Rapid sequence induction and full stomach

Airway·~5 min read· Physician-reviewed✓ Sourced · 5

Stem

A 71-year-old man, 78 kg, with type 2 diabetes, presents for emergency laparotomy for a small bowel obstruction after two days of vomiting. A nasogastric tube is draining bilious fluid. Blood pressure is 98/60, heart rate 114, and potassium 4.1 mEq/L. His airway examination is unremarkable, and he has no history of burns, neuromuscular disease or recent immobility.

Question

How will you induce anesthesia and secure his airway?

Ideal answer

HeadlineFull stomach, so rapid sequence induction: a cuffed tracheal tube with the shortest unprotected interval.

Suction under the pillow, tilting table, video laryngoscope, bougie, and a failure plan, since regurgitation leaves no time.
GLP-1 agonist question; NG on suction, left in: he is diabetic and the drug slows gastric emptying, though a full stomach anyway; sodium citrate 30 mL; H2 blocker and metoclopramide only if time allows.
Head-up, preoxygenate to end-tidal oxygen about 0.9, his reserve for apnea.¹
Ketamine or etomidate, not full-dose propofol, vasopressor ready, because he is hypovolemic.
Succinylcholine 1.5 mg/kg, about 120 mg, immediately, or rocuronium 1.2 mg/kg;² cricoid as he loses consciousness, intubate at 45–60 seconds, capnography, cuff up before releasing cricoid.

Watch for: his pressure: induction drug and positive pressure both drop it in a dry patient.

Breaking down the answer

Who is a full stomach — unfasted, obstruction, trauma and pain with opioids, pregnancy past the first trimester, symptomatic reflux, gastroparesis from diabetes or GLP-1 agonists, symptomatic obesity. Uncertain: gastric ultrasound, right lateral, antrum distended with solids.
Succinylcholine — fastest, most reliable conditions, and it wears off, but it raises potassium by about 0.5 mEq/L and is contraindicated after the acute phase of burns, major trauma, denervation and upper motor neuron injury, and in myopathies.³
Rocuronium instead — 1.2 mg/kg gives equivalent conditions at 60 seconds, with sugammadex 16 mg/kg to reverse.⁴ Changes if: succinylcholine contraindicated or a difficult intubation expected.
Cricoid pressure — 10 N awake rising to 30 N at loss of consciousness; benefit is weakly evidenced and it can worsen the view, so I release it if intubation is difficult or a supraglottic airway is needed.¹ A nasogastric tube does not make it ineffective.
Ventilation in the apneic interval — classic RSI withholds it; gentle breaths below 15–20 cmH2O for a patient who will desaturate, a child, a parturient, the critically ill: hypoxia kills faster than aspiration.¹ Nasal oxygen at up to 15 L/min costs nothing.¹
Agent and position — propofol when stable; ketamine 1–2 mg/kg or etomidate 0.3 mg/kg when hypovolemic or septic. Head-up 20–30° improves preoxygenation and reduces passive regurgitation; head-down protects if regurgitation occurs, so I tilt down if I see fluid.

Follow-up question

The view is grade 3 and your first attempt fails. His saturation is 94% and falling. What do you do?

Follow-up answer

HeadlineA failed first attempt with a falling saturation: I call for help and make one optimized second attempt.

Cricoid stays on unless it is the problem: bougie, external laryngeal manipulation, video laryngoscope if the first was direct. Failing that, I release cricoid and mask ventilate: he needs oxygen more than protection; if the mask fails, a second-generation supraglottic airway, which protects better against aspiration than a first-generation device.¹ With oxygenation restored: wake him if succinylcholine was used and surgery can wait, or, as here, intubate through the supraglottic airway with a fiberscope. If he regurgitates: turn the head, suction, head-down, intubate once I see cords, suction the trachea before the first positive-pressure breath.

Pitfalls that cost points

Describing "modified RSI" without saying what is modified and why.
Giving succinylcholine to the burned or paraplegic patient because it was "RSI."
Treating cricoid pressure as sacred when the view is obscured.

Rapid-fire

Q: Why 1.5 mg/kg of succinylcholine rather than 1 mg/kg? A: It reliably produces full relaxation at 45–60 seconds; lower doses leave some patients with incomplete conditions when I need them.

Q: Why does sodium citrate matter if you are intubating anyway? A: It raises gastric pH within minutes so that an aspiration is less injurious; it adds volume, so I give it only immediately before induction.

Q: Should a patient stop a GLP-1 agonist before surgery? A: Most continue it (2024 multisociety guidance); I defer elective surgery during escalation or with GI symptoms, 24-hour liquid diet if high risk, gastric ultrasound when unsure.⁵ Symptomatic and urgent: a full stomach.

Q: Why not intubate every full stomach awake? A: Topicalization abolishes airway reflexes, so awake intubation does not protect against aspiration; I reserve it for the full stomach with a predicted difficult airway.

Numbers to know

Item	Value
Succinylcholine	1.5 mg/kg IV; contraindicated after acute phase of burns, denervation³
Rocuronium for RSI	1.2 mg/kg IV; sugammadex 16 mg/kg to reverse
Cricoid force	10 N awake, 30 N asleep¹
Preoxygenation target	End-tidal O2 fraction 0.87–0.9¹
Sodium citrate	30 mL of 0.3 M within 20 min of induction
GLP-1 agonist	Usually continue; 24 h liquid diet if high risk; defer if escalating or symptomatic⁵

Sources

1.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults · DAS, 2015 · ebi.ac.ukFull text via Europe PMC (PMC4650961); preoxygenation, cricoid pressure and RSI sections.
2.Rocuronium bromide injection prescribing information · FDA / DailyMed · dailymed.nlm.nih.gov
3.QUELICIN (succinylcholine chloride) injection prescribing information · FDA / DailyMed · dailymed.nlm.nih.gov
4.BRIDION (sugammadex) injection prescribing information · FDA / DailyMed · dailymed.nlm.nih.gov
5.New Multi-society Clinical Practice Guidance Released (perioperative GLP-1 receptor agonists) · ASA, 2024 · asahq.orgASA news release summarizing the October 2024 multisociety guidance; replaces the 2023 ASA consensus advice to hold weekly agents for one week.

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.