it was subsequently approved on December 15, 2015 for use in the United States. 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 competitively inhibiting acetylcholinesterase, an enzyme that breaks down acetylcholine. This results in an accumulation of acetylcholine present in the neuromuscular junction, effectively reversing the paralysis of the patient. The dosage is between 0.03 and 0.07 mg/kg. A common side effect of this drug is bradycardia. Therefore, glycopyrrolate, an anticholinergic drug, should be given immediately prior to 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. Pre-Intubation Steps 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