Key result
Propofol leads emergency RSI outside the OR at ~63% usage alongside severe post-induction hypotension risks.
Why the study?
Emergency tracheal intubation outside the operating theatre carries increased risk, with guidelines cautioning against high-dose propofol due to associated haemodynamic instability.
Cross-Sectional (n=250)
Yes
Emergency tracheal intubation outside the operating theatre in the UK frequently involves propofol at elective doses, deviating from guidelines and contributing to high rates of post-induction hypotension.
Answers are grounded in this paper and cite their sources.
Characterizes UK induction practices for non-OR emergency intubation; leaves open optimal strategies to reduce haemodynamic instability.
Summary Introduction Emergency tracheal intubation outside the operating theatre carries increased risk for patients. Guidelines caution against high dose propofol for induction in this context, due to associated haemodynamic instability. This study aimed to describe induction strategies and adverse events for these patients in UK practice. Methods We conducted a prospective, multicentre cross‐sectional service evaluation of adults who required emergency tracheal intubation outside the operating theatre. Data were collected as a convenience sample by anaesthetic and critical care teams using an online form. Primary outcomes were the selection and dose of induction drugs. Secondary outcomes were: vasopressor co‐administration; severe hypotension (systolic blood pressure < 80 mmHg); severe hypoxia (peripheral oxygen saturation < 80%); and cardiac arrest. Results Twenty‐three NHS hospitals reported 250 emergency tracheal intubations. Not including 17 (7%) performed during cardiac arrest, there were 233 rapid sequence inductions. Propofol was used in 147 (63%); fentanyl in 172 (74%); ketamine in 53 (23%); and midazolam in 51 (22%). Propofol with fentanyl was the most common combination (97/233, 42%), at median (IQR [range]) doses of 1.4 (0.8–2.0 [0.04–3.3]) mg.kg ‐1 and 2.0 (1.3–2.9 [0.5–6.0]) μg.kg ‐1 , respectively. Severe hypotension affected 24/219 (11%) patients with recorded post‐induction blood pressures. Severe hypoxia affected 14/221 (6%) patients with recorded post‐induction oxygen saturations. Post‐induction cardiac arrest occurred in 6/233 (3%) patients. For patients who did not receive pre‐emptive vasopressors at induction, 40/105 (38%) subsequently required vasopressor administration. Discussion Patients who required tracheal intubation outside operating theatres experienced high rates of post‐induction hypotension. Propofol was the most used induction drug, often at doses typical for elective anaesthesia. Pre‐emptive vasopressor use was inconsistent. These practices deviate from existing guidelines and represent a modifiable risk factor for adverse events. We recommend standardised protocols for tracheal intubation outside operating theatres, including guidance on induction drug selection, dose and pre‐emptive vasopressor use.
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Ramasamy et al. (2026) conducted a cross-sectional in Emergency tracheal intubation outside the operating theatre (n=250). Rapid sequence induction drugs was evaluated on Selection and dose of induction drugs. Among 233 adults undergoing emergency rapid sequence induction outside the operating theatre, propofol was the most frequently used induction drug, and severe post-induction hypotension occurred in 11%.
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