What are the recommended medications for intubation?

Recommended Medications for Intubation

For rapid sequence intubation (RSI), the recommended first-line medications are etomidate (0.2-0.3 mg/kg IV) or ketamine (1-2 mg/kg IV) as sedative-hypnotic agents, combined with succinylcholine (1.5 mg/kg IV) or rocuronium (0.9-1.2 mg/kg IV) as neuromuscular blocking agents. 1, 2

Sedative-Hypnotic Agents

First-line options:

• Etomidate (0.2-0.3 mg/kg IV)

  • Preferred for patients with cardiovascular compromise
  • Rapid onset (5-15 seconds) and short duration (5-15 minutes)
  • Minimal cardiovascular depression
  • Maintains hemodynamic stability
  • Caution in septic patients due to potential adrenal suppression 2, 3, 4

• Ketamine (1-2 mg/kg IV)

  • Recommended for patients with septic or hypovolemic shock
  • Provides analgesia and amnesia
  • Maintains or increases blood pressure through sympathomimetic effects
  • May increase intracranial pressure (relative contraindication in head injury) 2

Alternative options:

• Propofol (1-2.5 mg/kg IV)

  • Avoid in hemodynamically unstable patients
  • Causes significant vasodilation and hypotension
  • Rapid onset and short duration 2

• Midazolam (0.2 mg/kg IV)

  • Longer onset time compared to other agents
  • Can cause significant hypotension at RSI doses
  • Less effective as a sole agent for RSI 1

Neuromuscular Blocking Agents

First-line options:

• Succinylcholine (1.5 mg/kg IV)

  • Fastest onset (30-60 seconds) and shortest duration (5-10 minutes)
  • Contraindications: hyperkalemia, malignant hyperthermia risk, burns, crush injuries, denervation injuries 1

• Rocuronium (0.9-1.2 mg/kg IV)

  • Onset within 1-2 minutes at higher doses
  • Duration 30-40 minutes
  • Preferred when succinylcholine is contraindicated
  • Sugammadex should be available for reversal in "cannot intubate/cannot oxygenate" scenarios 1, 5

Pre-Intubation Considerations

1. Pre-oxygenation

   • Non-invasive ventilation recommended for hypoxemic patients
   • High-flow nasal oxygen can be used, especially for non-severely hypoxemic patients 1

2. Adjunctive medications

   • Atropine (0.01-0.02 mg/kg) for children aged 28 days to 8 years to prevent bradycardia 1
   • Lidocaine (1-2 mg/kg IV) may be considered to blunt sympathetic response 2

Medication Selection Algorithm

1. Hemodynamically stable patient

   • Sedative: Etomidate (0.2-0.3 mg/kg) or Propofol (1-2.5 mg/kg)
   • Paralytic: Succinylcholine (1.5 mg/kg) if no contraindications, otherwise Rocuronium (0.9-1.2 mg/kg)

2. Hemodynamically unstable patient

   • Sedative: Etomidate (0.2-0.3 mg/kg) or Ketamine (1-2 mg/kg)
   • Paralytic: Rocuronium (0.9-1.2 mg/kg) or Succinylcholine (1.5 mg/kg)

3. Septic patient

   • Sedative: Ketamine (1-2 mg/kg) preferred over etomidate
   • Paralytic: Either Succinylcholine or Rocuronium 2, 4

4. Head injury with increased ICP

   • Sedative: Etomidate (0.2-0.3 mg/kg)
   • Paralytic: Either Succinylcholine or Rocuronium
   • Consider mannitol (0.25-1 g/kg) for acute intracranial hypertensive crisis 1

Special Considerations

• COVID-19 patients: Modified rapid sequence induction with sufficient muscle paralysis after loss of consciousness. Midazolam 2-5 mg with etomidate (10-20 mg) or propofol for induction, fentanyl 100-150 μg or sufentanil 10-15 μg, and succinylcholine 1 mg/kg or rocuronium 1 mg/kg 1

• Pediatric patients: Etomidate is recommended for children >2 years except in sepsis. Ketamine (3-4 mg/kg before 18 months, 2 mg/kg after) is an alternative 1

Common Pitfalls and Caveats

1. Inadequate dosing: Ensure adequate doses of both sedative and paralytic agents to achieve optimal intubating conditions 6

2. Failure to anticipate hemodynamic effects: Have vasopressors immediately available, especially when using propofol or midazolam 2

3. Ignoring contraindications: Be aware of specific contraindications for each agent (e.g., succinylcholine in hyperkalemia, etomidate in sepsis) 3, 4

4. Inadequate preparation: Ensure all equipment is ready and functioning before administering medications 1

5. Neglecting post-intubation sedation: Plan for ongoing sedation after RSI medications wear off to prevent awareness during paralysis 2

Remember that the choice of intubation medications should be guided by the patient's clinical condition, with particular attention to hemodynamic status, neurological status, and underlying pathology.