Patients who have no pulse and have apnea or those with severe obtundation can (and should) be intubated without pharmacologic assistance. Other patients are given sedating and paralytic drugs to minimize discomfort and facilitate intubation (termed rapid sequence intubation) (see table Sedative and Analgesic Medications for Induction of Intubation).
(See also Overview of Respiratory Arrest, Airway Establishment and Control, and Tracheal Intubation.)
Sedation and analgesia for intubation
Medications to cause paralysis for intubation
Skeletal muscle relaxation with an IV neuromuscular blocker (NMBA) facilitates intubation (6).
> 1 to 2 days old, and acute kidney injury because of potential concerns about hyperkalemia (78). Other NMBAs should also be considered in patients with possible penetrating eye injury because of concerns about increased intraocular pressures due to fasciculations. Malignant hyperthermia can be caused by depolarizing neuromuscular blockers as well as certain anesthetics. Malignant hyperthermia accounts for a small percentage of overall anesthesia-related deaths (9, 10).
11).
Alternative nondepolarizing neuromuscular blockers have longer duration of action (> 30 minutes) but also have slower onset unless used in high doses that prolong paralysis significantly (1, 12
succinylcholine) can be used for rapid sequence intubation (1).
13).
Sedative and Analgesic Medications for Induction of Intubation
Medication | Dose (IV) | Considerations |
|---|---|---|
0.5–1 mg/kg (loading dose) and 0.25–0.5 mg/kg (subsequent maintenance doses) | A medication that is used to induce sedation and amnesia very quickly (< 1 minute) | |
0.1–0.15 mg/kg over 1 minute (loading dose) | ||
0.02–0.03 mg/kg (as 0.5–1 mg loading dose) | A short-acting analgesic (minimal sedation); the maximum single dose should not exceed 2.5 mg | |
0.5 mcg/kg every 2 minutes | A short-acting synthetic opioid;the initial dose is 50-100 mcg for adults, and the maximum total dose is 5 mcg/kg (or approximately 250 mcg) | |
1–2 mg/kg over 1–2 minutes (loading dose) and 0.25–0.5 mg/kg (maintenance dose) | ||
* Data from Miner JR, Burton JH: Clinical practice advisory: Emergency department procedural sedation with propofol. Ann Emerg Med 50(2):182–187.e1, 2007. doi:10.1016/j.annemergmed.2006.12.017 | ||
† Data from Miner JR, Danahy M, Moch A, Biros M: Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 49(1):15–22, 2007. doi:10.1016/j.annemergmed.2006.06.042 | ||
‡ Data from Horn E, Nesbit SA: Pharmacology and pharmacokinetics of sedatives and analgesics. Gastrointest Endosc Clin N Am 14(2):247–268, 2004. doi:10.1016/j.giec.2004.01.001 | ||
019101s063lbl.pdf (fda.gov). Revised December 15, 2023. Accessed June 11, 2024 and from Brown TB, Lovato LM, Parker D: Procedural sedation in the acute care setting. Am Fam Physician 2005;71(1):85–90, 2005. | ||
¶ Data from David H, Shipp J: A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 57(5):435–441, 2011. doi:10.1016/j.annemergmed.2010.11.025 and from Brown TB, Lovato LM, Parker D: Procedural sedation in the acute care setting. Am Fam Physician 71(1):85–90, 2005. | ||
Topical anesthesia for intubation
Post-intubation sedation and analgesia
16).
References
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2. Kotani Y, Piersanti G, Maiucci G, et al: Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care 77:154317, 2023. doi:10.1016/j.jcrc.2023.154317
3. Teong CY, Huang CC, Sun FJ: The Haemodynamic Response to Endotracheal Intubation at Different Time of Fentanyl Given During Induction: A Randomised Controlled Trial. Sci Rep 10(1):8829, 2020. doi:10.1038/s41598-020-65711-9
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6. Lundstrøm LH, Duez CHV, Nørskov AK, et al: Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review. Br J Anaesth 120(6):1381–1393, 2018. doi:10.1016/j.bja.2017.11.106
7. Blanié A, Ract C, Leblanc PE, et al: The limits of succinylcholine for critically ill patients. Anesth Analg 115(4):873–879, 2012. doi:10.1213/ANE.0b013e31825f829d
8. Cooperman LH: Succinylcholine-induced hyperkalemia in neuromuscular disease. JAMA 213(11):1867–1871, 1970.
9. Hirshey Dirksen SJ, Larach MG, Rosenberg H, et al: Special article: Future directions in malignant hyperthermia research and patient care. Anesth Analg 113(5):1108–1119, 2011. doi:10.1213/ANE.0b013e318222af2e
10. Rosenberg H, Davis M, James D, Pollock N, Stowell K: Malignant hyperthermia. Orphanet J Rare Dis 2:21, 2007. doi:10.1186/1750-1172-2-21
11. de Caen AR, Berg MD, Chameides L, et al: Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 132(18 Suppl 2):S526–S542, 2015. doi:10.1161/CIR.0000000000000266
12. Plaud B, Baillard C, Bourgain JL, et al: Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 39(1):125–142, 2020. doi:10.1016/j.accpm.2020.01.005
13. Schreiber JU, Lysakowski C, Fuchs-Buder T, Tramèr MRAnesthesiology 103(4):877–884, 2005. doi:10.1097/00000542-200510000-00027
14. Walsh ME, Shorten GD: Preparing to perform an awake fiberoptic intubation. Yale J Biol Med 71(6):537–549, 1998.
15. Wills BK, Cumpston KL, Downs JW, Rose SR: Causative Agents in Clinically Significant Methemoglobinemia: A National Poison Data System Study. Am J Ther 28(5):e548–e551, 2020. doi:10.1097/MJT.0000000000001277
16. Devlin JW, Skrobik Y, Gélinas C, et al: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 46(9):e825-e873, 2018. doi:10.1097/CCM.0000000000003299
