From the Guidelines
Yes, unresponsive patients can be intubated without Rapid Sequence Intubation (RSI) drugs, as the latest evidence suggests that the use of RSI drugs may not be necessary in patients with severely decreased level of consciousness who lack protective airway reflexes 1. This approach is often referred to as "crash intubation" and is appropriate for patients with a Glasgow Coma Scale (GCS) score of 8 or less who are unable to protect their airway. When performing intubation without medications, the clinician should still prepare standard intubation equipment including a properly sized endotracheal tube, functioning laryngoscope, suction, bag-valve-mask for pre-oxygenation, and backup airway devices.
Key Considerations
- The patient should be positioned optimally with the head elevated if possible, pre-oxygenated for 3-5 minutes if time allows, and the procedure performed with careful attention to avoid trauma.
- The physiological basis for this approach is that deeply unresponsive patients lack the gag reflex, cough reflex, and muscle tone that would normally make intubation difficult or dangerous without sedation and paralysis.
- However, clinicians should be aware that some unresponsive patients may still have intact reflexes or develop them during the procedure, potentially complicating the intubation attempt.
Evidence-Based Recommendations
- A recent study published in Critical Care Medicine in 2023 found 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 1.
- Another study published in Anaesthesia in 2017 recommended the use of a hypnotic agent that facilitates rapid sequence induction (RSI) in ICU patients, but also acknowledged that the choice of agent depends on medical history and the clinical situation of the patient 1.
Best Practices
- Clinicians should prioritize proper technique and patient safety when performing intubation without RSI drugs.
- The use of RSI drugs should be individualized based on the patient's medical history and clinical situation.
- Clinicians should be aware of the potential complications of intubation without RSI drugs and be prepared to respond accordingly.
From the Research
Intubation of Unresponsive Patients without RSI Drugs
- Unresponsive patients can be intubated without Rapid Sequence Intubation (RSI) drugs, but the approach may vary depending on the clinical scenario and patient-specific factors 2.
- The use of neuromuscular blocking agents (NMBAs) is not always necessary, and alternative methods such as medication-assisted preoxygenation and awake intubation can be considered 3.
- Studies have shown that intubation without paralysis can be performed successfully, but it may be associated with a higher risk of complications such as aspiration and airway trauma 4.
- The selection of medications for intubation without RSI drugs should be individualized based on the patient's condition, and factors such as the risk of aspiration, elevated intracranial pressure, and potential contraindications to NMBAs should be taken into account 5, 2.
- Propofol and remifentanil have been used successfully for rapid sequence intubation without NMBAs in certain clinical scenarios, such as in pediatric patients with elevated intracranial pressure 2.
Considerations for Intubation without RSI Drugs
- The decision to intubate without RSI drugs should be made on a case-by-case basis, taking into account the patient's medical history, current condition, and potential risks and benefits 6, 3.
- The choice of medications and the approach to intubation should be guided by the patient's specific needs and the clinical scenario, rather than a one-size-fits-all approach 5, 3.
- Further research is needed to determine the optimal approach to intubation without RSI drugs and to identify the most effective medications and techniques for different clinical scenarios 3.