From the Guidelines
Intubation typically requires the administration of sedative and neuromuscular blocking agents to facilitate tracheal tube placement.
Commonly Used Medications
- Sedation: etomidate (0.2-0.3 mg/kg) or propofol (1-2 mg/kg), as recommended by 1
- Neuromuscular blockade: rocuronium (0.6-1.2 mg/kg) or succinylcholine (1-1.5 mg/kg), with durations of action ranging from 30 seconds to 60 minutes depending on the specific agent and dose, as stated in 1 The choice of medication and dosage is tailored to the individual patient's needs and medical history, with the goal of achieving rapid sequence intubation while minimizing adverse effects.
Key Considerations
- The selection of a sedative-hypnotic agent that attenuates hypotension during RSI is desirable, as noted in 1
- Ketamine may be a reasonable option for RSI because of its quick onset and short duration of action, its preservation of respiratory drive, and its sympathomimetic properties, as mentioned in 1
- Rocuronium at a dose above 0.9 mg/kg [1.0–1.2 mg/kg] should be used when succinylcholine is contraindicated, as recommended by 1
- Sugammadex should probably be rapidly available when rocuronium is used, as suggested by 1
From the FDA Drug Label
In US clinical studies, a total of 1137 patients received rocuronium bromide, including 176 pediatric, 140 geriatric, 55 obstetric, and 766 other adults. Intubation using doses of rocuronium bromide 0.6 to 0. 85 mg/kg was evaluated in 203 adults in 11 clinical studies. Rapid Sequence Intubation Intubating conditions were assessed in 230 patients in six clinical studies where anesthesia was induced with either thiopental (3 to 6 mg/kg) or propofol (1.5 to 2. 5 mg/kg) in combination with either fentanyl (2 to 5 mcg/kg) or alfentanil (1 mg).
The medications used for intubation include:
- Rocuronium bromide: used for intubation at doses of 0.6 to 0.85 mg/kg
- Thiopental: used for rapid sequence induction at doses of 3 to 6 mg/kg
- Propofol: used for rapid sequence induction at doses of 1.5 to 2.5 mg/kg
- Fentanyl: used in combination with thiopental or propofol at doses of 2 to 5 mcg/kg
- Alfentanil: used in combination with thiopental or propofol at a dose of 1 mg
- Succinylcholine: used for intubation at doses of 1 to 1.5 mg/kg 2
From the Research
Medications Used for Intubation
The medications used for intubation can be categorized into several steps, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia.
- Pretreatment medications include:
- Induction agents include:
- Neuromuscular blocking agents include:
- Post-intubation sedation and analgesia medications are not specified in the provided studies.
Considerations for Medication Selection
The selection of medications for intubation depends on various factors, including patient-specific factors, half-life, and adverse effect profiles 3, 5.
- The use of succinylcholine and rocuronium as neuromuscular blocking agents has been compared, with minimal differences in first-pass success rates 3.
- Rocuronium in large doses (i.e., > or = 1 mg kg-1) is an alternative to succinylcholine in a classical rapid-sequence setting under relatively light anesthesia 5.
- The order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation is debated, with some studies suggesting that administering the neuromuscular blocking agent first may result in modestly faster time to intubation 7.
Impact of Medications on Sedation Initiation
The impact of rocuronium and succinylcholine on sedation initiation after rapid sequence intubation has been evaluated, with results showing that patients receiving rocuronium had a significantly longer time to sedation or analgesia compared to patients receiving succinylcholine 6.
- The presence of an emergency medicine pharmacist was found to significantly decrease the time to administration of sedation or analgesia after rapid sequence intubation 6.