RSI medication preferences

[The kitchen sink]

For those of us intubating ICU patients on the reg, what are your prefered RSI meds?

I’m talking about your COVID pts satting in the 60s, septic shock with BPs in the 60s etc

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[jdh71]

As long as the head isn’t sick I use ketamine and usually sux as long as the kidneys are fine. I like to give some versed prior. You don’t often have to slam in meds. You can give some push doses of phenylephrine or epinephrine to make sure blood pressure stays reasonable during.

 

[Radetzky]

Propofol

 

[CCM-MD]

Etomidate and roc.

Substitute etomidate for ketamine if very hypotensive.

 

[Katheudontas parateroumen]

Coming from anesthesia/cc background. These patients are generally not going to remember anything significant given their shock state, hypoxia, acidosis, brain trauma, or whatever bad reason they need a crashing intubation. So hypnotic choice isn’t so important in my opinion. Give less, you could always give more. They’d rather be alive than dead.
Versed 2-4 mg followed by roc is my general go to. Propofol if I have it 30mg with NE bolus. Etomidate about 6-10mg, maybe my least favorite but it’s readily available since it’s not narcotic. Ketamine for asthma/copd is nice. Rocuronium is my go to paralytic, gives about an hour of paralysis to get lines in easy, check vent pressures, etc. I’d consider sux for super obese pts where dosing is more reliable based on body weight but I’m sure pounding 200mg roc would put anyone down too. In any case, I always try to have some upper push dose sticks (NE, epi, phenyl, etc) and some downer (esmolol) with me along with the RSI meds.

 

[Nephro critical care]

It seems to me that I get a better view of cords with succinycholine. Roc gives you an hour of paralysis so the pt dosent start bucking the vent soon and its ideal to throw in lines etc. But seems easier to tube with sux.
I use sux if available and pt not hyperkalemic.

 

[grt398]

As a fellow, preferences seem to depend on whether my attending is PCCM vs anesthesia vs EM vs neurocrit background. It's actually been useful to see the variety and I'm sure depends on their training background, but preferences seem to be:

PCCM - etomidate/roc
Anesthesia - prop/(roc or succ) with neo bolus up front/possibly 10 mcg epi bolus and the neo/baby epi stick always available for additional pushes PRN.
EM - prefers roc for paralytic, but otherwise lots of variation in etomidate/prop/versed/ketamine
NCC - etomidate/succ has been most common for some reason but I've done <10 intubations in the neuroICU so that's probably not a fair sample

 

[chessknt]

Coming from anesthesia/cc background. These patients are generally not going to remember anything significant given their shock state, hypoxia, acidosis, brain trauma, or whatever bad reason they need a crashing intubation. So hypnotic choice isn’t so important in my opinion. Give less, you could always give more. They’d rather be alive than dead.
Versed 2-4 mg followed by roc is my general go to. Propofol if I have it 30mg with NE bolus. Etomidate about 6-10mg, maybe my least favorite but it’s readily available since it’s not narcotic. Ketamine for asthma/copd is nice. Rocuronium is my go to paralytic, gives about an hour of paralysis to get lines in easy, check vent pressures, etc. I’d consider sux for super obese pts where dosing is more reliable based on body weight but I’m sure pounding 200mg roc would put anyone down too. In any case, I always try to have some upper push dose sticks (NE, epi, phenyl, etc) and some downer (esmolol) with me along with the RSI meds.

Super true especially the first part. Icu course is so long any psychological trauma of a light intubation will be overwritten by the horrors of being critically I’ll, proned, rectal tube etc etc. I always shoot lighter that the crazy doses I read about (eg 0.3 mg/kg etomidate, 2 mg/kg protocol etc). I do switch up my amnestic agent to try to stay versatile with dousing but I usually use roc to help with lines and initial vent management.

 

[The kitchen sink]

Sometimes i’ll push versed/fentanyl and peak at the cords, if its open I place the tube. Am I too barbaric for this? A propfol gtt will be hanging immediately ready to go, as well as levophed gtt.

If not sedated enough, add some propofol +/- roc. If hypotensive, etomidate + roc.

Not much experience with ketamine for intubating, I’m assuming folks will push some versed followed by ketamine ? Please do share.

 

[jdh71]

Sometimes i’ll push versed/fentanyl and peak at the cords, if its open I place the tube. Am I too barbaric for this? A propfol gtt will be hanging immediately ready to go, as well as levophed gtt.

