What is the recommended administration rate for Rapid Sequence Intubation (RSI) medications?

Rapid Sequence Intubation (RSI) Medication Administration Rates

RSI medications should be administered as IV push with sedative agents given over 2-3 minutes and neuromuscular blocking agents given rapidly over seconds. 1

Sedative Administration Rates

Benzodiazepines

• Midazolam: Administer over 2-3 minutes at 0.2-0.4 mg/kg (maximum 20 mg)
  • Peak effect occurs at 3-5 minutes
  • Rapid administration increases risk of respiratory depression and hypotension
  • Allow sufficient time (2-3 minutes) for midazolam to take effect before administering muscle relaxant 1

Induction Agents

• Etomidate: Administer over 3-5 minutes at 0.2-0.4 mg/kg (maximum 20 mg)

  • Preferred for patients with head injury, multisystem trauma, or hypotension
  • Rapid onset (10-15 minutes) with minimal hemodynamic effects 1

• Ketamine: Administer over 1-2 minutes at 1-2 mg/kg IV

  • For IM route (4-5 mg/kg), onset occurs within approximately 5 minutes
  • Titrate repeat doses to desired effect
  • Rapid infusion increases risk of laryngospasm, particularly with concomitant upper respiratory infections 1

• Fentanyl: Administer over several minutes at 1-2 mg/kg

  • Rapid administration associated with glottic and chest wall rigidity
  • Higher doses (1-5 mg/kg) for intubation should be administered more slowly 1

Neuromuscular Blocking Agent Administration

Depolarizing Agents

• Succinylcholine: Administer as rapid IV push
  • Standard dose: 1-1.5 mg/kg IV
  • Caution in patients with bradycardia (associated with post-RSI bradycardia) 2

Non-depolarizing Agents

• Rocuronium: Administer as rapid IV push
  • For RSI: 0.6-1.2 mg/kg IV
  • Higher doses (1 mg/kg) recommended for optimal intubating conditions 3, 4

Medication Order and Timing

• The interval between sedative and neuromuscular blocker should be less than 30 seconds 5
• Administering the neuromuscular blocking agent first may result in modestly faster time to intubation (approximately 6 seconds) 6
• Both medication order sequences (sedative first vs. paralytic first) are acceptable 6

Important Considerations

Hemodynamic Monitoring

• Monitor blood pressure and ECG continuously during RSI medication administration
• Rapid infusion of certain agents (e.g., magnesium) may cause hypotension and bradycardia 1

Pediatric Considerations

• Standardized medication protocols improve efficiency and reduce redosing requirements
• In pediatric patients, efficient administration (interval <30 seconds between sedative and neuromuscular blocker) is associated with better outcomes 5

Common Pitfalls to Avoid

1. Inadequate sedation: Ensure sufficient time for sedative effect before administering paralytic
2. Overly rapid administration: Pushing sedatives too quickly increases risk of hypotension
3. Delayed paralysis: Extended time between sedative and paralytic may lead to desaturation
4. Medication selection errors: Use standardized protocols to reduce inappropriate medication use 2

Remember that RSI medications should be administered by experienced clinicians or adequately trained individuals supervised by an experienced clinician familiar with neuromuscular blocking agents 3. Always have reversal agents and airway equipment immediately available.