From the Guidelines
Endotracheal intubation (ETI) with induction medications should be performed using a rapid sequence induction (RSI) approach, which involves the administration of a sedative-hypnotic agent and a neuromuscular-blocking agent (NMBA) in rapid succession, followed by immediate placement of an endotracheal tube before assisted ventilation 1.
Steps for ETI with Induction Medications
- Pre-oxygenation: Meticulous pre-oxygenation should be performed with a well-fitting mask for 3–5 min, using a closed circuit or a rebreathing circuit to minimize the risk of virus-containing exhaled gas being expelled into the room 1.
- Medication selection: A sedative-hypnotic agent such as ketamine 1–2 mg/kg or etomidate should be used for induction of anesthesia, and a neuromuscular-blocking agent such as rocuronium 1.2 mg/kg or succinylcholine 1.5 mg/kg should be used for neuromuscular blockade 1.
- Intubation technique: Laryngoscopy should be performed with the device most likely to achieve prompt first-pass tracheal intubation, such as a videolaryngoscope, and a tracheal tube size 7.0–8.0 mm internal diameter (ID) in women or 8.0–9.0 mm ID in men should be used 1.
- Post-intubation management: A vasopressor should be immediately available for managing hypotension, and gentle continuous positive airway pressure (CPAP) may be applied if the seal is good, to minimize the need for mask ventilation 1.
Key Considerations
- Patient positioning: Patient positioning, including ramping in the obese and reverse Trendelenburg positioning, should be adopted to maximize safe apnoea time 1.
- Cardiovascular instability: If there is increased risk of cardiovascular instability, ketamine is recommended for induction of anesthesia, and rocuronium should be given as early as practical to minimize apnoea time and risk of patient coughing 1.
From the Research
Steps for Endotracheal Intubation (ETI) with Induction Medications
The process of endotracheal intubation (ETI) with induction medications involves several steps, including:
- Pretreatment: This phase occurs three minutes before administration of induction and neuromuscular blockers, and its purpose is to attenuate the pathophysiologic response to laryngoscopy and intubation 2.
- Induction: The purpose of induction is to produce a state of general anesthesia, allowing for the administration of paralytics and facilitation of ideal intubating conditions 2. Commonly used induction agents include etomidate, ketamine, and propofol 3, 4, 5, 6.
- Paralysis: Neuromuscular blockers such as succinylcholine and rocuronium are used to facilitate intubation 3, 4.
- Post-intubation sedation and analgesia: This step is crucial for maintaining patient comfort and stability after intubation 3.
Induction Medications
The selection of induction medications is critical for the success of ETI. The most commonly used induction agents are:
- Etomidate: Known for its favorable hemodynamic profile, etomidate is often used in patients with shock or sepsis 3, 5.
- Ketamine: Ketamine is another commonly used induction agent, particularly in combination with propofol ("ketofol") for critically ill patients 6.
- Propofol: Propofol is also used as an induction agent, although it may be associated with hypotension 4, 6.
Considerations for Medication Selection
The selection of induction medications should be based on patient-specific factors, including:
- Hemodynamic stability: Etomidate and ketamine may be preferred in patients with shock or sepsis due to their favorable hemodynamic profiles 3, 5.
- Comorbidities: Patients with certain comorbidities, such as cardiovascular disease, may require careful selection of induction medications to minimize risks 4.
- Medication interactions: The potential for medication interactions should be considered when selecting induction medications, particularly in patients receiving multiple medications 2.