Recommended Medication Regimen for Rapid Sequence Intubation (RSI)
The recommended medication regimen for rapid sequence intubation consists of a sedative-hypnotic induction agent (etomidate or ketamine) followed by a neuromuscular blocking agent (either succinylcholine or rocuronium). 1
Sedative-Hypnotic Agent Selection
- Etomidate (0.3 mg/kg IV) is preferred in hemodynamically unstable patients due to its favorable cardiovascular profile with minimal effects on blood pressure 1, 2
- Ketamine (1-2 mg/kg IV) is an alternative first-line agent with sympathomimetic properties that help maintain hemodynamic stability 1
- Most studies demonstrate no significant difference in mortality between etomidate and other induction agents, making etomidate a reasonable choice for critically ill patients 2
- Etomidate may cause transient adrenal suppression, but corticosteroid administration following etomidate is not recommended as studies show no difference in mortality outcomes 2, 1
Neuromuscular Blocking Agent Selection
- A neuromuscular blocking agent (NMBA) must be administered when a sedative-hypnotic induction agent is used for intubation (strong recommendation) 2
- Succinylcholine (1-1.5 mg/kg IV) is the first-line NMBA when no contraindications exist 1
- Caution is warranted with succinylcholine in patients with baseline bradycardia as it has been associated with post-RSI bradycardia (RR = 1.81) 3
- Rocuronium (0.9-1.2 mg/kg IV) is the preferred alternative when succinylcholine is contraindicated 1, 4
- For rapid sequence intubation, rocuronium doses of 0.6 to 1.2 mg/kg provide excellent or good intubating conditions in most patients within 2 minutes 4
Medication Administration Sequence
- The sedative-hypnotic agent must be administered before the neuromuscular blocking agent to prevent awareness during paralysis 1
- Some evidence suggests that administering the neuromuscular blocking agent first (followed immediately by the sedative) may result in modestly faster time to intubation (approximately 6 seconds shorter) 5
- Regardless of administration order, both medications should be given in rapid succession (within 30 seconds of each other) 5
Post-Intubation Considerations
- When using rocuronium, which has a longer duration of action than the sedative effects of etomidate, prompt initiation of post-intubation analgesia and sedation is essential 6
- The median time to first analgosedative intervention after etomidate-rocuronium RSI is approximately 7 minutes 6
- Continuous monitoring of vital signs and sedation status is necessary to prevent awareness during prolonged paralysis 6, 7
Special Considerations
- In patients with sepsis, etomidate (0.3 mg/kg) remains a reasonable choice as studies have not demonstrated negative clinical outcomes from transient adrenal suppression 2, 3
- For obese patients, dosing should be based on actual body weight rather than ideal body weight to ensure adequate intubating conditions 4
- RSI with etomidate is not recommended for rapid sequence induction in Cesarean section patients due to poor or inadequate intubating conditions observed in clinical studies 4
Common Pitfalls to Avoid
- Using etomidate-only intubation without a neuromuscular blocking agent results in significantly worse laryngoscopy conditions and lower intubation success rates compared to complete RSI 8
- Inadequate post-intubation sedation when using longer-acting paralytics like rocuronium can lead to awareness during paralysis 6, 3
- Inappropriate use of succinylcholine in patients with contraindications (approximately 13% of cases in observational studies) 3
- Failure to have reversal agents available when using high-dose rocuronium (≥0.9 mg/kg) 1