What medications should be given to intubate a hemodynamically stable and alert patient with respiratory distress and severe retractions?

From the Guidelines

For a patient in respiratory distress with severe retractions who is hemodynamically stable and alert, rapid sequence intubation (RSI) with a hypnotic agent such as etomidate, ketamine, or propofol, and a neuromuscular blocking agent like succinylcholine or rocuronium, is the recommended approach. The choice of hypnotic agent depends on the patient's medical history and clinical situation, with etomidate, ketamine, and propofol being suitable options 1.

Key Considerations

• The selection of a neuromuscular blocking agent should be based on the patient's vital signs and medical history, with succinylcholine being the first-line agent of choice for RSI in patients with signs of distress, and rocuronium being an alternative when succinylcholine is contraindicated 1.
• Rocuronium should be used at a dose of 1.0-1.2 mg/kg when succinylcholine is contraindicated, and sugammadex should be rapidly available when rocuronium is used 1.
• The device used for intubation should be chosen based on the operator's experience and the availability of equipment, with the ProSeal and Fastrach devices being potential options.

Medication Administration

• Administer a sedative agent such as etomidate (0.3 mg/kg IV) or ketamine (1-2 mg/kg IV) immediately before intubation.
• Use a neuromuscular blocking agent like succinylcholine (1-1.5 mg/kg IV) or rocuronium (1-1.2 mg/kg IV) to facilitate intubation.
• Consider pretreatment with fentanyl (1-3 mcg/kg IV) 3 minutes before induction to blunt sympathetic response.
• Post-intubation, initiate sedation with propofol (5-80 mcg/kg/min), midazolam (0.02-0.1 mg/kg/hr), or dexmedetomidine (0.2-0.7 mcg/kg/hr) for comfort.

Important Considerations

• Ensure that rescue devices are available and consider having vasopressors ready in case of post-intubation hypotension.
• The choice of medication and device should be tailored to the individual patient's needs and medical history.

From the FDA Drug Label

To be administered only by experienced clinicians or adequately trained individuals supervised by an experienced clinician familiar with the use, actions, characteristics, and complications of neuromuscular blocking agents. Tracheal intubation: Recommended initial dose is 0.6 mg/kg. Rapid sequence intubation: 0.6 to 1.2 mg/kg. For induction of general anesthesia, before administration of other anesthetic agents. Individual response to the drug is variable, particularly when a narcotic premedication is not used. The dosage should be titrated to the desired effect according to the patient’s age and clinical status Unpremedicated Patients: In the absence of premedication, an average adult under the age of 55 years will usually require an initial dose of 0.3 to 0.35 mg/kg for induction, administered over 20 to 30 seconds and allowing 2 minutes for effect.

To intubate a hemodynamically stable and alert patient with respiratory distress and severe retractions, the following medications should be given:

• Rocuronium (0.6 mg/kg) for tracheal intubation, as a nondepolarizing neuromuscular blocking agent to facilitate intubation.
• Midazolam (0.3 to 0.35 mg/kg) for induction of general anesthesia, titrated to the desired effect according to the patient’s age and clinical status. These medications should be administered by experienced clinicians or adequately trained individuals, with careful monitoring and titration to achieve the desired effect 2, 3.

From the Research

Medications for Intubation

To intubate a hemodynamically stable and alert patient with respiratory distress and severe retractions, the following medications can be considered:

• Midazolam: a benzodiazepine that can be used for sedation prior to intubation, with a rapid onset of action and a half-life of approximately 1 hour 4
• Propofol: a sedative-hypnotic agent that can be used for induction of anesthesia, with a rapid onset of action and a short duration of action 5, 6, 7, 8
• Fentanyl: an opioid analgesic that can be used for pain relief and sedation, often used in combination with propofol for intubation 5, 8
• Rocuronium: a non-depolarizing neuromuscular blocking agent that can be used to facilitate intubation, with a rapid onset of action and a duration of action of approximately 30-60 minutes 5, 8

Considerations for Medication Choice

When choosing medications for intubation, the following factors should be considered:

• The patient's hemodynamic stability and respiratory status
• The need for rapid sequence intubation (RSI) versus a more gradual approach
• The potential for respiratory depression and the need for ventilatory support
• The patient's medical history and potential contraindications to certain medications
• The availability of reversal agents, such as flumazenil for benzodiazepines and naloxone for opioids 4

Alternative Options

Alternative options for intubation medications include:

• Dexmedetomidine: a sedative agent that can be used for patients with or at risk for acute respiratory distress syndrome (ARDS) 7
• Sevoflurane: an inhalational anesthetic agent that can be used for induction of anesthesia, with a slower onset of action but a more gradual approach to intubation 8