Airway management and rapid sequence induction in ICU

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Red flags

• ICU intubation is high-risk: 45.2% of critically ill intubations had a major adverse peri-intubation event in the INTUBE study (cardiovascular instability 42.6%, severe hypoxaemia 9.3%, cardiac arrest 3.1%) — pre-oxygenation and haemodynamic preparation are non-negotiable
• Pre-oxygenation is critical — denitrogenation (3 min tidal breathing or 8 deep breaths of 100% O2) buys roughly 6-10 min of safe apnoea in the healthy adult, MUCH less in the critically ill (shunt, low FRC, obesity, pregnancy, sepsis)
• Peri-intubation cardiac arrest occurs in 3.1% of ICU intubations — mostly from cardiovascular collapse after induction — prevent with haemodynamic optimisation BEFORE induction (fluids, vasopressors, reduced induction dose)
• Always have a PLAN B (supraglottic airway — i-gel/LMA) and PLAN C (surgical airway — eFONA scalpel-bougie cricothyroidotomy) drawn up and ready BEFORE the first laryngoscopy
• CICO (can't intubate, can't oxygenate) is immediately life-threatening — declare it, announce the difficulty and go to eFONA scalpel-bougie cricothyroidotomy without delay; do not persist with repeated adjuncts and laryngoscopy
• Suxamethonium risks hyperkalaemia in the critically ill — the risk rises steeply with ICU length of stay (37% of patients intubated after ICU day 16 developed K ≥6.5 mmol/L vs 1% before), and burns, crush injury, denervation and immobilisation (once beyond the acute phase), malignant hyperthermia susceptibility and pre-existing hyperkalaemia are classic contraindications
• Etomidate causes adrenal suppression even after a SINGLE dose (adrenal insufficiency OR 6.7 vs ketamine; meta-analyses conflict on mortality) — many units prefer ketamine 2 mg/kg in septic shock
• Oesophageal intubation is the most common life-threatening airway disaster — ALWAYS confirm with WAVEFORM capnography (a flat ETCO2 trace = oesophageal intubation until proven otherwise)