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.)
Седація та анальгезія для інтубації
Laryngoscopy and intubation are uncomfortable; in conscious patients, a short-acting IV drug with sedative or combined sedative and analgesic properties is mandatory.
Etomidate 0.3mg/kg is a nonbarbiturate sedative-hypnotic used for induction. Although there are concerns that etomidate may increase mortality in some critically ill patients, etomidate is still recommended for rapid sequence intubation in critically ill patients (1, 2).
Fentanyl is a fast-acting synthetic opioid that can be used to reduce the hypertensive and tachycardic response to stimulation from the intubation procedure (3). Fentanyl dose IV for adults is 5 mcg/kg ideal body weight (2 to 5 mcg/kg in children). NOTE: This dose is higher than the analgesic dose and needs to be reduced if used in combination with a sedative-hypnotic (eg, propofol, etomidate). Fentanyl is an opioid and has analgesic as well as sedative properties. However, at higher doses, chest wall rigidity may occur (4).
Ketamine 1 to 2 mg/kg IV is a dissociative anesthetic with cardiostimulatory properties. It is generally safe but may cause hallucinations or bizarre behavior on awakening. These adverse effects can be managed with low doses of prophylactic benzodiazepines. Use of ketamine and etomidate results in similar post-intubation 28-day survival rates in patients who are critically ill and require intubation (5).
Propofol, a sedative and amnesic, is commonly used in induction at doses of 1.5 to 3 mg/kg IV but can cause cardiovascular depression leading to hypotension.
Barbiturates (eg, thiopental, methohexital) are not commonly used because they tend to cause hypotension.
Міорелаксанти для інтубації
Skeletal muscle relaxation with an IV neuromuscular blocker (NMBA) facilitates intubation (6).
Succinylcholine (1.5 mg/kg IV, 2.0 mg/kg for infants), a depolarizing neuromuscular blocker, has the most rapid onset (30 seconds to 1 minute) and shortest duration (3 to 5 minutes). It should be avoided in patients with burns, muscle crush injuries > 1 to 2 days old, and acute kidney injury because of potential concerns about hyperkalemia (7). Succinylcholine should also be avoided patients with spinal cord injury and certain neuromuscular diseases (eg, multiple sclerosis, muscular dystrophy) because of concerns of iatrogenic hyperkalemia (8). 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).
Pretreatment with atropine to prevent possible bradycardia prior to succinylcholine administration is not recommended (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). These include atracurium, cisatracurium, mivacurium, rocuronium, and vecuronium.
Either succinylcholine or rocuronium (if there are contraindications to succinylcholine) can be used for rapid sequence intubation (1).
Pretreatment with small doses of nondepolarizing NMBAs prior to succinylcholine is suggested to prevent fasciculations and myalgias (13).
Седативні та знеболюючі препарати для індукції інтубації
Medication | Dose (IV) | Considerations |
|---|---|---|
Propofol* | 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) |
Etomidate† | 0.1–0.15 mg/kg over 1 minute (loading dose) | Etomidate does not provide pain relief and may require the use of a short-acting synthetic opioid |
Midazolam‡ | 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 |
Fentanyl§, ¶ | 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) |
Ketamine¶ | 1–2 mg/kg over 1–2 minutes (loading dose) and 0.25–0.5 mg/kg (maintenance dose) | Ketamine a short-acting dissociative sedative; doses should be adjusted when used in combination with other sedatives or in patients with obesity (based on ideal body weight not actual weight) |
* 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 | ||
§ Data from Hikma. Fentanyl citrate injection [package insert]. U.S. Food and Drug Administration website. 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. | ||
Місцева анестезія для інтубації
Intubation of an awake patient requires anesthesia of the nose and pharynx. A commercial aerosol preparation of benzocaine, tetracaine, butyl aminobenzoate (butamben), and benzalkonium is commonly used (14). Alternatively, 4% lidocaine can be nebulized and inhaled via face mask. Caution is needed when benzocaine is used because it can cause methemoglobinemia (15).
Седація та аналгезія після інтубації
Appropriate medications should also be immediately available for post-intubation sedation and analgesia. Combinations of opioids and benzodiazepines (eg, fentanyl and midazolam) can be quickly administered as bolus doses. Continuous infusion of sedatives such as propofol or dexmedetomidine can also be used.
After initial intubation and resuscitation, clinical practice guidelines recommend the use of light sedation (rather than deep sedation) in adult critically ill patients and recommend the use of propofol or dexmedetomidine over benzodiazepines. Benzodiazepines have a higher incidence of delirium (16).
Література
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. 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
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. 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. 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 MR: Prevention of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials. Anesthesiology 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
