What is the best approach for intubation in a patient without access to paralytics (muscle relaxants)?

Intubation Without Paralytics: Approach and Considerations

When paralytics are unavailable, use high-dose induction agents with deep sedation to facilitate intubation, though this approach carries significantly higher risks of complications including aspiration, airway trauma, and mortality compared to standard rapid sequence intubation. 1

Key Principles for Non-Paralytic Intubation

Medication Strategy

1. Deep sedation approach:

   • Use propofol (2-3 mg/kg) or ketamine (1.5-2 mg/kg) at higher doses than typical induction 1, 2
   • Add short-acting opioids like fentanyl (2-3 mcg/kg) to improve intubating conditions 1
   • Consider benzodiazepines (midazolam 0.1-0.2 mg/kg) to reduce emergence reactions with ketamine 2

2. Ketamine advantages:

   • Maintains hemodynamic stability better than propofol 2
   • Does not suppress respiratory drive as significantly 2
   • Caution: Does not suppress pharyngeal and laryngeal reflexes alone 2

Technical Approach

1. Optimize first attempt:

   • Position patient optimally (head elevation, sniffing position)
   • Use videolaryngoscopy if available 1
   • Have bougie/stylet immediately available 1
   • Consider BURP maneuver (Backward, Upward, Rightward Pressure) 1

2. Backup strategies:

   • Have second-generation supraglottic airway device (SGA) immediately available 1
   • Prepare for potential surgical airway if initial attempts fail 1

Expected Outcomes and Complications

Success Rates

• First-pass success rates without paralytics: 22-78% (vs. 72-95% with paralytics) 1
• Significantly higher failure rates compared to standard rapid sequence intubation 1

Complications to Anticipate

• Aspiration risk: 15% without paralytics vs. rare with paralytics 3
• Airway trauma: 28% without paralytics vs. minimal with paralytics 3
• Mortality: 3% without paralytics vs. 0% with paralytics in comparative studies 3
• Pharyngeal/laryngeal injury: 18.7-22.6% without paralytics vs. 9.7% with paralytics 1

Critical Caveats

1. Avoid ketamine alone for airway procedures:

   • Ketamine does not suppress pharyngeal and laryngeal reflexes 2
   • FDA specifically warns against using ketamine as sole agent for procedures involving the pharynx, larynx, or bronchial tree 2

2. Awareness risk:

   • Patients may experience awareness during intubation without paralytics 4
   • Ensure adequate depth of anesthesia before attempting intubation 1

3. Rescue strategy:

   • If initial attempts fail, insert a second-generation SGA (e.g., LMA Supreme, i-gel) 1
   • Consider fiberoptic intubation through SGA if expertise available 1
   • Be prepared for surgical airway if oxygenation cannot be maintained 1

Algorithm for Non-Paralytic Intubation

1. Pre-oxygenate thoroughly (3-5 minutes or 8 vital capacity breaths)
2. Administer high-dose induction agent:
   • Hemodynamically stable: Propofol 2-3 mg/kg
   • Hemodynamically unstable: Ketamine 1.5-2 mg/kg
3. Add adjunctive medications:
   • Fentanyl 2-3 mcg/kg (improves intubation conditions)
   • Consider lidocaine 1.5 mg/kg (blunts airway reflexes)
4. Wait for adequate depth (jaw relaxation, loss of eyelash reflex)
5. Perform laryngoscopy with videolaryngoscope if available
6. If first attempt fails:
   • Optimize positioning and reattempt once
   • If second attempt fails, insert second-generation SGA
   • Consider fiberoptic intubation through SGA if available

Remember that this approach carries significantly higher risks than standard rapid sequence intubation with paralytics, and should only be used when paralytics are absolutely unavailable.