Pulmonary Disorders I
Occurs before an induction agent or NMBA is administered
hypertension, tachycardia, potentially increased ICP in patients with impaired cerebral autoregulation)
to laryngoscopy. However, because of low quality of evidence and lack of demonstration of benefit to the
patient, this step is more commonly omitted.
Fentanyl or lidocaine can be used as a pretreatment medication (Table 7).
Atropine and defasciculating doses of nondepolarizing NMBAs are not recommended for routine use in
RSI for adult patients.
More contemporarily, this step may be called βpreintubation optimization,β which involves stabilization
Health Syst Pharm. 2023;80(4):182-195).
Agent
Dose
Onset
Duration
Advantages
Disadvantages
Fentanyl
IV: 1β3
mcg/kg
< 30 s
0.5β1 hr
| β’ | Blunts hypertensive response |
|---|
from intubation
| β’ | Recommended over other |
|---|
opioids because of its rapid
onset and short duration of
action
| β’ | Chest wall rigidity |
|---|
(doses > 100 mcg/kg)
| β’ | Hypotension, |
|---|
bradycardia, and
respiratory depression
Agent
Dose
Onset
Duration
Advantages
Disadvantages
Lidocaine
IV: 1.5
mg/kg
45β90 s
10β20 min
| β’ | May prevent increase in ICP |
|---|
through blunting of cough
reflex
| β’ | May reduce bronchospasm in |
|---|
patients with reactive airway
disease
| β’ | Contraindicated in |
|---|
patients with an amide
anesthetic allergy,
bradycardia, or severe
heart block
ICP = intracranial pressure; IV = intravenous(ly).
Given as rapid intravenous push immediately before the paralyzing agent to help achieve optimal
conditions for intubation
Agents used for induction during RSI include barbiturates, benzodiazepines (midazolam), etomidate,
ketamine, and propofol (Table 8).
Barbiturates
Thiopental is no longer available in the United States.
Methohexital is rarely used because of its adverse effect profile, including respiratory depression,
hypotension, and histamine release.
Etomidate
A nonbarbiturate, imidazole derivative with a rapid onset of action and a very short elimination
half-life
Enhances the effects of Ξ³-aminobutyric acid, thereby blocking neuroexcitation and inducing
unconsciousness (does not provide analgesia)
Transiently inhibits the conversion of cholesterol to cortisol by inhibiting 11Γ-hydroxylase, leading
to transient adrenal suppression