What is the recommended administration rate for rapid intubation drugs, such as etomidate (sedative) and succinylcholine (neuromuscular blocking agent) or rocuronium (neuromuscular blocking agent)?

From the Guidelines

For rapid sequence intubation, etomidate should be administered at 0.3 mg/kg IV as a single bolus dose, given over 30-60 seconds, followed immediately by succinylcholine at 1.5-2 mg/kg IV or rocuronium at 1.0-1.2 mg/kg IV as a rapid bolus. The choice of neuromuscular blocking agent (NMBA) depends on the patient's medical history and clinical situation, with succinylcholine being the first-line agent for patients with vital signs of distress and rocuronium being an alternative when succinylcholine is contraindicated 1. The timing between medications is critical, with the NMBA being administered immediately after confirming the sedative effect, typically within 30-60 seconds of sedative administration 1. This sequence allows for rapid onset of both sedation and paralysis, facilitating optimal intubation conditions within 45-60 seconds after NMBA administration. Proper dosing and timing are essential because underdosing may result in inadequate intubating conditions, while proper administration ensures patient comfort, amnesia, and optimal muscle relaxation. Clinicians should have emergency medications readily available, including vasopressors for potential hypotension, particularly with etomidate. Pre-oxygenation before medication administration is crucial to maximize the safe apnea period during intubation attempts. Some key considerations include the use of pre-oxygenation with high-flow nasal oxygen or noninvasive positive pressure ventilation when laryngoscopy is expected to be challenging, and the administration of peri-intubation vasopressors or IV fluids for hypotensive critically ill patients undergoing RSI 1. Overall, the goal of rapid sequence intubation is to minimize the risk of aspiration and ensure optimal intubating conditions, and the choice of medications and technique should be guided by the patient's individual needs and medical history. Key points to consider include:

• The use of a sedative-hypnotic induction agent, such as etomidate, to facilitate intubation
• The selection of an NMBA, such as succinylcholine or rocuronium, based on the patient's medical history and clinical situation
• The importance of proper dosing and timing of medications to ensure optimal intubating conditions
• The need for pre-oxygenation and emergency medications, including vasopressors, to be readily available.

From the FDA Drug Label

Midazolam should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect. For induction of general anesthesia, before administration of other anesthetic agents. Individual response to the drug is variable, particularly when a narcotic premedication is not used. The dosage should be titrated to the desired effect according to the patient’s age and clinical status When midazolam is used before other intravenous agents for induction of anesthesia, the initial dose of each agent may be significantly reduced, at times to as low as 25% of the usual initial dose of the individual agents. Unpremedicated Patients: In the absence of premedication, an average adult under the age of 55 years will usually require an initial dose of 0.3 to 0. 35 mg/kg for induction, administered over 20 to 30 seconds and allowing 2 minutes for effect.

The recommended administration rate for rapid intubation drugs, such as etomidate (sedative) and succinylcholine or rocuronium (neuromuscular blocking agents), is not directly stated in the provided drug labels. However, for midazolam, the administration rate is:

• Titrate slowly over at least 2 minutes
• Allow an additional 2 or more minutes to fully evaluate the sedative effect.
• For induction of general anesthesia, administer over 20 to 30 seconds and allow 2 minutes for effect. It is essential to note that the administration rate may vary depending on the patient's age, clinical status, and other factors, and should be individualized and titrated to the desired effect 2.

From the Research

Rapid Intubation Drugs Administration

The administration rate for rapid intubation drugs is crucial for the success of the procedure.

• The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas 3.
• Etomidate and rocuronium have become increasingly popular for sedation and paralysis, respectively, in rapid sequence intubation, due to their rapid onset of action and relatively few hemodynamic adverse effects 4.
• The choice of induction agent and neuromuscular blocking agent depends on patient-specific factors, half-life, and adverse effect profiles 3.

Administration Order and Rate

• The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation is debated 5.
• Administering the neuromuscular blocking agent before the sedative agent may result in modestly faster time to intubation, with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds 5.
• However, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with, as the order of medication administration may not be associated with awareness of neuromuscular blockade 5.

Medication Considerations

• Pretreatment medications, such as atropine, lidocaine, and fentanyl, are not commonly used due to limited evidence for their use outside of select clinical scenarios 3.
• Etomidate and ketamine are the most commonly used induction agents due to their favorable hemodynamic profiles, with etomidate producing less hypotension than ketamine in patients presenting with shock or sepsis 3.
• Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, with minimal differences between them in first-pass success rates 3.