What is the recommended dosing regimen for intubation?

Recommended Dosing Regimen for Intubation

For rapid sequence intubation (RSI), succinylcholine at 1-2 mg/kg IV (2 mg/kg for infants <6 months) or rocuronium at 0.6-1.2 mg/kg IV should be used, along with an appropriate sedative agent such as etomidate (0.2-0.4 mg/kg), ketamine (1-2 mg/kg), or propofol (2-6 mg/kg). 1

Neuromuscular Blocking Agents

Succinylcholine

• IV: 1-2 mg/kg (2 mg/kg for infants <6 months of age) 1
• IM: 4 mg/kg (5 mg/kg for infants <6 months of age) 1
• Onset: 30-45 seconds after IV administration, 3-5 minutes after IM administration 1
• Duration: 5-10 minutes 1
• Advantages: Rapid onset and short duration of action 1
• Contraindications: History of malignant hyperthermia, severe burns/crush injury, spinal cord injury, neuromuscular disease, myopathy 1
• Consider pretreatment with atropine 0.02 mg/kg (minimum dose: 0.1 mg; maximum dose: 1 mg) to prevent bradycardia or asystole 1

Rocuronium

• IV: 0.6-1.2 mg/kg for intubation 1, 2
• Higher doses (0.9-1.2 mg/kg) provide excellent intubating conditions in less than 2 minutes 2
• Onset: Satisfactory conditions for intubation generally occur in 60-90 seconds 1
• Duration: 30-45 minutes (dose-dependent) 1, 2
• Preferred alternative when succinylcholine is contraindicated 1
• Consider higher doses (slightly above 0.6 mg/kg) in patients with nerve agent exposure or organophosphate poisoning 1

Sedative Agents

Etomidate

• IV/IO: 0.2-0.4 mg/kg (maximum: 20 mg) 1
• Advantages: Minimal hemodynamic effects, lowers ICP, good option for patients with head injury, multisystem trauma, or hypotension 1, 3
• Considerations: May cause transient adrenal suppression, brief myoclonic activity (hiccups, cough, twitching) 1

Ketamine

• IV: 1-2 mg/kg, titrate repeat doses to desired effect 1
• IM: 4-5 mg/kg (onset within ~5 minutes); may repeat half the initial dose if needed 1
• Advantages: Provides dissociative sedation/anesthesia and analgesia, relatively stable hemodynamic profile 1, 3
• Considerations: May cause laryngospasm (especially with rapid infusion or upper respiratory infection), increased salivation, avoid in patients with increased ICP 1
• Consider using atropine or glycopyrrolate to prevent increased salivation 1

Propofol

• IV: 2-6 mg/kg 1
• Considerations: May need lower dose if other sedatives/narcotics have been administered 1
• Cautions: Causes vasodilation and decreased cardiac output; higher doses associated with hypotension and apnea 1
• Not recommended in patients with cardiovascular dysfunction or volume depletion 1

Adjunctive Medications

Lidocaine

• IV: 1-2 mg/kg as a single dose 30 seconds to 5 minutes before airway instrumentation 1
• Optional adjunct for RSI in patients with head injury/increased ICP 1
• Less likely to provide additional benefit when a neuroprotective agent that reduces ICP (e.g., etomidate) is used 1

Midazolam

• IV: 0.2 mg/kg for RSI 1
• Allow sufficient time (2-3 minutes) for midazolam to take effect before administration of muscle relaxant 1
• Lower doses are ineffective for RSI 1

Practical Considerations

• Personnel with skills in airway management must be present and prepared when neuromuscular blocking agents are administered 1
• Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available 1
• Monitor oxygen saturation throughout the procedure 1
• For rapid sequence induction, preoxygenation is essential 1
• When using rocuronium, flush IV tubing with saline before administration to avoid precipitation and obstruction when used after thiopental or propofol 1
• In critically ill patients, ketamine (2 mg/kg) may be a safer alternative to etomidate for endotracheal intubation, particularly in patients with sepsis 3

Special Populations

• For patients with shock or hemodynamic instability, consider etomidate or ketamine as they have more favorable hemodynamic profiles 4, 3
• In patients with increased ICP, etomidate is preferred as it lowers ICP and does not usually lower blood pressure 1
• When succinylcholine is contraindicated, high-dose rocuronium (0.9-1.2 mg/kg) is an appropriate alternative 2, 4
• The combination of etomidate and s-ketamine for anesthesia induction produces excellent intubating conditions after 60 seconds using 0.6 mg/kg of rocuronium 5

Remember that ventilatory support is necessary when using neuromuscular blocking agents, and personnel with airway management skills must be present and prepared to respond when these agents are administered 1.