answered survey items in a consistent manner. Similar quantities were calculated by physician status (resident and attending).

Results: Four hundred ninety surveys were received from 58 institutions (44% institution response rate); 93% of respondents reported using a modified RSII, and of those 85% consistently completed the survey instrument. A majority of respondents (71%, CI: 63%-77%) reported administering oxygen before anesthesia induction, applying cricoid pressure, and attempting to ventilate the lungs via a facemask before securing the airway. Respondents noted that they would use a modified RSII procedure if the patient were either moderately or morbidly obese (each ∼59%, 53%-64%), had a history but no current symptoms of gastroesophageal reflux disease (52%, 46%-57%), had a hiatal hernia (42%, 36%-48%) or were a trauma patient who had been NPO for at least 8 h (39%, 33%-45%). Similar RSII results were obtained when repeating the analysis on the subset that did not enforce the consistency requirements.

Conclusions: Based on our survey we have established three defining features of a modified RSII: (1) oxygen administration before induction; (2) the use of cricoid pressure; and (3) an attempt to ventilate the patient's lungs before securing the airway. Although this definition seems intuitively obvious, no previous work has tested whether it is commonly accepted.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Inhalation
  • Anesthesia / adverse effects
  • Anesthesia / methods*
  • Clinical Competence
  • Health Care Surveys
  • Humans
  • Internship and Residency
  • Intubation, Intratracheal* / adverse effects
  • Laryngeal Masks
  • Laryngopharyngeal Reflux / etiology
  • Laryngopharyngeal Reflux / prevention & control*
  • Logistic Models
  • Odds Ratio
  • Oxygen / administration & dosage
  • Positive-Pressure Respiration
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • United States


  • Oxygen