What is the recommended rate of administration for intubation medications, such as etomidate (amidate) and rocuronium, during rapid sequence intubation?

From the Guidelines

The recommended rate of administration for intubation medications during rapid sequence intubation (RSI) is as follows: etomidate (Amidate) should be administered at a dose of 0.3 mg/kg IV as a rapid push over 10-20 seconds, while rocuronium should be given at a dose of 1.0-1.2 mg/kg IV also as a rapid push over 10-20 seconds. These medications should be administered in sequence, with the sedative agent (etomidate) given first, immediately followed by the paralytic agent (rocuronium) 1. After administration, allow approximately 45-60 seconds for optimal intubating conditions to develop before attempting laryngoscopy. For patients with hemodynamic instability, consider reducing the etomidate dose to 0.2 mg/kg. The rapid administration of these medications is crucial for RSI to minimize the time between loss of protective reflexes and securing the airway, thereby reducing aspiration risk. The quick onset of etomidate (30-60 seconds) provides rapid sedation while rocuronium's onset (45-60 seconds at these doses) ensures adequate muscle relaxation for optimal intubating conditions. Some key points to consider when choosing the medications and their administration rates include:

• The importance of minimizing the time to intubation to reduce the risk of aspiration and other complications 1
• The selection of a sedative-hypnotic agent that attenuates hypotension during RSI, with etomidate being a common choice due to its favorable hemodynamic profile 1
• The use of a neuromuscular-blocking agent (NMBA) such as rocuronium to optimize intubating conditions and reduce the occurrence of difficult or failed airways 1 Always have emergency airway equipment readily available before administering these medications. It is also important to note that the guidelines for RSI are based on the best available evidence and may vary depending on the specific clinical context and patient population 1.

From the FDA Drug Label

The recommended initial dose of rocuronium bromide injection, regardless of anesthetic technique, is 0.6 mg/kg. 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 rate of administration for intubation medications, such as rocuronium, is not explicitly stated in terms of speed of push, but the recommended dose is 0.6 mg/kg, and this dose can be expected to provide intubating conditions in less than 2 minutes.

• The dose for tracheal intubation is 0.6 mg/kg.
• Rapid sequence intubation can be achieved with 0.6 to 1.2 mg/kg of rocuronium bromide injection. The FDA label does not provide information on the rate of administration in terms of how fast the medication can be pushed, only the dose and expected effect. 2

From the Research

Recommended Rate of Administration for Intubation Medications

The recommended rate of administration for intubation medications, such as etomidate and rocuronium, during rapid sequence intubation is not explicitly stated in terms of a specific rate of administration. However, the following points can be considered:

• The selection and use of medications to facilitate rapid sequence intubation (RSI) is critical for success 3.
• Etomidate and rocuronium are commonly used for RSI due to their favorable hemodynamic profiles 3, 4.
• The literature suggests minimal differences between succinylcholine and high-dose rocuronium in first-pass success rates, and selection between the two is based on patient-specific factors, half-life, and adverse effect profiles 3.
• The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas, including optimal induction agent selection and dosing in patients presenting with shock or sepsis 3.

Administration Considerations

Some key considerations for the administration of intubation medications include:

• Pretreatment medications, such as atropine, lidocaine, and fentanyl, may be used, but their use has fallen out of favor due to limited evidence for their use outside of select clinical scenarios 3.
• Induction agents, such as etomidate and ketamine, should be chosen based on their hemodynamic profiles and the patient's specific condition 3, 5.
• Neuromuscular blocking agents, such as succinylcholine and rocuronium, should be selected based on patient-specific factors, half-life, and adverse effect profiles 3, 5.
• The role of the emergency medicine pharmacist is crucial in updating practice patterns and providing optimal patient care 6.

Postintubation Sedation

Postintubation sedation is an important consideration after rapid sequence intubation, and the choice of neuromuscular blocker may affect the timing and dose of sedation medications:

• Rocuronium is associated with a delay in postintubation sedation compared with succinylcholine 7.
• The time from neuromuscular blocker administration to the first dose of sedation may be longer for rocuronium compared with succinylcholine 7.
• The total hourly weight-adjusted fentanyl dose may be lower for patients intubated with rocuronium compared with succinylcholine 7.