What is used in combination with Ketamine for Rapid Sequence Intubation (RSI)?

From the Guidelines

Ketamine is recommended as an effective induction agent for rapid sequence intubation (RSI), particularly in hemodynamically unstable patients, with a recommended dose of 1-2 mg/kg IV given as a single bolus 1.

Key Considerations for Ketamine Use in RSI

• The dose for RSI is 1-2 mg/kg IV given as a single bolus, with the lower end of the dosing range (1 mg/kg) recommended for patients in shock or with cardiovascular compromise.
• Ketamine provides both sedation and analgesia while maintaining respiratory drive and preserving hemodynamic stability through its sympathomimetic effects, making it valuable in hypotensive patients.
• Ketamine should be used cautiously in patients with severe hypertension, increased intracranial pressure, or coronary artery disease due to its potential to increase blood pressure and heart rate.
• Common side effects include emergence reactions, increased secretions, and laryngospasm, and consider pretreatment with an antisialagogue like glycopyrrolate (0.2-0.4 mg IV) to reduce secretions.

Pairing Ketamine with a Neuromuscular Blocking Agent

• Ketamine should be paired with a neuromuscular blocking agent such as rocuronium (1-1.2 mg/kg) or succinylcholine (1.5-2 mg/kg) to complete the RSI sequence and facilitate intubation 1.
• The choice of neuromuscular blocking agent depends on the patient's condition and the presence of any contraindications.

Clinical Guidelines and Recommendations

• The Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient recommend ketamine as a suitable induction agent for RSI 1.
• The guidelines also suggest that there is no difference between etomidate and other induction agents, including ketamine, with respect to mortality or the incidence of hypotension or vasopressor use in the peri-intubation period and through hospital discharge 1.

From the Research

Ketamine and RSI

• Ketamine is used as an induction agent in rapid sequence intubation (RSI) due to its favorable hemodynamic profile 2, 3, 4, 5.
• The use of ketamine in RSI can facilitate airway management in critically injured patients and may provide hemodynamic benefits during the procedure 3, 5.
• Ketamine can be used to facilitate alternative approaches to RSI, such as delayed sequence intubation and ketamine-only breathing intubation, which may increase patient safety in certain scenarios 4.
• A standardized RSI protocol that includes ketamine can simplify the procedure and reduce the need for medication redosing and medication-related hypotension 5.

Comparison with Other Agents

• Succinylcholine and rocuronium are the preferred neuromuscular blocking agents for RSI, but ketamine can be used as an alternative induction agent 6, 3.
• Etomidate and ketamine are the most commonly used induction agents for RSI due to their favorable hemodynamic profiles, but etomidate may produce less hypotension than ketamine in patients with shock or sepsis 3.
• The choice of induction agent and neuromuscular blocking agent for RSI depends on patient-specific factors, such as the presence of certain medical conditions or the need for a specific type of anesthesia 6, 3.

Clinical Considerations

• The use of ketamine in RSI requires careful consideration of the patient's medical history and current condition, as well as the potential risks and benefits of the procedure 2, 3, 4, 5.
• The optimal selection, dosing, and administration of RSI medications, including ketamine, is complicated and requires further research to determine the best practices 3.