From the Guidelines
For rapid sequence intubation (RSI) in adults, ketamine is typically administered at a dose of 1-2 mg/kg IV as the induction agent. The recommended approach is to give ketamine as a single IV push over 30-60 seconds, followed immediately by a paralytic agent such as rocuronium (1-1.2 mg/kg) or succinylcholine (1-1.5 mg/kg) 1. Ketamine is particularly valuable in hemodynamically unstable patients as it maintains blood pressure and cardiac output while providing dissociative anesthesia. The onset of action is rapid (30-60 seconds) with a duration of 10-20 minutes. When using ketamine for RSI, be aware that it may cause increased secretions, so consider pre-treatment with glycopyrrolate (0.2-0.4 mg IV) in non-emergent situations.
Some key points to consider when using ketamine for RSI include:
- The selection of a sedative-hypnotic agent that attenuates hypotension during RSI is desirable 1
- Ketamine may be a reasonable option for RSI because of its quick onset and short duration of action, its preservation of respiratory drive, and its sympathomimetic properties 1
- Recent evidence suggests that ketamine can be used safely in most clinical scenarios, including patients with increased intracranial pressure or psychiatric disorders 1
- Ketamine also provides analgesic effects, which is beneficial for post-intubation management
Always have airway equipment ready, maintain oxygenation throughout the procedure, and be prepared to manage potential side effects including emergence reactions. The use of ketamine as an induction agent for RSI has been studied extensively, and the current evidence suggests that it is a safe and effective option for many patients 1.
From the Research
Recommended Dosage of Ketamine for RSI in Adults
- The recommended dosage of ketamine for rapid sequence intubation (RSI) in adults is typically 1 to 2 mg/kg intravenously 2.
- A study found that higher doses of ketamine (> 2 mg/kg) were associated with increased odds of adverse events, including hypotension, laryngospasm, and bradycardia 2.
- Another study used a standardized RSI protocol with ketamine 2 mg/kg intravenously and found that dosing was appropriate with a mean dose of 1.9-mg/kg ketamine administered 3.
Comparison with Other Medications
- A study compared the combination of etomidate and s-ketamine (0.5 mg/kg) with fentanyl and found that the ketamine group had better intubating conditions 4.
- Another study compared rocuronium and succinylcholine for RSI and found that both provided clinically acceptable intubation conditions, but rocuronium may be a substitute for succinylcholine 5.
- A randomized clinical trial found that rocuronium failed to demonstrate noninferiority compared to succinylcholine for first-attempt intubation success rate in out-of-hospital emergency settings 6.
Key Findings
- Ketamine is a commonly used medication for RSI in adults, with a recommended dosage of 1 to 2 mg/kg intravenously 2, 3.
- Higher doses of ketamine may be associated with increased adverse events 2.
- The choice of medication for RSI depends on various factors, including the patient's condition and the clinician's preference 4, 5, 6.