What drug combination is generally used for sedation during endotracheal intubation?

From the Guidelines

The most commonly used drug combination for sedation during endotracheal intubation is a sedative agent, such as propofol (1-2 mg/kg) or midazolam (0.1-0.3 mg/kg), paired with an analgesic agent, such as fentanyl (2-3 mcg/kg) or remifentanil (1-3 ng/ml), to provide optimal sedation and analgesia.

Sedation Options

The choice of sedative agent depends on the patient's hemodynamic status, comorbidities, and the clinical scenario.

• Propofol is a commonly used sedative agent due to its rapid onset and short duration of action, with a terminal half-life of 1.5-3 hours 1.
• Midazolam is an alternative sedative agent that can be used, with a duration of action of 1-2 hours and a terminal half-life of 1.5-3 hours 1.

Analgesia Options

Analgesic agents, such as fentanyl or remifentanil, can be added to the sedation regimen to provide pain relief and blunt physiological responses to intubation.

• Fentanyl is a commonly used analgesic agent, with a duration of action of 30-60 minutes and a terminal half-life of 6-10 minutes 1.
• Remifentanil is an alternative analgesic agent, with a rapid onset and short duration of action, and a terminal half-life of 1-20 minutes 1.

Clinical Considerations

The choice of specific agents and dosing regimens should be individualized based on the patient's clinical status and the specific procedure being performed.

• Appropriate monitoring and resuscitation equipment should be available before proceeding with intubation.
• The patient's hemodynamic status, comorbidities, and potential drug interactions should be carefully considered when selecting a sedation regimen.
• The most recent and highest quality study, published in 2020, provides guidance on the characteristics of drugs used commonly during awake tracheal intubation, including sedatives, analgesics, and antisialogogues 1.

From the FDA Drug Label

The induction dose requirements of propofol injectable emulsion may be reduced in patients with intramuscular or intravenous premedication, particularly with narcotics (e.g., morphine, meperidine, and fentanyl, etc.) and combinations of opioids and sedatives (e.g., benzodiazepines, barbiturates, chloral hydrate, droperidol, etc.) Rapid Sequence Intubation Intubating conditions were assessed in 230 patients in six clinical studies where anesthesia was induced with either thiopental (3 to 6 mg/kg) or propofol (1.5 to 2.5 mg/kg) in combination with either fentanyl (2 to 5 mcg/kg) or alfentanil (1 mg)

The drug combination generally used for sedation during endotracheal intubation is propofol and narcotics (such as fentanyl), or propofol and benzodiazepines. This combination may be used with other agents, such as thiopental or alfentanil, to achieve the desired level of sedation and intubating conditions. 2 3

From the Research

Sedation for Endotracheal Intubation

• The combination of midazolam, fentanyl, and propofol is often used for sedation during endotracheal intubation 4.
• A study found that a combination of fentanyl, midazolam, and propofol provided better intubating conditions than fentanyl, lignocaine, and propofol in the absence of neuromuscular blocking agents 4.
• Another study suggested that midazolam alone can be effective in facilitating endotracheal intubation by paramedics, with a success rate of 85% 5.
• The use of ketamine and benzodiazepines/opioids is also common for procedural sedation, with ketamine providing adequate analgesia and preserving airway muscle tone, but it is associated with adverse effects 6.
• A review of pharmacotherapies used during rapid sequence intubation (RSI) found that etomidate and ketamine are the most commonly used induction agents, and succinylcholine and rocuronium are the preferred neuromuscular blocking agents 7.

Drug Combinations and Dosing

• A study found that a combination of midazolam 1 mg, alfentanil 500 µg, and propofol target infusion effect-site concentration (Ce) 2 µg mL-1 was the optimal regimen for deep sedation and rapid recovery 8.
• The same study found that regimens consisting of a fixed dose of alfentanil and either 5 µg mL-1 Ce propofol, or 1 mg midazolam with 3-5 µg mL-1 Ce of propofol, or 2 mg midazolam with 2 µg mL-1 Ce propofol provided adequate sedation and rapid recovery 8.
• A study on the use of midazolam for facilitated endotracheal intubation found that a single dose of midazolam was sufficient for ETI in 85% of cases, with a mean dose of 3.6 mg 5.