- Rapid sequence intubation (RSI) is a process whereby an induction agent and a neuromuscular blocking agent are given in rapid succession to facilitate endotracheal intubation
- The selection of a specific sedative depends on multiple factors: the clinical scenario, which includes patient factors (includes cardiorespiratory and neurologic status, allergies, comorbidity) and the clinician’s experience/training and institutional factors, as well as the characteristics of the sedative
- Etomidate remains the most commonly used induction agent, however, it is not without its own pharmacologic considerations
- The use of ketamine is continuing to rise especially due to its unique pharmacologic profile and its niche is becoming prevalent in situations where the risk of hypotension is significant
|Dose||0.3 mg/kg IV||1-2 mg/kg||1.5-2 mg/kg|
|Administration||IV push||IV Push||IV push|
|Formulation||20 mg/ 10 ml vial||Prefilled 50 mg/5 ml Syringe||1000 mg/100 ml vial|
|PK/PD||Onset: ~20 seconds Duration: 4-10 minutes Metabolism: Hydrolysis of the ethylester side Renal Excretion: 75%||Onset: ~ IV 30 seconds IM 3-4 minutes Duration: 5-10 minutes Metabolism: N- demethylation Renal Excretion: 91%||Onset: ~10-50 seconds Duration: 3-10 minutes Metabolism: CYP2B6 Renal Excretion: 88%|
|Adverse Effects||Injection site pain, nausea, vomiting, myoclonus||Hypertension, tachycardia, emergency phenomenon||Hypotension, bradycardia|
|Drug Interactions||No major reactions||No major reactions||No major reactions|
|Compatibility||Incompatible with vitamin c and vecuronium||Incompatible with furosemide, insulin, phenytoin, and sodium bicarbonate||Incompatible with methylprednisolone, phenytoin, and metoclopramide|
|Comments||There is hypothetical concerns about adrenal insufficiency with a single dose. Hemodynamically neutral||Rapid IV push my cause apnea, Option for delayed sequence intubation. Increase BP and HR||Large dose rapid doses can cause large drops in HR and BP. Option for increase ICP|
|Etomidate||↔ BP, ↔ CO, ↔ HR, ↓ cortisol , ↔ ICP||Prolonged inhibition of steroid synthesis in the critically ill; withdrawn from number of countries|
|Ketamine||↑BP, ↑ HR, ↑ CO, ↔ cortisol, ↑↓ ICP||↔ or ↑ CPP and ↔ ICP with standard anesthetic management|
|Propofol||↓ BP, ↔ HR,↓ CO, ↔ cortisol, ↓ ICP||Hemodynamic compromise marked in elderly, ASA 3 or more or hypovolemic patients with ‘standard’ induction dose|
|Ketamine||Ketmaine has some bronchodilatory properties and can be useful if intubating for asthma angioedema, airway narrowing from anaphylaxis, infection or malignant processes are the typical examples||The dose should be greatly reduced in shock states- most notably hypovolemic shock as it is a direct myocardial depressant There are some case reports of cardiac arrest when full induction doses of ketamine are pushed in these patients. In those patients I will push 10mg at a time until dissociation occurs (usually around 0.2-0.3 mg/kg in my experience).|
|Etomidate||Most commonly used unless there circumstance where the patient will not be paralyzed such as difficult airways such as angioedema, airway narrowing from anaphylaxis, infection or malignant processes||Very short duration of action is important- 3 to 5 minutes Etomidate with rocuronium can be a recipe for paralysis without sedation unless you are right on top of providing post intubation sedation|
|Propofol||Due to vasodilatory and anti-epileptic properties, propofol is most useful in hypertensive head bleeds and patients with status epilepticus those with enough BP to work with but titrate 10 mg at a time||Hypotension and bradycardia should be noted, especially in trauma patients|
|Overview of Evidence|
|Author, year||Design/ sample size||Intervention & Comparison||Outcome|
|Dietrich, 2018||Retrospective review/ n=83||Propofol vs Non-propofol (etomidate or midazolam)||↑ post-intubation hypotension with propofol OR 3.64 (95% CI 1.16- 13.24) Similar rates of hypotension were seen among patients who received ≤2 mg/kg and those receiving >2 mg/kg No significant differences between groups in hospital length of stay or mortality|
|Lyons, 2015||Cohort study/ n=261||Etomidate+ Succinylcholine (Group 1) vs Fentanyl+ ketamine+ rocuronium (Group 2)||Significantly better laryngeal views with fentanyl/ketamine/rocuronium group 100% first attempt intubation with fentanyl/ketamine/rocuronium group ↑ post-intubation MAP+ HR with etomidate + succinylcholine|
|Bruder, 2015||Cochrane Review||Etomidate Midazolam Propofol Ketamine||There was no difference in mortality, hospital LOS, duration of ventilation, and duration of vasopressors Etomidate associated with ↑ ACTH and ↓ in cortisol level|
|Tekwani K, 2010||RCT/ n=122||Etomidate 0.3 mg/kg vs midazolam 0.1 mg/kg||No significant differences in median hospital LOS (9.5 vs 7.3 days), ICU LOS (4.2 vs 3.1 days), In-hospital mortality ( 26% vs 43%) or ventilator days|
|Jabre P, 2009||RCT/ n=469||Etomidate 0.3 mg/kg vs Ketamine 2 mg/kg||No difference in intubating condition, SOFA score, 28 day mortality, Vent free days, vasopressor support, or GCS|
|White, 1982||RCT/ n= 80||Ketamine1.5 mg/kg Thiopental 4 mg/kg Midazolam 0.3 mg/kg Midazolam 0.15 mg/kg + ketamine 0.75 mg/kg||Thiopental ↓ MAP by 11%, ketamine increased MAP by 10%, while neither midazolam nor the midazolam-ketamine combination significantly changed MAP Midazolam effectively attenuated both the cardiostimulatory responses and unpleasant emergence reactions associated with ketamine|
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