What is the recommended rapid‑sequence intubation strategy for a patient with renal failure, including choice and dosing of induction agents, analgesics, neuromuscular blockers, fluid management, and ventilation settings?

Rapid Sequence Intubation in Renal Failure

For patients with renal failure requiring intubation, use etomidate (0.2-0.3 mg/kg) or ketamine (1-2 mg/kg) as the induction agent, avoid succinylcholine after 24 hours of established renal failure due to hyperkalemia risk, and use rocuronium (0.9-1.2 mg/kg) as the neuromuscular blocker with sugammadex immediately available for reversal. 1, 2, 3

Induction Agent Selection

Etomidate is the preferred induction agent for hemodynamically unstable renal failure patients because it produces minimal cardiovascular depression while maintaining rapid unconsciousness. 1, 2, 4 The dose is 0.2-0.3 mg/kg IV, which does not require adjustment in renal failure. 2

Ketamine (1-2 mg/kg IV) is an acceptable alternative, particularly for agitated patients requiring medication-assisted preoxygenation, though it may cause paradoxical hypotension in critically ill patients with depleted catecholamine stores. 1, 2, 3 Ketamine does not require dose adjustment in renal failure and has no active metabolites that accumulate. 1

• Avoid propofol in hemodynamically unstable renal patients due to significant vasodilation and hypotension risk, though it can be used at 2 mg/kg in stable patients. 3
• No significant mortality difference exists between etomidate and other induction agents, but etomidate produces less hypotension in shock states. 1, 4, 5

Neuromuscular Blocker Selection

Rocuronium (0.9-1.2 mg/kg) is the neuromuscular blocker of choice in renal failure patients. 1, 2, 3, 4 This high-dose regimen provides onset comparable to succinylcholine (median 1 minute) with clinical duration of 58-67 minutes. 2, 3

Succinylcholine must be avoided in established renal failure (beyond 24 hours) due to life-threatening hyperkalemia risk from upregulated acetylcholine receptors and baseline elevated potassium levels. 3, 5 If the patient requires immediate intubation within the first 24 hours of acute kidney injury and has normal potassium, succinylcholine 1.5 mg/kg can be used. 2, 4

• Sugammadex must be immediately available when using rocuronium to enable rapid reversal (within 3 minutes) in "cannot intubate/cannot oxygenate" scenarios. 1, 2, 3, 4
• Rocuronium does not require dose adjustment in renal failure, though its duration may be slightly prolonged. 6, 7

Analgesic Considerations

Avoid morphine, codeine, meperidine, tramadol, and tapentadol in renal insufficiency (GFR <30 mL/min/1.73 m²) and end-stage renal disease due to accumulation of active metabolites causing toxicity. 1

Preferred opioids for renal failure patients include:

• Fentanyl (no active metabolites, no dose adjustment needed) 1
• Sufentanil (no active metabolites) 1
• Methadone (no active metabolites, but requires experienced clinician due to accumulation risk) 1

Use hydrocodone, oxycodone, and hydromorphone with caution and reduce dosage by 50% in severe renal insufficiency. 1

Preoxygenation Strategy

Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation in severely hypoxemic renal failure patients (PaO₂/FiO₂ <150), as these patients are at highest risk for catastrophic desaturation. 1, 3, 4

For agitated or uncooperative renal failure patients, use medication-assisted preoxygenation (delayed sequence intubation) with ketamine 1-1.5 mg/kg IV to achieve dissociative state, followed by 3 minutes of preoxygenation before administering rocuronium. 2, 3, 4 Studies show mean oxygen saturation increases of 8.9% with this approach. 2, 4

• High-flow nasal oxygen (HFNO) should be used when difficult laryngoscopy is anticipated. 1, 3, 4
• Position the patient in semi-Fowler (head and torso inclined) position to reduce aspiration risk and potentially improve first-pass success. 1, 3, 4

Fluid and Hemodynamic Management

Include a cardiovascular component in the intubation protocol by defining specific parameters for fluid challenge and early vasopressor administration, as all induction agents can cause vasodilation and hypotension by abolishing sympathetic tone. 1, 3

Prepare vasopressors before induction in hemodynamically unstable renal failure patients, particularly those with volume depletion or on dialysis. 6, 5 The presence of severe acidosis, intravascular volume depletion, and heart failure complicates both pre-induction and induction periods. 6

Post-Intubation Ventilation

Apply PEEP of at least 5 cmH₂O immediately after intubation in hypoxemic renal failure patients. 1, 3

Perform a recruitment maneuver after intubation in hypoxemic patients by integrating it into the respiratory protocol. 1, 3

Use bicarbonate rather than lactate as buffer in dialysate if the patient requires renal replacement therapy post-intubation, particularly in circulatory shock or lactic acidemia. 1

Critical Pitfalls to Avoid

Never administer neuromuscular blocker before the sedative-hypnotic agent, as this causes awareness during paralysis—a devastating complication. 2, 3, 4

Do not use succinylcholine in established renal failure beyond 24 hours due to hyperkalemia risk, which can cause cardiac arrest. 3, 5

Avoid meperidine, morphine, and codeine completely in renal insufficiency due to toxic metabolite accumulation (normeperidine, morphine-6-glucuronide). 1

Ensure adequate preoxygenation before induction, as renal failure patients often have baseline hypoxemia and metabolic acidosis that accelerates desaturation. 1, 3, 4

Have backup airway equipment immediately available, including video laryngoscopy and supraglottic airways, as renal failure patients may have fluid overload causing airway edema. 4