What are the recommended induction drugs for intubation in a patient with Chronic Kidney Disease (CKD)?

Induction Drugs for Intubation in Chronic Kidney Disease

For patients with CKD requiring intubation, use etomidate (0.2-0.4 mg/kg IV) as the first-line induction agent, combined with fentanyl (1-2 mcg/kg IV) for analgesia, followed by succinylcholine (1.0-1.5 mg/kg IV) or rocuronium (1.0-1.2 mg/kg IV) for neuromuscular blockade. 1

Induction Agent Selection

Etomidate is the preferred induction agent in CKD patients because it provides superior hemodynamic stability compared to other agents, which is critical given the high prevalence of cardiovascular disease in this population. 1, 2 The American Heart Association specifically recommends etomidate for patients with cardiovascular disease, and CKD patients have substantially elevated cardiovascular risk. 1

• Dosing: Etomidate 0.2-0.4 mg/kg IV (14-28 mg for a 70 kg patient) 1
• The Society of Critical Care Medicine confirms no mortality difference between etomidate and other agents, but etomidate maintains the most favorable hemodynamic profile. 1

Ketamine serves as the alternative when etomidate is contraindicated or unavailable, though it carries higher rates of peri-intubation hypotension (18.3% vs 12.4% with etomidate). 1, 3

• Dosing: Ketamine 1-2 mg/kg IV (use the higher end of this range for adequate hemodynamic stability) 1
• Ketamine's sympathomimetic properties can help maintain blood pressure, but this advantage must be weighed against the increased hypotension risk. 3

Avoid propofol in hemodynamically unstable CKD patients due to its vasodilatory effects and propensity to cause hypotension. 4

Analgesic Premedication

Administer fentanyl before induction to suppress laryngeal reflexes and optimize intubating conditions while allowing lower doses of hypnotics. 1, 5

• Dosing: Fentanyl 1-2 mcg/kg IV (70-140 mcg for a 70 kg patient) 1
• This co-induction strategy promotes cardiovascular stability, which is particularly important in CKD patients with underlying cardiac disease. 5

Neuromuscular Blocking Agent Selection

A neuromuscular blocking agent must be administered to facilitate intubation and reduce complications in critically ill patients. 5, 1

First-Line: Succinylcholine

Use succinylcholine when no contraindications exist. 1, 4

• Dosing: Succinylcholine 1.0-1.5 mg/kg IV (70-105 mg for a 70 kg patient) 1
• Provides rapid onset with first-pass success rates of 79.4% 1

Critical Contraindications in CKD Patients

Do not use succinylcholine if the patient has:

• Hyperkalemia (common in advanced CKD) 1
• Immobilization >3 days 1
• Burns or crush injuries 1
• Known myopathy or muscular dystrophy 1
• History of malignant hyperthermia 1

This is particularly important in CKD patients who frequently have baseline hyperkalemia and metabolic derangements. 6, 7

Alternative: Rocuronium

When succinylcholine is contraindicated, use rocuronium. 1, 4

• Dosing: Rocuronium 1.0-1.2 mg/kg IV (70-84 mg for a 70 kg patient) 1
• First-pass success rate of 74.6% (slightly lower than succinylcholine) 1
• Sugammadex must be immediately available for reversal if "cannot intubate/cannot oxygenate" situation occurs. 1, 5

Critical Sequencing and Safety Measures

The sedative-hypnotic agent (etomidate or ketamine) MUST be administered before the neuromuscular blocking agent to prevent awareness during paralysis. 1, 4, 3 Failure to follow this sequence results in awareness in approximately 2.6% of emergency intubations. 1

Essential Medications to Have Immediately Available:

• Sugammadex (if using rocuronium) 1
• Vasopressors (for hemodynamic support) 1
• Atropine 1

Special Considerations for CKD Patients

Drug Dosing Adjustments

Most induction agents do NOT require dose adjustment in CKD because they are primarily hepatically metabolized. 6 However, maintain heightened vigilance for:

• Hemodynamic instability: CKD patients have high rates of cardiovascular disease and volume status abnormalities. 8, 2
• Electrolyte derangements: Check potassium before using succinylcholine, as hyperkalemia is common in CKD. 6, 7
• Metabolic acidosis: May affect drug distribution and response. 7

Avoid Nephrotoxic Agents

Do not use nephrotoxic drugs perioperatively in CKD patients, as acute kidney injury superimposed on CKD dramatically worsens outcomes. 8 While induction agents are generally safe, avoid:

• NSAIDs for post-intubation analgesia 7
• Aminoglycoside antibiotics if prophylaxis needed 5

Positioning and Preoxygenation

Use semi-Fowler positioning (head and torso inclined) to reduce aspiration risk and improve first-pass success. 5, 4

For severe hypoxemia (common in volume-overloaded CKD patients):

• Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 5, 4
• Consider high-flow nasal oxygen when difficult laryngoscopy is anticipated 5, 4

Common Pitfalls and How to Avoid Them

Pitfall #1: Using succinylcholine without checking potassium

• Always verify potassium levels before intubation in CKD patients, as hyperkalemia with succinylcholine can cause cardiac arrest. 6, 7

Pitfall #2: Inadequate hemodynamic preparation

• CKD patients often have unpredictable volume status and cardiovascular disease; have vasopressors drawn up before induction. 8, 2

Pitfall #3: Administering neuromuscular blockade before sedation

• This causes awareness during paralysis; always give etomidate or ketamine first. 1, 3

Pitfall #4: Using propofol in unstable patients

• Propofol's vasodilatory effects can cause profound hypotension in CKD patients with cardiovascular disease; choose etomidate instead. 1, 4