From the Guidelines
Rapid sequence intubation (RSI) should be performed by administering a sedative and a neuromuscular blocking agent simultaneously, with pre-oxygenation, and immediate placement of an endotracheal tube, as recommended by the Society of Critical Care Medicine clinical practice guidelines 1. The process involves several key steps, including:
- Pre-oxygenation with 100% oxygen for 3-5 minutes or 8 vital capacity breaths to minimize the risk of hypoxemia
- Administration of a sedative, such as etomidate (0.3 mg/kg), ketamine (1-2 mg/kg), or propofol (1-2 mg/kg), followed immediately by a paralytic agent, such as succinylcholine (1-1.5 mg/kg) or rocuronium (1-1.2 mg/kg) 1
- Application of cricoid pressure (Sellick maneuver) to reduce aspiration risk, although this practice is becoming less universal
- Waiting 45-60 seconds for full effect of the medications, then proceeding with laryngoscopy and tube placement
- Having backup airway equipment ready, including a bag-valve mask, supraglottic airways, and surgical airway tools RSI is indicated to reduce the risk of aspiration in at-risk patients and to optimize intubating conditions, reducing the occurrence of difficult or failed airways, esophageal tube placement, and complications 1. It is essential to note that RSI differs from standard intubation by eliminating the bag-mask ventilation step between sedation and intubation, which reduces gastric insufflation and aspiration risk, making it a valuable technique in emergency situations with full stomachs, trauma, or when rapid airway control is essential 1.
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 [see CLINICAL STUDIES (14.1)]. The process for rapid endotracheal intubation (ETI) involves administering rocuronium bromide injection at a dose of 0.6 to 1.2 mg/kg to provide excellent or good intubating conditions in most patients in less than 2 minutes. This should be done in appropriately premedicated and adequately anesthetized patients 2.
- Key points:
- Dose: 0.6 to 1.2 mg/kg
- Time to intubation: less than 2 minutes
- Patient status: appropriately premedicated and adequately anesthetized
- Important consideration: The administration of rocuronium bromide injection should only be done by experienced clinicians or trained individuals supervised by an experienced clinician familiar with the use, actions, characteristics, and complications of neuromuscular blocking agents 2.
From the Research
Rapid Endotracheal Intubation (ETI) Process
The process of rapid endotracheal intubation (ETI) involves several steps, including:
- Pretreatment with medications such as atropine, lidocaine, and fentanyl, although their use has fallen out of favor due to limited evidence for their use outside of select clinical scenarios 3
- Induction with a sedative, such as etomidate or ketamine, which are commonly used due to their favorable hemodynamic profiles 3, 4
- Administration of a neuromuscular blocking agent (NMBA), such as succinylcholine or rocuronium, to facilitate intubation 3, 5, 4
- Post-intubation sedation and analgesia to ensure patient comfort and safety 3
Medication Considerations
The selection of medications for rapid ETI is critical for success, and several factors must be considered, including:
- The patient's medical history and current condition, such as shock or sepsis 3
- The potential for adverse effects, such as hypotension or adrenal suppression 3, 4
- The availability of medications and the potential for drug shortages 6
Intubation Techniques
Several intubation techniques are available, including: