Neostigmine – It can be used to reverse nondepolarizing neuromuscular blocking agents which cannot be reversed with sugammadex, although its onset is much slower. It works by competing with acetylcholine for the binding sites of acetylcholinesterase, which in turn prevents the breaking down of acetylcholine. The dosage is between 0.03 and 0.07 mg/kg. The side effect of this drug is bradycardia. Therefore, glycopyrrolate should be given together with neostigmine to prevent bradycardia. Other medications
Thiopental
Metaraminol or ephedrine, where hypotension may occur secondary to the sedating drugs. Phenylephrine – This drug is administered to those with hypotension post intubation as a result of lidocaine, midazolam, fentanyl, propofol, and ketamine. The dosages range from 50 to 200 μg in adults. It has quick onset and quick elimination. The common side effect is reflex bradycardia. Technique
Rapid sequence intubation refers to the pharmacologically induced sedation and neuromuscular paralysis prior to intubation of the trachea. The technique is a quicker form of the process normally used to induce general anesthesia. A useful framework for describing the technique of RSI is the "seven Ps". Preparation
The patient is assessed to predict the difficulty of intubation. Continuous physiological monitoring such as ECG and pulse oximetry is put on the patient. The equipment and drugs for the intubation are planned, including the endotracheal tube size, the laryngoscope size, and drug dosage. Drugs are prepared in syringes. Intravenous access is obtained to deliver the drugs, usually by placing one or two IV cannulae.
Preoxygenation
The aim of preoxygenation is to replace the nitrogen that forms the majority of the functional residual capacity with oxygen. This provides an oxygen reservoir in the lungs that will delay the depletion of oxygen in the absence of ventilation (after paralysis). For a healthy adult, this can lead to maintaining a blood oxygen saturation of at least 90% for up to 8 minutes. This time will be significantly reduced in obese patients, ill patients and children. Preoxygenation is usually performed by giving 100% oxygen via a tightly fitting face mask. Preoxygenation or a maximum of eight deep breaths over 60 seconds resulting in blood oxygenation is not different from that of quiet breathing volume for 3 minutes.Newer methods of preoxygenation include the use of a nasal cannula placed on the patient at 15 LPM at least 5 minutes prior to the administration of the sedation and paralytic drugs. High flow nasal oxygen has been shown to flush the nasopharynx with oxygen, and then when patients inspire they inhale a higher percentage of inspired oxygen. Small changes in FiO2 create dramatic changes in the availability of oxygen at the alveolus, and these increases result in marked expansion of the oxygen reservoir in the lungs prior to the induction of apnea. After apnea created by RSI the same high flow nasal cannula will help maintain oxygen saturation during efforts securing the tube (oral intubation). The use of nasal oxygen during pre-oxygenation and continued during apnea can prevent hypoxia before and during intubation, even in extreme clinical cases.