Why is Fentanyl (a synthetic opioid analgesic) administered prior to Rapid Sequence Intubation (RSI) and before the full induction dose?

From the Guidelines

Fentanyl pretreatment before rapid sequence induction (RSI) is crucial to minimize the risk of morbidity and mortality by blunting the sympathetic response to laryngoscopy and intubation, and the most recent guidelines support its use as part of a comprehensive RSI protocol 1. The primary goal of fentanyl pretreatment is to suppress the sympathetic surge that occurs during intubation, which can lead to dangerous increases in heart rate, blood pressure, and intracranial pressure, particularly in patients with cardiovascular disease, increased intracranial pressure, or aortic dissection. Some key points to consider when administering fentanyl pretreatment include:

• Typical dosage: 1-3 mcg/kg IV approximately 3 minutes before the induction agent, allowing the medication to reach peak effect when laryngoscopy occurs 1
• Potential side effects: higher doses may cause chest wall rigidity or respiratory depression, so careful titration is necessary 2
• Special considerations: in hemodynamically unstable patients, consider using lower doses (0.5-1 mcg/kg) to avoid hypotension, while higher doses within the range may be appropriate for patients with severe hypertension or those at high risk of complications from hemodynamic changes, with careful monitoring 2 The use of fentanyl pretreatment as part of a complete RSI protocol, including appropriate preoxygenation, induction agent, and neuromuscular blocking agent administration, is supported by recent guidelines 1.

From the Research

Pretreatment with Fentanyl prior to RSI

• Fentanyl is used as a pretreatment agent prior to Rapid Sequence Intubation (RSI) due to its ability to provide optimal intubating conditions with minimal impact on hemodynamic parameters 3.
• The use of fentanyl as a pretreatment agent can help to minimize the risk of peri-intubation cardiac arrest, which is a potential complication of RSI 4.
• Fentanyl has a neutral hemodynamic response and fast onset of action, making it a suitable choice for use in critically ill patients 3.

Benefits of Fentanyl Pretreatment

• Fentanyl can help to reduce the risk of hypotension and hypertension during RSI, which can be beneficial for patients with underlying cardiovascular disease 4.
• The use of fentanyl as a pretreatment agent can also help to reduce the risk of awareness during paralysis, which is a potential complication of RSI 3.
• Fentanyl has been shown to be effective in reducing the hemodynamic responses to laryngoscopy and tracheal intubation, which can be beneficial for patients with head injuries or other conditions that require neuroprotection 5.

Comparison with other Agents

• Fentanyl has been compared to other agents, such as alfentanil and sufentanil, in terms of its effects on hemodynamic parameters during RSI 6.
• The results of these studies suggest that fentanyl is a suitable choice for use as a pretreatment agent prior to RSI, due to its ability to provide optimal intubating conditions with minimal impact on hemodynamic parameters 6.
• The choice of pretreatment agent will depend on the individual patient's needs and medical history, as well as the specific requirements of the RSI procedure 7.