What is the recommended approach for using paralytics and intubation in patients?

Rapid Sequence Intubation with Paralytics: Recommended Approach

Always administer a sedative-hypnotic induction agent when using a neuromuscular blocking agent (NMBA) for intubation to prevent awareness during paralysis. 1

Pre-Intubation Positioning and Preparation

Position the patient in semi-Fowler position (head and torso inclined 25-30°) to reduce aspiration risk and improve first-pass intubation success. 2, 3 For patients without cervical spine concerns, use the "sniffing position" (lower cervical flexion with upper cervical extension) to optimize laryngeal visualization. 3

• Ensure the bed mattress is firm to optimize head extension and access to the cricothyroid membrane if emergency front-of-neck access becomes necessary 3
• For obese patients, use ramping technique with head extended so the face is horizontal 3
• In suspected cervical spine injury, maintain neutral head/neck position or tilt the entire bed head-up rather than flexing the neck 3

Preoxygenation Strategy

Use high-flow nasal oxygen (HFNO) when laryngoscopy is expected to be challenging, and noninvasive positive pressure ventilation (NIPPV) for patients with severe hypoxemia (PaO2/FiO2 < 150). 2

• For agitated, delirious, or combative patients who cannot tolerate preoxygenation devices, use medication-assisted preoxygenation (delayed sequence intubation) with ketamine, which can increase oxygen saturation by approximately 8.9% before NMBA administration 2
• Adequate preoxygenation is critical as apnea oxygenation time is often extremely short in critically ill patients 1

Medication Selection: Induction Agents

Administer a sedative-hypnotic induction agent immediately before the paralytic, with etomidate showing no significant difference from other agents (ketamine, midazolam, propofol) regarding mortality or hypotension. 1

The 2023 Society of Critical Care Medicine guidelines provide conditional recommendation that etomidate, ketamine, midazolam, or propofol are all acceptable choices, with selection based on hemodynamic status. 1 Despite historical concerns about etomidate and adrenal suppression, the most recent high-quality evidence shows no mortality difference. 1

Common induction dosing:

• Midazolam 2-5 mg with etomidate 10-20 mg, OR propofol if hemodynamics allow 1
• Fentanyl 100-150 µg or sufentanil 10-15 µg to suppress laryngeal reflexes 1
• Ketamine for medication-assisted preoxygenation in uncooperative patients 2

Neuromuscular Blocking Agent Selection

Administer either succinylcholine 1 mg/kg or rocuronium 1.0-1.2 mg/kg when no contraindications to succinylcholine exist. 2, 4

The 2023 guidelines indicate these agents are equivalent for first-attempt intubation success when dosed appropriately. 2 However, there are critical differences:

Succinylcholine advantages:

• Faster onset with muscle fasciculation completion indicating readiness for intubation 1
• Shorter duration reduces risk of prolonged awareness if sedation is inadequate 5
• Preferred for rapid sequence intubation in most emergency situations 2

Rocuronium considerations:

• Use 1.0-1.2 mg/kg for RSI (higher than maintenance dosing) 4
• Have sugammadex immediately available at bedside for "cannot intubate/cannot oxygenate" scenarios 1, 4
• Longer duration may delay post-intubation sedation administration, potentially increasing awareness risk 5
• NOT recommended for rapid sequence induction in cesarean sections or pediatric patients 4

Intubation Technique

Use video laryngoscopy when available, performed by the most experienced clinician present to minimize repeated attempts and viral aerosol exposure. 1

• Remove outer gloves immediately after intubation completion and don fresh gloves 1
• Use optimal external laryngeal manipulation (OELM) or BURP technique (backward, upward, rightward pressure on thyroid cartilage) during first attempt 1
• If Cormack-Lehane grade 3 view obtained, use an introducer (bougie) 1
• Have alternative laryngoscopes ready (McCoy, straight blade) 1
• Prepare emergency cricothyroidotomy kit before starting 1

Critical Safety Considerations

Common pitfalls to avoid:

1. Never administer NMBA without sedative-hypnotic agent - This causes awareness during paralysis, with reported incidence of 2.6% when inadequate sedation used 1

2. Inadequate preoxygenation - Critically ill patients desaturate rapidly; use medication-assisted preoxygenation for uncooperative patients rather than proceeding with inadequate preparation 2

3. Delayed post-intubation sedation - When using rocuronium, be aware that 40.9% of patients receive additional sedation within 15 minutes, with mean time to sedation being 20 minutes across all patients 5

4. Medication errors - Rocuronium administration results in paralysis that can lead to respiratory arrest and death if given to wrong patient; confirm proper selection and clearly label intended dose 4

5. Hemodynamic instability - Have vasopressors prepared in prefilled syringes at bedside; consider fluid resuscitation before RSI when possible 1

Equipment and Monitoring Requirements

RSI should only be performed when facilities for mechanical ventilation, oxygen therapy, and reversal agents are immediately available. 4

• Use peripheral nerve stimulator to monitor neuromuscular blockade depth, need for additional doses, and adequacy of recovery 4
• Have closed airway suction system available to reduce viral aerosol production 1
• Prepare all equipment before starting as visualization may be suboptimal due to restricted space and vapor condensation on eye shields 1