What is the Rapid Sequence Intubation (RSI) preparation for a 90kg male patient with Respiratory Failure?

From the Guidelines

For Rapid Sequence Intubation (RSI) in a 90kg man with respiratory failure, I recommend using etomidate 20mg IV (0.2-0.3mg/kg) as the induction agent of choice, as it has a favorable hemodynamic profile and there is no significant difference in mortality or incidence of hypotension compared to other induction agents, as suggested by the Society of Critical Care Medicine clinical practice guidelines 1. The selection of etomidate is based on its ability to maintain hemodynamic stability, which is crucial in critically ill patients with respiratory failure.

• Pre-oxygenation for 3-5 minutes using a non-rebreather mask or bag-valve-mask with 100% oxygen should be performed before induction.
• For premedication, administer fentanyl 100mcg IV to blunt sympathetic response.
• Follow immediately with a paralytic agent such as rocuronium 90mg IV (1mg/kg) or succinylcholine 180mg IV (1.5-2mg/kg), as recommended by the guidelines 1.
• Apply cricoid pressure during the procedure if aspiration risk is high.
• After confirming tube placement with end-tidal CO2, secure the endotracheal tube and initiate mechanical ventilation with initial settings of tidal volume 6-8mL/kg ideal body weight, respiratory rate 14-16 breaths/minute, and FiO2 100%, then titrate based on arterial blood gases.
• Have vasopressors such as phenylephrine or norepinephrine ready for post-intubation hypotension, as the guidelines suggest that there is insufficient evidence to make a recommendation on the use of peri-intubation vasopressors or IV fluids for hypotensive critically ill patients undergoing RSI 1. This approach provides rapid airway control while minimizing hemodynamic instability, which is particularly important in respiratory failure where the patient may have limited physiological reserve and be prone to rapid desaturation during the procedure, as supported by the guidelines 1.

From the FDA Drug Label

2.3 Rapid Sequence Intubation 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

For a 90kg man, the recommended dose of rocuronium bromide injection for Rapid Sequence Intubation (RSI) is 0.6 to 1.2 mg/kg.

• The dose for this patient would be:
  • 0.6 mg/kg: 0.6 mg/kg x 90 kg = 54 mg
  • 1.2 mg/kg: 1.2 mg/kg x 90 kg = 108 mg This dose will provide excellent or good intubating conditions in most patients in less than 2 minutes 2.

From the Research

RSI Prep Intubation for a 90kg Man with Respiratory Failure

• The patient's weight is 90kg, and the goal is to determine the appropriate dosage for rapid sequence intubation (RSI) in the context of respiratory failure.
• According to the study 3, the recommended rocuronium dose for RSI is 1.0 mg/kg, but the optimal dose for emergency airway management is not clear.
• The study 3 found that rocuronium dosed ≥1.4 mg/kg was associated with higher first-attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension, with no increase in adverse events.
• For a 90kg man, the dose of rocuronium would be:
  • 1.0 mg/kg: 90 mg
  • 1.4 mg/kg: 126 mg
• Another study 4 compared rocuronium and succinylcholine for RSI intubation and found that succinylcholine was superior to rocuronium for achieving excellent intubating conditions.
• The study 5 discussed the selection and use of medications to facilitate RSI, including the use of succinylcholine and rocuronium as neuromuscular blocking agents.
• The study 6 highlighted the advantages of using etomidate and rocuronium for RSI in pediatric patients, including rapid onset of action and minimal hemodynamic adverse effects.
• The study 7 evaluated intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction and found that propofol resulted in better intubating conditions than etomidate.

Medication Selection and Dosing

• The selection of medication for RSI should be based on patient-specific factors, including weight, medical history, and current condition 5.
• The dosing of rocuronium should be individualized, and the study 3 suggests that a dose of ≥1.4 mg/kg may be associated with higher first-attempt success in certain patients.
• The use of succinylcholine may be considered as an alternative to rocuronium, especially in patients where rapid intubation is critical 4.

Clinical Considerations

• The patient's respiratory failure should be taken into consideration when selecting medications for RSI, and the goal should be to minimize the risk of further compromising the patient's respiratory status 5.
• The use of medications with minimal hemodynamic adverse effects, such as etomidate and rocuronium, may be beneficial in patients with respiratory failure 6.