What is the recommended medication regimen for intubation?

Recommended Medication Regimen for Intubation

For rapid sequence intubation in adults, administer etomidate 0.2-0.4 mg/kg (maximum 20 mg) as the induction agent followed immediately by succinylcholine 1-1.5 mg/kg as the neuromuscular blocking agent, or use rocuronium 1.0-1.2 mg/kg when succinylcholine is contraindicated. 1

Induction Agent Selection

First-Line: Etomidate

• Etomidate 0.2-0.4 mg/kg IV (maximum 20 mg) is the preferred induction agent for most adult patients due to its hemodynamic stability and ability to lower intracranial pressure 2, 1
• Provides optimal conditions for patients with head injury, multisystem trauma, or hypotension 2
• Does not have analgesic properties and may cause brief myoclonic activity (hiccups, cough, twitching) 2
• Causes transient adrenal suppression that is generally not clinically significant, though consideration should be given in septic patients 1

Alternative: Ketamine

• Ketamine 1-2 mg/kg IV is the preferred alternative, particularly in hemodynamically unstable patients 2, 1
• Provides sympathomimetic effects that help maintain blood pressure 1
• Increasingly favored in critically ill patients due to cardiovascular stability 2
• Critical caveat: Patients with depleted catecholamine stores (severe shock, chronic critical illness) may not benefit from ketamine's sympathomimetic effects and could experience hypotension 3

Third Option: Propofol

• Propofol is a rapidly reversible agent that can be used when etomidate and ketamine are not suitable 2
• Propofol carries higher risk of hypotension in critically ill patients and should be used cautiously 2
• Doses of 2 mg/kg are typically used for induction 2

Neuromuscular Blocking Agent Selection

First-Line: Succinylcholine

• Succinylcholine 1-1.5 mg/kg IV is the first-line paralytic for patients with respiratory or cardiovascular compromise 2, 1
• Provides rapid onset and short duration of action 2
• Absolute contraindications include: hyperkalemia, burns >24 hours old, crush injuries, prolonged immobilization, or neuromuscular disease due to risk of fatal hyperkalemic cardiac arrest 1

Alternative: Rocuronium

• Rocuronium 1.0-1.2 mg/kg IV should be used when succinylcholine is contraindicated 2, 1, 4
• The FDA-approved dose for rapid sequence intubation is 0.6-1.2 mg/kg 4
• Doses of 0.9-1.2 mg/kg provide intubating conditions equivalent to succinylcholine at 60 seconds 2, 1
• Research demonstrates that 1.04 mg/kg provides 95% probability of successful intubation at 60 seconds when combined with fentanyl and propofol 5
• Sugammadex must be immediately available for potential reversal in "can't intubate, can't ventilate" scenarios 2, 1

Adjunctive Medications

Opioid Co-Induction

• Fentanyl 1-2 mg/kg IV administered as an adjunct enables lower doses of hypnotics, promoting cardiovascular stability 2
• Co-induction with rapidly-acting opioids minimizes intracranial pressure changes 2
• Rapid administration of fentanyl can cause glottic and chest wall rigidity, even at doses as low as 1 mg/kg, so titrate slowly over several minutes unless a muscle relaxant is also being administered 2
• Higher doses (1-5 mg/kg) are often recommended specifically for intubation 2

Pediatric Pretreatment

• Atropine 0.01-0.02 mg/kg IV (maximum 0.5 mg) must be administered to children aged 28 days to 8 years before intubation 1
• This is particularly important when using succinylcholine or in patients with septic shock or hypovolemia 1

Pediatric Dosing Modifications

• Succinylcholine: 2 mg/kg IV for infants and small children; 1 mg/kg for older children/adolescents 1
• Ketamine: 1-2 mg/kg IV (preferred in children) 1
• Etomidate: 0.2-0.4 mg/kg IV for children >2 years (avoid in sepsis) 1
• Rocuronium: 0.9-1.2 mg/kg IV when succinylcholine contraindicated 1
• Rocuronium is not recommended for rapid sequence intubation in pediatric patients per FDA labeling 4

Critical Pitfalls to Avoid

Dosing Errors

• Underdosing rocuronium (using 0.6 mg/kg instead of 1.0-1.2 mg/kg) significantly worsens intubating conditions and increases complications 6
• The intubation model matters: true RSI (immediate administration after hypnotic) requires higher rocuronium doses than modified RSI 6
• With thiopental induction, conventional rocuronium doses (0.6-0.7 mg/kg) provide significantly worse conditions than with propofol; high doses (0.9-1.2 mg/kg) are required 6

Medication Availability

• Never use rocuronium without immediately available sugammadex, as prolonged paralysis creates dangerous situations if intubation fails 1
• Ensure vasopressors are immediately available to manage potential hypotension during induction 3

Technique Without Muscle Relaxants

• Avoiding neuromuscular blocking agents is associated with increased difficulty and complications in critically ill patients 2
• If muscle relaxants must be avoided, remifentanil 4 mcg/kg with propofol 2 mg/kg can provide acceptable conditions, but this is not standard practice 7
• Research shows that even with high-dose opioids (fentanyl 0.2 mg), intubation without muscle relaxants produces worse vocal cord conditions 8

Monitoring Requirements

• Quantitative Train-of-Four (TOF) must be >90% before extubation 9
• Peripheral nerve stimulator is recommended for determination of drug response and need for additional doses 4