Induction Medications for RSI

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

Etomidate

Ketamine

Propofol

Dose

1-2 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

Author, year

Design/ sample

size

Intervention & Comparison

Outcome

Dietrich,

2018

Retrospective

review/ n=83

Propofol

vs

Non-propofol (etomidate or midazolam)

increased post-intubation hypotension with propofol OR 3.64 (95% CI

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

increased 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 increased ACTH and decreased in cortisol level

Tekwani K,

2010

Jabre P. Lancet. 2009 Jul 25;374(9686):293-300.

Tekwani KL. Ann Emerg Med. 2010 Nov;56(5):481-9

Lyon RM anaesthesia. Crit Care. 2015 Apr 1;19:134.

Bruder EA. . Cochrane Database Syst Rev. 2015 Jan 8;1:CD010225.

Mace SE. Emerg Med Clin North Am. 2008 Nov;26(4):1043-68

Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from http://www.micromedexsolutions.com/

Dietrich SK.. Am Surg. 2018 Sep 1;84(9):1504-1508.

White PF. Anesthesiology. 1982 Oct;57(4):279-84.

Jabre P. Lancet. 2009 Jul 25;374(9686):293-300.

Tekwani KL. Ann Emerg Med. 2010 Nov;56(5):481-9

Lyon RM anaesthesia. Crit Care. 2015 Apr 1;19:134.

Bruder EA. . Cochrane Database Syst Rev. 2015 Jan 8;1:CD010225.

Mace SE. Emerg Med Clin North Am. 2008 Nov;26(4):1043-68