What are the recommendations for performing Rapid Sequence Intubation (RSI) in patients with hemodynamic instability?

From the Guidelines

For patients with hemodynamic instability requiring rapid sequence intubation (RSI), a modified approach is recommended to minimize cardiovascular collapse, prioritizing the use of induction agents with minimal hemodynamic effects, such as etomidate or ketamine, as suggested by the Society of Critical Care Medicine clinical practice guidelines 1. When performing RSI in hemodynamically unstable patients, it is crucial to consider the potential impact of induction agents on blood pressure and cardiac function.

• The selection of a sedative-hypnotic agent that attenuates hypotension during RSI is desirable, with etomidate having a favorable hemodynamic profile, although its use in critically ill patients has raised concerns regarding adrenal enzyme inhibition 1.
• Ketamine may be a reasonable option for RSI due to its quick onset and short duration of action, as well as its sympathomimetic properties, which can help preserve blood pressure 1.
• The use of propofol is generally discouraged in hemodynamically unstable patients due to its profound effect on blood pressure, which may exacerbate hypotension 1.
• For neuromuscular blockade, rocuronium or succinylcholine can be used at full doses, as they have minimal hemodynamic effects, as recommended by the Society of Critical Care Medicine clinical practice guidelines 1.
• Additional considerations include aggressive volume resuscitation prior to intubation, reducing standard doses of induction agents by 25-50% in severely unstable patients, and preparing push-dose vasopressors and vasopressor infusions as needed 1.
• Maintaining a shorter apneic period through optimal pre-oxygenation and having all equipment ready is also essential to minimize the risk of cardiovascular collapse during RSI in hemodynamically unstable patients. The Society of Critical Care Medicine clinical practice guidelines suggest that there is no difference between etomidate and other induction agents administered for RSI with respect to mortality or the incidence of hypotension or vasopressor use in the peri-intubation period and through hospital discharge, based on moderate quality of evidence 1.
• The guidelines also recommend administering a sedative-hypnotic induction agent when a neuromuscular-blocking agent is used for intubation, and suggest that either rocuronium or succinylcholine can be used for RSI when there are no known contraindications to succinylcholine, based on low quality of evidence 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Recommendations for RSI in Hemodynamically Unstable Patients

The following are recommendations for performing Rapid Sequence Intubation (RSI) in patients with hemodynamic instability:

• Etomidate is an induction agent known for its smooth intubating conditions and cardiovascular stability, but its use has been debated due to concerns about adrenal insufficiency 2.
• Single-dose etomidate for RSI may impact outcome after severe injury, with an increased risk of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome 3.
• A modified RSI protocol using fentanyl, ketamine, and rocuronium may be a safer and more effective alternative to traditional RSI protocols using etomidate and suxamethonium, with improved laryngoscopy views and first-pass intubation success 4.
• The use of fentanyl with ketamine for RSI may result in fewer patients with systolic blood pressure measurements outside the target range, but may also increase the risk of hypotension 5.
• Ketamine and etomidate have been compared in several studies, with no significant difference in 30-day survival, but etomidate was associated with a higher incidence of adrenal insufficiency, while ketamine required more post-intubation vasopressor support 6.

Key Considerations

When performing RSI in hemodynamically unstable patients, the following factors should be considered:

• The choice of induction agent, with etomidate, ketamine, and fentanyl being commonly used options 2, 3, 4, 5, 6.
• The risk of adrenal insufficiency associated with etomidate use 2, 6.
• The potential for hypotension or hypertension with different induction agents 3, 4, 5.
• The importance of careful patient selection and monitoring during RSI 4, 5, 6.