What is the recommended regimen for rapid sequence intubation (RSI)?

Recommended Regimen for Rapid Sequence Intubation (RSI)

Administer etomidate 0.2-0.4 mg/kg IV as the induction agent followed immediately by either succinylcholine 1-1.5 mg/kg IV or rocuronium 0.9-1.2 mg/kg IV as the neuromuscular blocking agent, with the sedative-hypnotic ALWAYS given before the paralytic to prevent awareness during paralysis. 1, 2, 3

Patient Positioning

• Position the patient in semi-Fowler (head and trunk inclined) rather than supine positioning during RSI 1
• This positioning improves preoxygenation through increased functional residual capacity and may reduce aspiration risk, though it may slightly increase difficult laryngoscopy rates 1

Preoxygenation Strategy

• Use high-flow nasal oxygen (HFNO) for preoxygenation when laryngoscopy is expected to be challenging 1
• Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation in patients with severe hypoxemia (PaO2/FiO2 < 150) 1
• For agitated or combative patients unable to tolerate face mask, NIPPV, or HFNO, consider medication-assisted preoxygenation 1

Gastric Decompression

• Perform nasogastric tube decompression when benefit outweighs risk in patients at high risk of regurgitation 1

Induction Agent Selection

Etomidate is the preferred induction agent for critically ill patients:

• Dose: 0.2-0.4 mg/kg IV 2
• Provides superior hemodynamic stability with no mortality difference compared to other agents 1, 2
• The Society of Critical Care Medicine confirms no difference in mortality, hypotension, or vasopressor use between etomidate and other induction agents 1

Ketamine serves as the alternative when etomidate is contraindicated:

• Dose: 1-2 mg/kg IV 2, 4
• Despite theoretical sympathomimetic benefits, ketamine shows higher rates of peri-intubation hypotension compared to etomidate (18.3% vs 12.4%) 2, 4
• In patients with depleted catecholamine stores (sepsis, chronic critical illness), ketamine may cause paradoxical hypotension 2

Critical Timing Consideration

• The sedative-hypnotic agent MUST be administered before the neuromuscular blocking agent 2, 4
• Failure to provide adequate sedation before paralysis results in awareness during paralysis in approximately 2.6% of emergency intubations 4, 5

Neuromuscular Blocking Agent Selection

Either succinylcholine or rocuronium is appropriate when no contraindications exist:

Succinylcholine (first-line when no contraindications):

• Dose: 1-1.5 mg/kg IV 2, 4
• Shorter duration of action provides safety margin if intubation fails 1, 6

Rocuronium (when succinylcholine contraindicated):

• Dose: 0.9-1.2 mg/kg IV for rapid sequence conditions 2, 3
• The FDA label confirms that 0.6-1.2 mg/kg provides excellent or good intubating conditions in less than 2 minutes 3
• Lower doses (0.6 mg/kg) may result in suboptimal intubating conditions 3, 7
• Sugammadex must be immediately available when using high-dose rocuronium for reversal in "cannot intubate, cannot ventilate" scenarios 2

Hemodynamically Unstable Patients

• Use etomidate 0.3 mg/kg IV in hemodynamically unstable patients 2
• If ketamine is chosen as alternative, consider lower end of dosing range (1 mg/kg) 2
• There is insufficient evidence to recommend routine peri-intubation vasopressors or IV fluids for hypotensive patients 1

Post-Intubation Sedation

• Initiate continuous sedation immediately after intubation to prevent awareness during ongoing paralysis 5
• Ketamine infusion (0.5-1 mg/kg/hr) is preferred for hemodynamically unstable patients 5
• Post-intubation hypotension is common and associated with increased mortality and prolonged ICU stays 5

Common Pitfalls and How to Avoid Them

Awareness During Paralysis:

• Never administer the neuromuscular blocking agent before the induction agent 2, 4
• Patients receiving rocuronium are at higher risk of delayed post-RSI sedation compared to succinylcholine (median 12 vs 10 minutes), increasing awareness risk 8

Inadequate Dosing:

• Rocuronium doses below 0.9 mg/kg may produce suboptimal intubating conditions at 60 seconds 3, 7
• One study showed that etomidate with rocuronium 0.6 mg/kg at 60 seconds resulted in only 75% acceptable intubating conditions versus 94% with propofol 7

Corticosteroid Administration:

• Do NOT administer corticosteroids following etomidate use for the purpose of counteracting adrenal suppression 1
• Despite transient adrenal suppression, corticosteroid administration is not recommended 2

Ketamine in Catecholamine-Depleted States:

• Recognize that ketamine's sympathomimetic effects depend on endogenous catecholamine stores 2
• In septic or chronically ill patients with depleted stores, ketamine may paradoxically cause hypotension 2, 4