Rapid Sequence Intubation: 2023 SCCM Guidelines Summary
Core Medication Regimen
The Society of Critical Care Medicine 2023 guidelines recommend administering a sedative-hypnotic induction agent (etomidate 0.3 mg/kg IV or ketamine 1-2 mg/kg IV) immediately followed by a neuromuscular blocking agent (succinylcholine 1-1.5 mg/kg IV or rocuronium 0.9-1.2 mg/kg IV) for rapid sequence intubation in critically ill adults. 1
Induction Agent Selection
Etomidate (0.3 mg/kg IV) is the preferred first-line induction agent due to its favorable hemodynamic profile and extensive clinical experience, with no demonstrated mortality difference compared to other agents 1, 2, 3
Ketamine (1-2 mg/kg IV) serves as an alternative when etomidate is contraindicated or unavailable, though it carries higher rates of peri-intubation hypotension (18.3% vs 12.4% with etomidate, OR 1.4) 1, 3
The critical finding from the 2023 guidelines is that etomidate-induced adrenal suppression does NOT require corticosteroid administration, as multiple RCTs showed no mortality benefit from hydrocortisone supplementation following etomidate use 1, 3
Neuromuscular Blocking Agent Selection
Succinylcholine (1-1.5 mg/kg IV) remains the first-line paralytic when no contraindications exist, providing rapid onset (50 seconds) and shortest duration of action 1, 2, 4
Rocuronium (0.9-1.2 mg/kg IV) is the alternative when succinylcholine is contraindicated, with onset times of 55-75 seconds at higher doses comparable to succinylcholine 1, 5, 4
The FDA label specifies that rocuronium 0.6-1.2 mg/kg provides excellent or good intubating conditions in less than 2 minutes for rapid sequence intubation 5
Critical Sequencing and Timing
The sedative-hypnotic agent MUST be administered before the neuromuscular blocking agent to prevent awareness during paralysis - this is the most important safety principle in RSI 2, 3, 6
After rocuronium administration, wait at least 60 seconds before attempting intubation to ensure adequate neuromuscular blockade 3, 5
For succinylcholine, intubation can typically be attempted at 50-60 seconds after administration 4
Major Safety Concern: Post-Intubation Awareness
The 2023 guidelines highlight a critical safety issue: rocuronium's longer duration of action (58-67 minutes vs 5-10 minutes for succinylcholine) significantly delays post-intubation sedation and analgesia administration, placing patients at risk of being awake during paralysis. 1, 7, 8
Studies show patients receiving rocuronium had median time to first sedation of 12 minutes vs 10 minutes with succinylcholine, with lower rates of timely sedation (aHR 0.75) and analgesia (aHR 0.73) 7
Mean propofol infusion rates at 30 minutes were significantly lower in rocuronium patients (30 mcg/kg/min) compared to succinylcholine patients (42 mcg/kg/min, p=0.002) 8
The solution is to immediately initiate continuous sedation (propofol at adequate rates, not the commonly observed low rate of 20 mcg/kg/min) and analgesia after intubation, with bedside pharmacist involvement improving compliance (aHR 1.14) 1, 7
Special Population Considerations
Hemodynamically Unstable Patients
Etomidate 0.3 mg/kg IV is strongly preferred due to minimal cardiovascular effects 1, 2, 6
If ketamine is used, consider the lower end of dosing (1 mg/kg) as critically ill patients with depleted catecholamine stores may experience paradoxical hypotension despite ketamine's sympathomimetic properties 3, 6
Septic Patients
The 2023 guidelines definitively state that corticosteroid administration following etomidate is NOT recommended, as multiple RCTs (including a large multicenter study showing 46% vs 40% 28-day mortality with hydrocortisone vs placebo) demonstrated no mortality benefit 1, 3
Pediatric guidelines explicitly recommend ketamine over etomidate in septic shock due to adrenal suppression concerns, but adult guidelines do not make this distinction 3
Obese Patients
- Dose rocuronium based on actual body weight, not ideal body weight, as IBW dosing results in inadequate intubating conditions and shorter clinical duration 5
Common Pitfalls and Solutions
Pitfall 1: Inadequate Post-Intubation Sedation with Rocuronium
Problem: Rocuronium's 58-67 minute duration creates extended paralysis without adequate sedation, risking awareness 1, 7, 8
Solution: Immediately initiate propofol infusion at adequate rates (≥40 mcg/kg/min, not the commonly observed 20 mcg/kg/min) and fentanyl infusion (≥0.8 mcg/kg/h) before patient movement could serve as a cue 1, 7, 8
Solution: Consider involving a clinical pharmacist at bedside during RSI to improve timely analgosedation (aHR 1.14) 1, 7
Pitfall 2: Administering NMBA Before Induction Agent
Problem: This causes awareness during paralysis, which is potentially traumatic 2, 3, 6
Solution: Always administer etomidate or ketamine first, then immediately follow with succinylcholine or rocuronium 2, 3, 6
Pitfall 3: Poor Intubating Conditions with Etomidate/Rocuronium at 60 Seconds
Problem: Only 75% of patients had acceptable intubating conditions with etomidate 0.3 mg/kg and rocuronium 0.6 mg/kg at 60 seconds, with one patient unable to be intubated due to coughing 9
Solution: Use higher dose rocuronium (0.9-1.2 mg/kg) for RSI rather than 0.6 mg/kg, or consider propofol as induction agent (94% acceptable conditions vs 75% with etomidate) 5, 9
Pitfall 4: Hypotension Delaying Post-Intubation Sedation
Problem: Post-RSI hypotension (nadir SBP <100 mmHg) is associated with decreased likelihood of timely sedation (aHR 0.67) 7
Solution: Have vasopressors immediately available and initiate early if hypotension develops, while still providing adequate sedation rather than withholding it 3, 7
Preoxygenation and Positioning
Position patients in semi-Fowler position (head and trunk elevated) to improve first-pass success and reduce aspiration risk 2, 6
Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation in severely hypoxemic patients (PaO2/FiO2 <150) 1, 3
High-flow nasal oxygen (HFNO) can be used for preoxygenation in non-severely hypoxemic patients, though evidence is mixed for severely hypoxemic patients 1, 3