If not sedated enough, add some propofol +/- roc. If hypotensive, etomidate + roc.

Not much experience with ketamine for intubating, I’m assuming folks will push some versed followed by ketamine ? Please do share.

I don’t believe that etomidate “doesn’t effect BP” which doesn’t mean it’s a bad or wrong drug to use. Ketamine seems to effect BP less as long as it’s not slammed in. If it’s not slammed in patients will also continue to spontaneously breath nicely and you can usually keep on any PAP until your paralytic kicks in.

I don’t know that you are barbaric. I think there are many ways to skin this cat. And we all have to do what seems the most reasonable and we are comfortable with based on experience. I personally don’t like “peeky peeks” personally seen too much gagging and gastric contents into the airway than I ever want to again. I a big believer that while paralytics do take you into “no man’s land” they drastically improve first pass success and I don’t look until I’m ready to place a tube these days with a paralytic active. I have partners that (almost) never paralyze. You can find strong opinions either way.

I like a bit of versed often before to calm any anxiety and stop the memory formations.

 

[The kitchen sink]

I don’t believe that etomidate “doesn’t effect BP” which doesn’t mean it’s a bad or wrong drug to use. Ketamine seems to effect BP less as long as it’s not slammed in. If it’s not slammed in patients will also continue to spontaneously breath nicely and you can usually keep on any PAP until your paralytic kicks in.

I don’t know that you are barbaric. I think there are many ways to skin this cat. And we all have to do what seems the most reasonable and we are comfortable with based on experience. I personally don’t like “peeky peeks” personally seen too much gagging and gastric contents into the airway than I ever want to again. I a big believer that while paralytics do take you into “no man’s land” they drastically improve first pass success and I don’t look until I’m ready to place a tube these days with a paralytic active. I have partners that (almost) never paralyze. You can find strong opinions either way.

I like a bit of versed often before to calm any anxiety and stop the memory formations.

True.

Do you use roc or sux ?

 

[jdh71]

True.

Do you use roc or sux ?

Usually sux as long as that choice wouldn’t be great.

 

[The kitchen sink]

Usually sux as long as that choice wouldn’t be great.

What do you mean wouldn’t be great?

 

[jdh71]

What do you mean wouldn’t be great?

A patient with high K or myasthenia for instance.

 

[Radetzky]

A patient with high K or myasthenia for instance.

Myasthenia is not a contraindication to sux, you just need a good dose to be effective

 

[jdh71]

Myasthenia is not a contraindication to sux, you just need a good dose to be effective

I didn’t say it was contraindicated.

 

[The kitchen sink]

Myasthenia is not a contraindication to sux, you just need a good dose to be effective

Rhabdo or seizures would prob be a contraindication

 

[Nephro critical care]

Multiple studies have consistently shown succinylcholine to be superior to rocuronium. I don’t understand why some pulm/cc physicians are so afraid of sux and even paralytics in general.

 

[Radetzky]

Rhabdo or seizures would prob be a contraindication

I wouldn’t call seizures a contraindication, in fact prefer it because I want to see if they’re still seizing or not after they’ve been intubated (minimal access to continuous eeg)

 

[Radetzky]

Multiple studies have consistently shown succinylcholine to be superior to rocuronium. I don’t understand why some pulm/cc physicians are so afraid of sux and even paralytics in general.

Which are these studies that show sux superiority?

 

[Nephro critical care]

Rocuronium versus succinylcholine for rapid sequence induction intubation - PubMed

Succinylcholine created superior intubation conditions to rocuronium when comparing excellent intubation conditions. Using the less stringent outcome, clinically acceptable intubation conditions, the two agents were not statistically different. Intubation conditions were not statistically...

pubmed.ncbi.nlm.nih.gov

Effect of Rocuronium vs Succinylcholine on Successful Out-of-Hospital Rapid Sequence Intubation

This noninferiority trial compares the effect of rocuronium vs succinylcholine on first-attempt tracheal intubation success rate in out-of-hospital emergency situations among patients undergoing rapid sequence intubation.

jamanetwork.com

 

[The kitchen sink]

Multiple studies have consistently shown succinylcholine to be superior to rocuronium. I don’t understand why some pulm/cc physicians are so afraid of sux and even paralytics in general.

