What medications are used for endotracheal intubation?

From the Guidelines

For intubation, the recommended drugs include a hypnotic agent such as etomidate, ketamine, or propofol, along with a neuromuscular blocking agent like succinylcholine or rocuronium, with the choice depending on the patient's medical history and clinical situation. When considering the medications for intubation, it's crucial to prioritize those that facilitate rapid sequence induction (RSI) and have a strong evidence base for their use. According to 1, a hypnotic agent that facilitates RSI should probably be used, with options including etomidate, ketamine, or propofol, chosen based on the patient's medical history and clinical situation. For neuromuscular blockade, succinylcholine is probably the first-line agent of choice for RSI in patients with vital signs of distress, while rocuronium at a dose above 0.9 mg/kg should be used when succinylcholine is contraindicated, as suggested by 1. Additionally, a more recent study 1 compared the intubating conditions after administration of succinylcholine and rocuronium, finding that while succinylcholine provides excellent intubation conditions more frequently, no superiority was found when comparing succinylcholine 1.0 mg/kg with rocuronium at a dose greater than 0.9 mg/kg. Key considerations in the choice of medications include:

• The patient's hemodynamic stability, with etomidate preferred in unstable patients
• The presence of bronchospasm or hypotension, where ketamine may be beneficial
• The need for rapid sequence intubation, where succinylcholine or high-dose rocuronium are preferred
• The availability of emergency medications and proper monitoring of vital signs throughout the procedure. Given the most recent and highest quality evidence, the use of etomidate, ketamine, or propofol as a hypnotic agent, along with succinylcholine or rocuronium as a neuromuscular blocking agent, is recommended for intubation, taking into account the patient's specific clinical situation and medical history.

From the FDA Drug Label

In US clinical studies, a total of 1137 patients received rocuronium bromide, including 176 pediatric, 140 geriatric, 55 obstetric, and 766 other adults. Intubation using doses of rocuronium bromide 0.6 to 0.85 mg/kg was evaluated in 203 adults in 11 clinical studies. Rapid Sequence Intubation Intubating conditions were assessed in 230 patients in six clinical studies where anesthesia was induced with either thiopental (3 to 6 mg/kg) or propofol (1.5 to 2.5 mg/kg) in combination with either fentanyl (2 to 5 mcg/kg) or alfentanil (1 mg). The dose for induction of anesthesia in adult patients and in pediatric patients above the age of ten (10) years will vary between 0.2 mg/kg and 0.6 mg/kg of body weight, and it must be individualized in each case. The usual dose for induction in these patients is 0.3 mg/kg, injected over a period of 30 to 60 seconds. Administration of propofol injectable emulsion should be adjusted if fat is being inadequately cleared from the body. When propofol injectable emulsion is used in patients with increased intracranial pressure or impaired cerebral circulation, significant decreases in mean arterial pressure should be avoided because of the resultant decreases in cerebral perfusion pressure

Drugs used for intubation include:

• Rocuronium bromide: 0.6 to 0.85 mg/kg for intubation
• Etomidate: 0.2 mg/kg to 0.6 mg/kg for induction of anesthesia
• Propofol: 1 mg/kg to 2 mg/kg for induction of anesthesia These drugs are used in combination with other agents such as thiopental, fentanyl, and alfentanil for rapid sequence intubation 2, 3, 4.

From the Research

Induction Agents for Intubation

• Etomidate is a commonly used sedative-hypnotic for rapid sequence intubation, with a rapid onset of action and minimal respiratory or cardiovascular effects 5, 6, 7, 8
• Ketamine can be considered as an alternative to etomidate in certain patient populations, such as those with hypotension 8
• Propofol and midazolam are also mentioned as potential induction agents, although they may have more significant respiratory and cardiovascular effects than etomidate 5, 9, 8
• Thiopental is another induction agent that has been used for intubation, but it may have more significant hemodynamic effects than etomidate 5

Neuromuscular Blockers for Intubation

• Succinylcholine is a commonly used neuromuscular blocker for rapid sequence intubation, although it can have significant side effects and is not recommended for patients with certain medical conditions 9, 8
• Rocuronium is a alternative neuromuscular blocker that can provide optimal intubating conditions without the serious complications associated with succinylcholine 9, 7, 8
• Vecuronium is another neuromuscular blocker that can be used for intubation, although it is no longer recommended for pretreatment 8

Other Medications Used for Intubation

• Fentanyl can be used as a pretreatment medication to help blunt the sympathetic stimulation of intubation, and can also be used for post-intubation continuous sedation 8
• Lidocaine is no longer recommended for pretreatment due to lack of benefit 8
• Atropine and phenylephrine are mentioned as potential medications that can be used during intubation, although their specific roles are not clearly defined 9