| Population | Physiology and anatomy considerations | General recommendations | Medication recommendations |
| Elevated ICP | - Cerebral blood flow autoregulation impaired
- Systemic hypotension can aggravate brain injury via cerebral hypoperfusion
- Excessive systemic hypertension can increase ICP
- Manipulation of upper airway can increase cardiovascular sympathetic activity and cerebral blood flow from RSRL
- Certain RSI medications can cause increase in ICP
- Certain RSI medications (eg, propofol) can cause sympatholysis and hypotension
| - RSI preferred
- Use gentle, controlled technique
- Avoid prolonged or multiple intubation attempts
| - Pretreatment medications (eg, lidocaine, NMBA defasciculating dose, beta-blocker) are optional when performing RSI since no proven benefit
- When time allows, may pretreat with fentanyl 3 mcg/kg IV over 30 to 60 seconds unless patient is hypotensive or depends on sympathetic tone to maintain compensated BP
- Etomidate 0.3 mg/kg IV is preferred induction agent (ketamine 1 to 2 mg/kg IV is alternative if normotensive or hypotensive)
- Succinylcholine 1.5 mg/kg IV is preferred NMBA (rocuronium 1.2 to 1.5 mg/kg IV is alternative but has longer duration of effect)
- Make prefilled phenylephrine syringes (eg, 1 mg/10 mL) available at bedside
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| Obesity | - More rapid desaturation time (ie, decreased RSI safe apnea period) due to increased oxygen consumption and carbon dioxide production
- Increased BMV difficulty due to increased airway resistance and decreased functional residual capacity, especially when supine
- Increased likelihood of pharyngeal wall collapse
- Increased risk of aspiration pneumonitis
- Increased incidence of complications from comorbid diseases (eg, diabetes, atherosclerosis)
- Pharmacokinetic changes such as shorter duration of effect of renally excreted drugs
| - Anticipate difficult BMV, poor glottic visualization, and difficult tracheal intubation and/or cricothyrotomy
- Perform BMV with reverse Trendelenburg position and 2-person "thenar grip" technique
- Preoxygenate in an upright or semi-upright position (if possible) with flush-flow-rate oxygen (40 to 90 L/minute) via nonrebreather or HFNC
- Use NIPPV to improve preoxygenation if time allows
- Place patient in the ramped position (align the external auditory meatus and sternal notch) for intubation (if cervical spine precautions are not necessary)
- Provide oxygen by nasal cannula during the apneic phase of RSI
- Use video laryngoscope for first attempt
- Have tracheal tube introducer (bougie) available at the bedside
| - Use LBW to determine dose of induction agent
- Use TBW to determine dose of succinylcholine or rocuronium
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| Pregnancy | - More rapid desaturation time (ie, decreased RSI safe apnea period) due to increased basal metabolic rate and oxygen demand
- Increased minute ventilation and decreased PaCO2
- Reduced cardiac venous return and decreased functional residual capacity beyond 18 to 20 weeks of gestation from aortocaval and diaphragm compression by gravid uterus when supine
- Increased risk of aspiration
- Airway tissue can become redundant, friable, and prone to bleeding
- Enhanced sensitivity to nondepolarizing NMBA
| - Beyond 18 to 20 weeks of gestation, position supine patient with a 15-degree left lateral tilt
- Anticipate difficult BMV and tracheal intubation in third trimester
- Preoxygenate in an upright or semi-upright position (if possible) with flush-flow-rate oxygen (40 to 90 L/minute) via nonrebreather or HFNC
- Provide oxygen by nasal cannula during the apneic phase of RSI
- Have a smaller (6.5- to 7-mm) endotracheal tube available if supraglottic edema present
- Increase ventilator minute ventilation by approximately 20% for the first trimester and by 40% by term gestation
| - Use TBW to determine induction agent and NMBA doses
- Succinylcholine (1.5 mg/kg IV) is preferred paralytic agent, but if contraindicated, use rocuronium (1.2 to 1.5 mg/kg IV)
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| Older age | - Diminished cardiopulmonary reserve and less tolerance of hypoxia
- More difficult to adequately preoxygenate
- More difficult to create adequate mask seal if edentulous
- Limited neck mobility and stiffer chest walls
- Presence of comorbid condition and chronic illness
- Increased risk of hypopnea and hypotension from RSI medications
| - Focus on pre-intubation hemodynamic optimization if time allows
- Perform BMV with two-person "thenar grip" technique if difficult to obtain adequate seal
| - Etomidate 0.3 mg/kg IV is preferred induction agent (decrease dose to 0.15 mg/kg if SBP <100 mmHg or concern for hypoperfusion or shock)
- No change in NMBA doses
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