I’m just use to using roc from my training. I want to be more comfortable using sux though

 

[Radetzky]

Rocuronium versus succinylcholine for rapid sequence induction intubation - PubMed

Succinylcholine created superior intubation conditions to rocuronium when comparing excellent intubation conditions. Using the less stringent outcome, clinically acceptable intubation conditions, the two agents were not statistically different. Intubation conditions were not statistically...

pubmed.ncbi.nlm.nih.gov

Effect of Rocuronium vs Succinylcholine on Successful Out-of-Hospital Rapid Sequence Intubation

This noninferiority trial compares the effect of rocuronium vs succinylcholine on first-attempt tracheal intubation success rate in out-of-hospital emergency situations among patients undergoing rapid sequence intubation.

jamanetwork.com

The first study shows no difference when you take high dose roc into account.

As for the 2nd, I’m not going to take much conclusions from a study where the first pass success rate is 3/4.

Don’t get me wrong I too prefer sux but don’t think the literature is that convincing and people who fear the higher anaphylaxis rate of sux are perfectly justified too

 

[Siggy]

Multiple studies have consistently shown succinylcholine to be superior to rocuronium. I don’t understand why some pulm/cc physicians are so afraid of sux and even paralytics in general.

I won't say I'm afraid... I'm just comfortable not paralyzing patients. If I gotta, I gotta, but given most of my tubes are elderly patients who are already fairly encephalopathic +/- dementia, a little sedation generally goes a long way.

I generally moved more towards roc over succs. I don't really have a good reason why outside of concern for hyperK when labs aren't easily known (i.e. coordinating a rapid response with RSI on the floor). There's evidence of equivalence, (Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial - PubMed) and even the Cochrane review stated no difference if done with propofol. I imagine one of the issues is that while succs gives a clear indication of it's onset, rocc takes about a minute to take effect with no clear evidence of total paralysis (along the same lines of relaxing trismus), so I imagine most people aren't actually waiting long enough for it to take effect.

 

[coffeebythelake]

It seems to me that I get a better view of cords with succinycholine.

I think that means you should wait an extra 10 or 15 seconds after you give the high dose roc

 

[coffeebythelake]

Rocuronium versus succinylcholine for rapid sequence induction intubation - PubMed

Succinylcholine created superior intubation conditions to rocuronium when comparing excellent intubation conditions. Using the less stringent outcome, clinically acceptable intubation conditions, the two agents were not statistically different. Intubation conditions were not statistically...

pubmed.ncbi.nlm.nih.gov

Effect of Rocuronium vs Succinylcholine on Successful Out-of-Hospital Rapid Sequence Intubation

This noninferiority trial compares the effect of rocuronium vs succinylcholine on first-attempt tracheal intubation success rate in out-of-hospital emergency situations among patients undergoing rapid sequence intubation.

jamanetwork.com

You get the same intubation conditions (aka degree of muscle relaxation) by waiting a few more seconds after giving high dose roc. It also gives you more prolonged apnea time before desaturation. And you don't have to worry about thr nasty side effects and contraindications that exist with suxx. I almost exclusively use high dose roc for RSI

 

[turkeyjerky]

I would think that you guys would be more worried about an exaggerated hyperkalemic response to sux in these type of patients, as they've been immobile and at risk for critical illness neuropathy and myopathy. It's always been in the back of my mind to use roc if I ever get called to the ICU for an intubation.

 

[eefen]

As above almost always use high-dose roc and actually will usually watch a clock in the room with the rest of the team and count off at least 45 seconds before taking a look. And then you have time to optimize vent, check mechanics, get procedures done, etc. Obviously get sedation started right away - your induction agent will wear off before the roc does.

For a sedative, I'll usually use ketamine or etomidate depending on the situation, usually with a little versed.

If hemodynamics unstable, obviously fix that first if you can but will often dose-reduce induction agent a bit.

Have to be a little careful with ketamine - I like it, but have seen hypotension in super sick patients. It actually can function as a negative inotrope but usually that is negated by endogenous catecholamine release. If the patient is end-of-the-line critically ill, though, and catecholamine depleted, you can be in for a rough time. That last bit is true for any sedative agent, but somtimes I think people are a little too reliant on ketamine usual hemodynamic effects and are caught off guard when it doesn't play out that way. I've been there, at least. Always be prepared with some easily accessible pressor.

