What is the most common type of premedication for intubation?

Most Common Type of Premedication for Intubation

Atropine is the most common type of premedication used for intubation, particularly in pediatric patients and emergency situations where there is risk of bradycardia. 1

Types of Premedication by Patient Population

Pediatric Patients

Atropine is frequently used as premedication for intubation in pediatric patients, especially when:

• Using succinylcholine as a neuromuscular blocker 1
• There is higher risk of bradycardia during the procedure 1
• In children with upper respiratory infections (URIs) 1

The American Heart Association guidelines recommend:

• Dose: 0.02 mg/kg with no minimum dose 1
• Not routinely recommended for all pediatric intubations, but reasonable in specific situations 1

Adult Patients

For adults, premedication regimens often include:

1. Antisialogogue agents:

   • Glycopyrronium bromide: 0.2-0.4 mg (i.m.) or 0.1-0.2 mg (i.v.)
   • Atropine: 0.3-0.6 mg (i.m.) or 0.2-0.3 mg (i.v.)
   • Hyoscine hydrobromide: 0.2-0.6 mg 1

2. Sedatives:

   • Midazolam: 0.5-1 mg bolus 1, 2
   • Propofol: Target-controlled infusion 0.5-1 μg/ml 1
   • Dexmedetomidine: Bolus 0.5-1 μg/kg over 5 min followed by infusion 1

3. Analgesics:

   • Remifentanil: Target-controlled infusion 1-3 ng/ml 1, 3
   • Fentanyl: Bolus 0.5-1 μg/kg 1
   • Alfentanil: Bolus 5 μg/kg 1

Special Considerations

For Neuroprotection

• Lidocaine (1.5 mg/kg IV) given 3 minutes before intubation can blunt cough reflexes, prevent dysrhythmias, and potentially reduce increases in intracranial pressure 4, 5

For Children with Upper Respiratory Infections

• Salbutamol (albuterol) nebulization is recommended before general anesthesia in children under 6 years with URI 1
• Dose: 2.5 mg for children <20 kg, 5 mg for children >20 kg 1
• Reduces perioperative cough and bronchospasm by approximately 50% 1

For Neonates

• A combination of atropine, fentanyl, and succinylcholine has been shown to be safe and effective 6
• Alternative regimen: Midazolam 0.1 mg/kg and fentanyl 2 μg/kg 7

Pitfalls and Caveats

1. Atropine dosing cautions:

   • Low doses (<0.5 mg) may paradoxically cause bradycardia 8
   • Using adult dosing in neonates can lead to excessive anticholinergic effects 8

2. Lidocaine considerations:

   • While effective for reducing cough reflexes and dysrhythmias, evidence is conflicting regarding its use in children with URI 1
   • The French guidelines do not recommend using lidocaine (IV or topical) to decrease perioperative respiratory adverse events in children with URI 1

3. Remifentanil considerations:

   • Requires careful administration due to risk of respiratory depression 1, 3
   • Avoid bolus dosing 1

4. Midazolam considerations:

   • Peak effect at 5-10 minutes, so care must be taken with multiple doses 1
   • Can interact with other medications including erythromycin, which may double its half-life 2

Algorithm for Premedication Selection

1. Assess patient risk factors:

   • Age (pediatric vs. adult)
   • Hemodynamic stability
   • Risk of bradycardia
   • Presence of increased intracranial pressure
   • History of URI (in children)

2. For standard adult intubation:

   • Antisialogogue (glycopyrronium or atropine)
   • Sedative (midazolam or propofol)
   • Analgesic (fentanyl or remifentanil)

3. For pediatric intubation:

   • Atropine if using succinylcholine or if risk of bradycardia
   • Consider salbutamol pretreatment if URI present
   • Age-appropriate sedation and analgesia

4. For neonatal intubation:

   • Consider combination of atropine, fentanyl, and muscle relaxant
   • Avoid routine use of atropine unless specific indications present

5. For patients with increased ICP:

   • Consider lidocaine 1.5 mg/kg IV 3 minutes before intubation
   • Appropriate sedation to prevent pressure surges