From the Guidelines
For rapid sequence intubation (RSI) of a 75 kg male, I recommend using etomidate 15-22.5 mg IV (0.2-0.3 mg/kg) for induction, as it has a favorable hemodynamic profile and does not increase mortality or the incidence of hypotension or vasopressor use in the peri-intubation period and through hospital discharge, as suggested by the Society of Critical Care Medicine clinical practice guidelines 1.
Medication Regimen
To perform RSI, start with preoxygenation for 3-5 minutes with 100% oxygen. For premedication, administer fentanyl 75-150 mcg IV (1-2 mcg/kg) to blunt sympathetic response.
- Induction: etomidate 15-22.5 mg IV (0.2-0.3 mg/kg) or propofol 75-150 mg IV (1-2 mg/kg) if hemodynamically stable
- Neuromuscular blockade: succinylcholine 75-150 mg IV (1-2 mg/kg) for rapid onset (60-90 seconds) or rocuronium 45-60 mg IV (0.6-0.8 mg/kg) if succinylcholine is contraindicated, as recommended by the Society of Critical Care Medicine clinical practice guidelines 1
Procedure
After medication administration, wait 45-60 seconds before attempting laryngoscopy. Have backup airway equipment ready, including a bougie, video laryngoscope, and supraglottic airway device. Prepare for post-intubation management with sedation (propofol 5-50 mcg/kg/min or midazolam 1-2 mg IV) and analgesia (fentanyl 25-50 mcg IV hourly). Monitor vital signs closely during the procedure, especially blood pressure, as hypotension can occur following induction.
Important Considerations
It is essential to use actual body weight, rather than ideal body weight, for some non-resuscitation medications, such as succinylcholine, as stated in the American Heart Association guidelines 1. This regimen provides rapid unconsciousness and muscle relaxation while minimizing aspiration risk, which is the primary goal of RSI in emergency situations.
From the FDA Drug Label
In appropriately premedicated and adequately anesthetized patients, rocuronium bromide injection 0.6 to 1.2 mg/kg will provide excellent or good intubating conditions in most patients in less than 2 minutes The recommended initial dose of rocuronium bromide injection, regardless of anesthetic technique, is 0.6 mg/kg.
For a 75 kg male, the recommended initial dose for Rapid Sequence Intubation is 0.6 to 1.2 mg/kg, which would be 45 mg to 90 mg of rocuronium bromide injection. This dose may provide excellent or good intubating conditions in most patients in less than 2 minutes 2.
From the Research
Rapid Sequence Intubation for a 75 kg Male
Medication Options
- Etomidate and rocuronium have been increasingly popular for sedation and paralysis in rapid sequence intubation, with a rapid onset of action and relatively few hemodynamic adverse effects 3.
- Rocuronium can produce optimal intubating conditions without the serious complications associated with succinylcholine 3.
- However, etomidate suppresses adrenal function, making its use in patients with septic shock controversial 3.
Intubating Conditions
- A study comparing propofol and etomidate for rapid sequence induction found that 94% of patients in the propofol group had clinically acceptable intubating conditions, compared to 75% in the etomidate group 4.
- Rocuronium alone may not be sufficient for intubation at 60 seconds under rapid sequence induction conditions, especially when used with etomidate 4.
- Succinylcholine was found to be superior to rocuronium for achieving excellent intubating conditions in a Cochrane systematic review 5.
Considerations for Medication Choice
- The choice of premedication, induction agent, and paralytic will maximize the success of tracheal intubation and minimize complications 6.
- Rocuronium's long duration of effect may put patients at risk for wakeful paralysis once the short effects of etomidate have subsided 7.
- The dose of rocuronium should be at least 0.6 mg/kg, and succinylcholine should be at least 1 mg/kg for rapid sequence intubation 5.