From the Guidelines
Rapid sequence intubation (RSI) should be performed with a sedative and a neuromuscular blocking agent, with etomidate (0.3 mg/kg IV) or ketamine (1-2 mg/kg IV) as suitable sedation options, and succinylcholine (1.5-2 mg/kg IV) or rocuronium (1-1.2 mg/kg IV) as paralysis agents, considering the patient's condition and potential contraindications 1, 2.
Sedation Options
- Etomidate (0.3 mg/kg IV) has minimal hemodynamic effects, making it a suitable option for RSI 1.
- Ketamine (1-2 mg/kg IV) is beneficial in hypotensive patients due to its sympathomimetic properties 1.
- Propofol (1-2 mg/kg IV) may be used in hypertensive patients but can cause hypotension, and midazolam (0.2-0.3 mg/kg IV) has a variable onset, making it less commonly used for RSI.
Paralysis Agents
- Succinylcholine (1.5-2 mg/kg IV) provides rapid onset (30-60 seconds) and short duration (5-10 minutes), making it ideal for RSI, but it's contraindicated in patients with hyperkalemia, burns, or certain neuromuscular disorders 2.
- Rocuronium (1-1.2 mg/kg IV) is an alternative with slightly slower onset (60-90 seconds) but longer duration (30-40 minutes) 2.
Additional Considerations
- Pre-treatment with lidocaine (1.5 mg/kg IV) 3 minutes before intubation can blunt sympathetic response in patients with increased intracranial pressure.
- Fentanyl (2-3 mcg/kg IV) may be used for similar purposes.
- Atropine (0.02 mg/kg, minimum 0.1 mg) should be available for children under 10 years to prevent bradycardia.
- Medication selection should be tailored to the patient's condition, with dose adjustments for elderly, critically ill, or hemodynamically unstable patients 1, 2.
From the FDA Drug Label
In appropriately premedicated and adequately anesthetized patients, rocuronium bromide injection 0.6 to 1.2 mg/kg will provide excellent or good intubating conditions in most patients in less than 2 minutes The recommended initial dose of rocuronium bromide injection, regardless of anesthetic technique, is 0.6 mg/kg. Rapid sequence intubation: 0.6 to 1.2 mg/kg.
The recommended medication dose for Rapid Sequence Intubation (RSI) is 0.6 to 1.2 mg/kg of rocuronium bromide injection [3][4].
From the Research
Medication Doses for Rapid Sequence Intubation (RSI)
The following are the recommended medication doses for RSI:
- Etomidate: 0.1 to 0.3 mg/kg intravenously (IV) 5
- Midazolam: 1 to 2 mg IV 5
- Rocuronium: + 1.0 mg/kg is the recommended dose, but higher doses (≥1.4 mg/kg) may be associated with higher first-attempt success rates when using direct laryngoscopy 6 + 0.6 mg/kg has been used in combination with propofol or etomidate for rapid sequence induction 7
- Succinylcholine: + 1 mg/kg is the traditionally used dose, but lower doses (0.6 mg/kg and 0.45 mg/kg) may provide optimal intubation conditions 8 + The effective dose (ED95) of succinylcholine is less than 0.3 mg/kg, and the 1 mg/kg dose represents 3.5 to 4 times the ED(95) 8
- Fentanyl: 1µg/kg has been used as an induction agent in combination with etomidate and succinylcholine 8
- Atropine, lidocaine, and fentanyl may be used as pretreatment medications, but their use has fallen out of favor due to limited evidence for their use outside of select clinical scenarios 9
Considerations for Medication Selection and Dosing
The selection and dosing of medications for RSI should be based on patient-specific factors, such as:
- Hemodynamic profile: etomidate and ketamine have more favorable hemodynamic profiles than other induction agents 9, 5
- Body habitus: higher doses of rocuronium may be required for obese patients 6
- Pre-intubation hemodynamics: higher doses of rocuronium may be associated with higher first-attempt success rates in patients with pre-intubation hypotension 6
- Device used for intubation: direct laryngoscopy or video laryngoscopy may require different medication doses or selections 6