Medications to Aid Intubation

ByAbdulghani Sankari, MD, PhD, MS, Wayne State University
Reviewed/Revised Jul 2024
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    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

    Laryngoscopy and intubation are uncomfortable; in conscious patients, a short-acting IV drug with sedative or combined sedative and analgesic properties is mandatory.

    1, 2).

    34).

    ketamine5).

    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).

    Table
    Table

    Topical anesthesia for intubation

    14benzocaine is used because it can cause methemoglobinemia (15).

    Post-intubation sedation and analgesia

    16).

    References

    1. 1. Acquisto NM, Mosier JM, Bittner EA, et al: Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med51(10):1411–1430, 2023. doi:10.1097/CCM.0000000000006000

    2. 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. 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

    4. 4. Tammen AJ, Brescia D, Jonas D, Hodges JL, Keith P: Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients. J Intensive Care Med 38(2):196–201, 2023. doi:10.1177/08850666221115635

    5. 5. Matchett G, Gasanova I, Riccio CA, et al: Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 48(1):78–91, 2022. doi:10.1007/s00134-021-06577-x

    6. 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. 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. 8. Cooperman LH: Succinylcholine-induced hyperkalemia in neuromuscular disease. JAMA 213(11):1867–1871, 1970.

    9. 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. 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. 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. 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. 13. Schreiber JU, Lysakowski C, Fuchs-Buder T, Tramèr MRAnesthesiology 103(4):877–884, 2005. doi:10.1097/00000542-200510000-00027

    14. 14. Walsh ME, Shorten GD: Preparing to perform an awake fiberoptic intubation. Yale J Biol Med 71(6):537–549, 1998.

    15. 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. 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

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