What sedative is recommended after rapid sequence intubation (RSI)?

Recommended Sedatives After Rapid Sequence Intubation

After rapid sequence intubation (RSI), a sedative-hypnotic agent should always be administered to maintain sedation, with options including midazolam, propofol, or ketamine based on the patient's hemodynamic status. 1

Key Recommendations for Post-RSI Sedation

General Principles

• A sedative-hypnotic agent must be administered after RSI to prevent awareness during paralysis, which occurs in approximately 2.6% of emergency intubations 1, 2
• Timely administration of post-intubation sedation is critical, especially when long-acting paralytics like rocuronium are used 3
• Sedation should be initiated promptly after intubation, with median time to first dose typically being 10-12 minutes 3

Specific Sedative Options

For Hemodynamically Stable Patients:

• Propofol:
  • Initial infusion rate of 20-30 μg/kg/min (can be titrated up as needed) 3
  • Benefits: Rapid onset, short duration, easily titratable 4
  • Caution: May cause hypotension; use lower doses in elderly or debilitated patients 4

For Hemodynamically Unstable Patients:

• Ketamine:

  • Dose: 1-2 mg/kg IV bolus followed by 0.5-1 mg/kg/hr infusion 2
  • Benefits: Maintains hemodynamic stability through sympathomimetic properties 2
  • Particularly valuable in shock states 2

• Midazolam:

  • Dose: 0.01-0.05 mg/kg IV bolus (approximately 0.5-4 mg) followed by 0.02-0.10 mg/kg/hr infusion 5
  • Reduce dose by 25-50% in elderly, critically ill, or hemodynamically unstable patients 5
  • Benefits: Amnestic properties, relatively stable hemodynamic profile compared to propofol 5

Important Considerations

Timing of Sedation

• Patients receiving rocuronium are at higher risk of delayed sedation (median 12 minutes) compared to those receiving succinylcholine (median 10 minutes) 3
• The presence of a pharmacist during intubation is associated with improved timely administration of sedation (adjusted hazard ratio 1.14) 3

Hemodynamic Considerations

• Post-intubation hypotension is common and associated with increased mortality, prolonged ICU stays, and organ dysfunction 1
• Hypotension after intubation is predictive of decreased sedation administration (adjusted hazard ratio 0.67) 3
• For patients with hemodynamic instability, ketamine may be preferred over propofol due to its sympathomimetic effects 2

Dosing Adjustments

• Lower initial doses (25-50% reduction) should be used in elderly patients, those with severe systemic disease, or hemodynamic instability 5
• Titrate to the desired level of sedation by adjusting infusion rates up or down by 25-50% 5
• Find the minimum effective infusion rate to avoid drug accumulation and facilitate faster recovery 5

Common Pitfalls to Avoid

• Delaying sedation after RSI, especially with long-acting paralytics like rocuronium, which increases risk of awareness during paralysis 3
• Using inadequate initial doses of sedatives (median post-RSI propofol infusion rates are often too low at 20 μg/kg/min) 3
• Failing to adjust sedation requirements based on the patient's hemodynamic status 1
• Not providing concurrent analgesia, which should be administered within 21-24 minutes after intubation 3