What is the appropriate drug regimen for rapid sequence intubation of an unresponsive adult in septic shock with bradycardia?

Rapid Sequence Intubation in Septic Shock with Bradycardia and Unresponsiveness

Immediate Pre-Intubation Hemodynamic Optimization

Before administering any RSI medications, ensure norepinephrine is running at adequate doses to maintain MAP ≥65 mmHg, with immediate capability to uptitrate if hypotension worsens during induction. 1

• Confirm at least 30 mL/kg crystalloid has been administered in the first 3 hours 1
• Place an arterial line for continuous blood pressure monitoring if not already present 1
• Have vasopressin 0.03 units/min ready to add if norepinephrine alone cannot maintain MAP during the peri-intubation period 1

Induction Agent Selection

Use ketamine as the induction agent in this patient, NOT etomidate, despite the presence of septic shock. 2, 3

Rationale for Ketamine Over Etomidate

• While retrospective evidence suggests etomidate may produce less hypotension than ketamine in septic patients 2, etomidate suppresses the hypothalamic-pituitary-adrenal axis and may worsen outcomes in patients who require hydrocortisone for refractory shock 4
• This patient already has bradycardia, indicating severe hemodynamic compromise that may progress to vasopressor-refractory shock requiring hydrocortisone 4
• Ketamine maintains sympathetic tone and provides modest bronchodilation, which is advantageous in critically ill patients 5, 6
• The concern about ketamine-induced hypotension can be mitigated by ensuring adequate vasopressor support is running before induction 1

Ketamine Dosing

• Administer 1.5–2 mg/kg IV push for induction 5, 6
• Reduce to 1–1.5 mg/kg if the patient is profoundly hypotensive despite vasopressors 5

Neuromuscular Blocker Selection

Use rocuronium 1.2 mg/kg (based on actual body weight) as the paralytic agent, NOT succinylcholine. 7, 3

Rationale Against Succinylcholine

• Succinylcholine is contraindicated in this patient because baseline bradycardia significantly increases the risk of post-RSI bradycardia (RR 1.81,95% CI 1.11–2.94) 3
• Succinylcholine causes direct vagal stimulation and can precipitate severe bradycardia or even asystole in patients with pre-existing bradycardia 8
• In septic shock with bradycardia, the patient is already demonstrating abnormal vasomotor tone and cardiac compromise 8

Rocuronium Dosing

• 1.2 mg/kg IV push provides intubating conditions within 60 seconds comparable to succinylcholine 7, 2
• The standard 0.6 mg/kg dose has a slower onset (2–3 minutes) and is inadequate for true rapid sequence intubation 7
• Dose based on actual body weight, not ideal body weight 7

Pretreatment Medications

Administer atropine 0.5–1 mg IV 3 minutes before induction in this patient with baseline bradycardia and septic shock. 9, 8

Rationale for Atropine

• The 2015 AHA guidelines state that atropine remains the first-line drug for acute symptomatic bradycardia (Class IIa, LOE B) 9
• Atropine is specifically appropriate during septic shock where abnormal vasomotor tone and bradycardia may set up a negative feedback loop of cardiac hypoxia and hypoperfusion 8
• While atropine cannot prevent all episodes of bradycardia during intubation, it diminishes the overall incidence of vagally-mediated bradycardia 8
• The unresponsive state eliminates concerns about patient cooperation, making pretreatment feasible 5

Agents to Avoid in Pretreatment

• Do NOT use fentanyl as pretreatment in this patient—it can cause bradycardia and hypotension, both of which are already present 5, 6
• Do NOT use lidocaine—there is no evidence it provides benefit in septic shock, and it has no vasopressor, inotropic, or hemodynamic benefit 1

Post-Intubation Sedation and Analgesia

Immediately after successful intubation, initiate continuous sedation with a non-benzodiazepine agent (propofol or dexmedetomidine) plus fentanyl infusion, targeting light sedation (RASS -2 to 0). 10

• The Surviving Sepsis Campaign recommends minimizing continuous sedation in mechanically ventilated septic patients, targeting specific sedation goals 10
• Avoid bolus dosing of sedatives post-intubation in septic shock; use continuous infusions titrated to effect 10
• Ensure adequate analgesia is provided alongside sedation 5

Vasopressor Management During Peri-Intubation Period

Have the following vasopressor escalation plan ready before inducing:

1. Norepinephrine: Ensure running at adequate dose (typically 0.1–0.25 µg/kg/min) with ability to immediately uptitrate 1
2. Vasopressin 0.03 units/min: Add if MAP drops below 65 mmHg despite norepinephrine uptitration 1
3. Push-dose vasopressors: Consider having phenylephrine 100 µg aliquots drawn up for immediate rescue if profound hypotension occurs, despite the general recommendation against phenylephrine in septic shock 1

Critical Pitfalls to Avoid

• Never use etomidate in a patient with septic shock who may require hydrocortisone—it suppresses adrenal function and worsens outcomes 4
• Never use succinylcholine in a patient with baseline bradycardia—it dramatically increases the risk of severe bradycardia and cardiac arrest 3, 8
• Never use dopamine for bradycardia in septic shock—it is associated with 11% absolute increase in mortality and more arrhythmias compared to norepinephrine 1
• Never delay intubation to administer hydrocortisone—airway management takes priority, and hydrocortisone is only indicated after at least 60 minutes of vasopressor-refractory hypotension 4
• Never give rapid induction boluses without ensuring vasopressors are optimized—hemodynamic collapse during induction is the most common cause of peri-intubation cardiac arrest 10

Medication Administration Sequence

1. T-minus 3 minutes: Atropine 0.5–1 mg IV push 9, 8
2. T-minus 30 seconds: Verify norepinephrine is running and uptitrate if needed 1
3. T = 0: Ketamine 1.5–2 mg/kg IV push 5, 6
4. T + 15 seconds: Rocuronium 1.2 mg/kg IV push 7
5. T + 60 seconds: Attempt laryngoscopy and intubation 7
6. Immediately post-intubation: Initiate continuous sedation and analgesia infusions 10