Introduction

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 immediate post intubation period in the ED is a critical time for continued patient stabilization.

Clinical Detail

Depending on the paralytic used, clinicians can be eased into the assumption that the patient is tolerating the ventilator and not in need of sedation or analgesia

Administering analgesia and sedation is key to preventing patient awareness during paralysis and preventing PTSD

CategoryFentanyl
(Sublimaze)		Propofol
(Diprivan)		Midazolam
(Versed)		Dexmedetomidine
(Precedex)
DoseBolus: 0.35 to 1.5 mcg/kg IV every 0.5 to 1 hour
Infusion: 25-300 mcg/hr		Bolus:  
Infusion: Titrate in 5-50 mcg/kg/min		Bolus: 0.5 to 4 mg
Infusion: 1-10 mg/hr		Bolus: Not recommended
Infusion: 0.1-1.4 mcg/kg/hr
AdministrationIV Bolus + InfusionIV Bolus + InfusionIV Bolus + InfusionIV Infusion
PK/PDOnset: IV almost immediate
Duration: 30-60 min
Metabolism: CYP3A4
Excretion: >90% inactive metabolite renally eliminated		Onset: 10-40 sec
Duration: 3-10 min
Metabolism: Hepatic Phase II
Excretion: Urine (~88% metabolites)		Onset: 3-5 min
Duration: 30-80 min
Metabolism: CYP3A4 (active metabolites)
Excretion: 45% to 57% renally eliminated (metabolites)		Onset: 15-30 min
Duration: 4 hours
Metabolism: Hepatic Phase II + CYP2A6
Excretion:  
Adverse EffectsChest wall rigidity
CNS depression		Hypotension, bradycardia, hypertriglyceridemiaHypotension, respiratory depressionHypotension, bradycardia
Drug InteractionsCYP3A4 inhibitors, serotonergic agentsBupivacaine, St. John’s WortCYP3A4 inhibitors, CNS depressantsCNS depressants and antihypertensive
CompatibilityProtonixCalcium chloride. Nimbex, Cipro, gentamicin, phenytoinFosphenytoin, sodium bicarbonate, Zosyn, hydrocortisoneProtonix, phenytoin,

Comments per EM Physicians

AgentPhysician Comment
Fentanyl“I love fentanyl. short acting, quick action, has least hemodynamic effect of IV narcotics”
Propofol“I’m a big propofol fan. It has reliable sedation, quick onset. The hypotension is not ideal but these are sick patients anyway so I’m ok with starting pressors or more fluid if they can tolerate it to keep up with adequate propofol dosing.”
Dexmedetomidine“I’m also a Precedex fan! It has same quick on, quick off. Bradycardia I’ve seen has been related to infusion rate, but we used to use it primarily as part of CIWA (GAWAS) protocol where I worked and it saved us many an intubation.”
Midazolam“Versed has an onset slower than I would like, especially if we have to bolus from the pump for acute agitation on the vent. Sometimes sedation is prolonged. In my practice it has less reliable in dose effects than propofol. I’ve seen people chew through a lot of versed without adequate sedation, but all of the side effects. I tend not to use it.”

Evidence

Author, yearDesign/sample sizeIntervention & ComparisonOutcome
Groetzinger, 2018Retrospective review/ n=91Ketamine infusion 0.125 to 1.2 mg/kg/hr63% of patients discontinue other sedatives or analgesic within 24 hours of initiating ketamine
↑ in the number of sedation scores at goal
↓ in agitation, defined as SAS >4, after the initiation of ketamine
Shehabi, 2018Prospective Cohort/ n=703Light Sedation vs Deep Sedation (using sedation intensity score)Sedation intensity independently, in an ascending relationship, predicted increased risk of death, delirium, and delayed time to extubation
Fraser, 2013Meta-Analysis/ n=1,235 patientsBenzodiazepines vs Non-benzodiazepinesNon-benzodiazepine sedatives associated with ↓ ICU LOS and ↓ Ventilator days
Amini, 2013retrospective cohort study/ n=100rocuronium-assisted RSI) + PharmD vs rocuronium-assisted RSI) - PharmDPharmD associated with time to sedation 9 min vs 28 min
PharmD associated with time to analgesia 21 min vs 44 min
PharmD associated with sedation within 5 min 33% vs 11%
Watt, 2012retrospective cohort study/ n=200Succinylcholine 1.7 ± 0.7 mg/kg vs Rocuronium 1.3 ± 0.4 mg/kgAfter intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7).
Mean time to post intubation sedation was significantly greater with rocuronium compared to succinylcholine (27 min vs 15)
Shehabi (SPICE), 2012Prospective Cohort/ n=251Light Sedation vs Deep Sedation4 hours after starting mechanical ventilation 76% of patients were deeply sedated RASS, -3 to -5
Early deep sedation was a significant independent predictor of death and time to extubation.
Jakob, 2012RCT/ N=498Dexmedetomidine 0.2-1.4 mcg/kg/hr vs Midazolam 0.03-0.2 mg/kg/hrLighter sedation, fewer ventilation days
Strom, 2010RCT/ n=140No sedation (PRN morphine) vs Propofol or midazolam infusion + (PRN morphine)No sedation group had ↓ ventilator free days, ↓ ICU and ↓ hospital LOS

Conclusions

Source did not include a distinct Conclusions section for this pearl; see Clinical Detail and Evidence above.

References

  • Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from http://www.micromedexsolutions.com/
  • Groetzinger LM. Pharmacotherapy. 2018 Feb;38(2):181-188
  • Jakob SM. JAMA. 2012 Mar 21;307(11):1151-60.
  • Shehabi Y. (SPICE Investigators). Am J Respir Crit Care Med. 2012 Oct 15;186(8):724-31
  • Watt JM. Emerg Med J. 2013 Nov;30(11):893-5.
  • Amini A. Am J Health Syst Pharm. 2013 Sep 1;70(17):1513-7.
  • Fraser GL. Crit Care Med. 2013 Sep;41(9 Suppl 1):S30-8.
  • Shehabi Y. Crit Care Med. 2018 Jun;46(6):850-859.
    • Tags: post-intubation analgesia sedation RSI

    Source Artifact

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