Recall of Intubation with Ketamine and Rocuronium in Emergency Settings
Patients intubated with ketamine and rocuronium in the emergency department have essentially no recall of their intubation, as ketamine provides profound dissociative amnesia at standard induction doses.
Mechanism of Amnesia with Ketamine
Ketamine functions as a dissociative agent through N-methyl-D-aspartate (NMDA) glutamate receptor antagonism, providing simultaneous sedation, analgesia, and amnesia during procedures 1. This dissociative state is a fundamental property of the drug that distinguishes it from other sedatives.
Standard Dosing for RSI
The recommended ketamine dose for rapid sequence intubation is:
At these doses, patients achieve complete dissociation and have no explicit memory formation of the intubation procedure 1.
Evidence on Recall
While the provided guidelines extensively document ketamine's safety and efficacy for procedural sedation, they consistently note that:
- No studies report patient recall of intubation procedures when adequate ketamine doses are used 4
- In procedural sedation studies with ketamine, patients demonstrate complete amnesia for the procedure itself 4, 2
- The only "recall" documented is of pleasant or unpleasant dreams during sedation (occurring in 25% of patients), not actual procedural memory 4
Rocuronium's Role
Rocuronium at the recommended dose of 1.0-1.2 mg/kg provides complete neuromuscular blockade but has no effect on consciousness or memory 4. The paralysis prevents any physical response or movement during intubation, but amnesia is entirely dependent on the ketamine component 5.
Clinical Considerations
Important caveats regarding potential awareness:
Underdosing ketamine is the most common error in emergency sedation, with doses <1.5 mg/kg requiring supplemental dosing in over 50% of cases 2, 3. Inadequate initial dosing could theoretically allow awareness, though this is not documented in the literature.
High-dose ketamine (>2 mg/kg IV) has been associated with increased adverse events including hypotension and laryngospasm in prehospital settings 6, but does not appear to affect amnesia quality.
Patients with cocaine intoxication who receive ketamine for excited delirium have a 5.75-fold increased rate of subsequent intubation 7, suggesting potential for inadequate sedation in this population if initial dosing is insufficient.
Practical Implications
When ketamine is dosed appropriately at 1.5-2 mg/kg IV for RSI in the emergency department, explicit recall of the intubation procedure does not occur 2, 3, 1. The combination with rocuronium ensures excellent intubating conditions while ketamine provides complete amnesia 8, 9. The primary concern should be ensuring adequate initial dosing rather than worrying about patient recall.