What are the starting dosages for medications used in rapid sequence intubation (RSI)?

From the Guidelines

Rapid sequence intubation (RSI) should be performed with the following starting dosages for medications: etomidate (0.3 mg/kg IV), propofol (1.5-3 mg/kg IV), or ketamine (1-2 mg/kg IV) as the induction agent, and succinylcholine (1-2 mg/kg IV) or rocuronium (1-1.2 mg/kg IV) as the neuromuscular blocking agent. The selection of these medications is based on the patient's condition, with etomidate or ketamine preferred for hemodynamically unstable patients, and rocuronium for those with contraindications to succinylcholine such as hyperkalemia, burns, or neuromuscular disorders 1.

The procedure for RSI involves several key steps:

• Preoxygenation for 3-5 minutes using 100% oxygen
• Administration of a pretreatment agent such as fentanyl (2-3 mcg/kg IV) 3 minutes before induction to blunt sympathetic response
• Administration of an induction agent: etomidate, propofol, or ketamine
• Immediate administration of a neuromuscular blocking agent: succinylcholine or rocuronium
• Application of cricoid pressure during this phase if appropriate
• Waiting 45-60 seconds for complete paralysis, then proceeding with laryngoscopy and intubation
• Having backup medications ready, including vasopressors (epinephrine 10 mcg boluses) for hypotension and additional sedatives for post-intubation management

It is essential to tailor medication selection to the patient's condition and to continuously monitor vital signs throughout the procedure to detect and manage complications promptly 1. The most recent and highest quality studies support the use of these medications and procedures for RSI, with a focus on minimizing morbidity, mortality, and improving quality of life 1.

From the FDA Drug Label

To be administered only by experienced clinicians or adequately trained individuals supervised by an experienced clinician familiar with the use, actions, characteristics, and complications of neuromuscular blocking agents.

• Tracheal intubation: Recommended initial dose is 0.6 mg/kg. • Rapid sequence intubation: 0.6 to 1.2 mg/kg.

The starting dosages for medications used in rapid sequence intubation (RSI) are:

• Rocuronium: 0.6 to 1.2 mg/kg 2 Note that the exact dosage may vary depending on the specific medication and patient factors, and should be individualized and guided by clinical response.

From the Research

Medications Used in Rapid Sequence Intubation (RSI)

The medications used in RSI include:

• Sedative induction agents such as propofol, etomidate, midazolam, thiopental, and ketamine 3, 4, 5
• Neuromuscular blockers such as succinylcholine and rocuronium 3, 4, 6, 7, 5

Starting Dosages for RSI Medications

The starting dosages for RSI medications are:

• Succinylcholine: 0.45 mg/kg to 1 mg/kg 4, with a dose of 0.45 mg/kg providing optimal intubation conditions in ASA III & IV emergency non-prepared patients
• Rocuronium: 1.0 mg/kg to 1.4 mg/kg 6, 7, with a dose of 1.2 mg/kg to 1.3 mg/kg resulting in higher first-attempt success rates when using direct laryngoscopy
• Etomidate: 0.3 mg/kg 4
• Fentanyl: 1 µg/kg to 1 µg/kg 4
• Propofol: no specific dosage mentioned in the provided studies, but it has replaced thiopental as the most common intravenous hypnotic 3
• Ketamine: no specific dosage mentioned in the provided studies, but it represents a viable alternative in hypotensive patients 3

Factors Affecting Medication Dosage

The dosage of medications used in RSI can be affected by various factors, including:

• Patient's physical status, such as ASA III & IV 4
• Presence of severe acidosis, depletion of intravascular volume, heart failure, and severe pulmonary disease 3
• Use of direct or video laryngoscopy 7
• Patient's pre-intubation hemodynamics, such as hypotension 7