 

[The kitchen sink]

You get the same intubation conditions (aka degree of muscle relaxation) by waiting a few more seconds after giving high dose roc. It also gives you more prolonged apnea time before desaturation. And you don't have to worry about thr nasty side effects and contraindications that exist with suxx. I almost exclusively use high dose roc for RSI

Exactly

 

[tartesos]

Multiple studies have consistently shown succinylcholine to be superior to rocuronium. I don’t understand why some pulm/cc physicians are so afraid of sux and even paralytics in general.

I use them both. But I don’t always paralyze, about 80% of the time. I get a lot of hypercapnics, and Neuro pats that don’t need much.

 

[lunaire]

I don't think there's any significant difference between the drug choices, when used properly.

I generally use midazolam 2-4mg for amnesia, plus/minus propofol for hypnotic, then rocuronium 1.2mg/kg.

I always paralize unless there it is an obvious difficult intubation and likely difficult ventilation. Even then, the improved view etc might still nudge me to sux or roc-sugammadex. RE. roc vs sux - they both work the same, sux is dirtier, roc is longer acting, slower onset. When people say sux works better, they are basically saying they lack patience and cant wait a minute for the drug to work.

I also always have a bag of LR and norepi either primed & ready, or actively being mixed in the background.

 

[The kitchen sink]

I don't think there's any significant difference between the drug choices, when used properly.

I generally use midazolam 2-4mg for amnesia, plus/minus propofol for hypnotic, then rocuronium 1.2mg/kg.

I always paralize unless there it is an obvious difficult intubation and likely difficult ventilation. Even then, the improved view etc might still nudge me to sux or roc-sugammadex. RE. roc vs sux - they both work the same, sux is dirtier, roc is longer acting, slower onset. When people say sux works better, they are basically saying they lack patience and cant wait a minute for the drug to work.

I also always have a bag of LR and norepi either primed & ready, or actively being mixed in the background.

This is generally my practice as well

 

[Hamhock]

Let's make this interesting.

Except for the novices and those who are uncomfortable with recovery requiring LMA or a cric, is there any reason to not use 2 per kg roc over any dose of sucks?

HH

 

[Radetzky]

Let's make this interesting.

Except for the novices and those who are uncomfortable with recovery requiring LMA or a cric, is there any reason to not use 2 per kg roc over any dose of sucks?

HH

No

 

[sylvanthus]

Etomidate and succ or rocc depending.

 

[turkeyjerky]

Let's make this interesting.

Except for the novices and those who are uncomfortable with recovery requiring LMA or a cric, is there any reason to not use 2 per kg roc over any dose of sucks?

HH

--If there's a bad outcome, they'll come for you at peer review /s.

I literally can't think of any. Is there any literature on histamine release w/ high dose roc (more of a concern with aminosteroids)? I tried to search a little but I'm not seeing any reports of it. Logistically, it might cause a delay when the nurse has to go back to the pyxis for a third, then fourth, vial.

 

[2010houston]

Do you guys have sugammadex readily available in the unit? It has definitely changed the roc/sux discussion in anesthesia, if you DO get into trouble after paralysis.
Though when you intubate someone, it’s not like returning to spontaneous ventilation is a great choice. There’s a reason you were tubing them in the first place.

 

[lunaire]

Do you guys have sugammadex readily available in the unit? It has definitely changed the roc/sux discussion in anesthesia, if you DO get into trouble after paralysis.
Though when you intubate someone, it’s not like returning to spontaneous ventilation is a great choice. There’s a reason you were tubing them in the first place.

Not readily available, no. I'd need to call anesthesia on call to bring it to bedside. In my practice, I would need to diagnose the patient as high risk cannot intubate/cannot ventilate, and has contraindication for sux.

With that said, I am trained to perform several types of surgical airways... The patient will get a tube in their trachea once I paralize them, one way or another. Your selection of drug should somewhat depend on what option B and C is available to you, based on your skillset and available support.

 

[lunaire]

--If there's a bad outcome, they'll come for you at peer review /s.

I literally can't think of any. Is there any literature on histamine release w/ high dose roc (more of a concern with aminosteroids)? I tried to search a little but I'm not seeing any reports of it. Logistically, it might cause a delay when the nurse has to go back to the pyxis for a third, then fourth, vial.

Histamine release is only associated with the benzylisoquinolinium NMDBs, more specifically atracurium & mivacurium. It's a chemical structure thing. Sux, cisatracurium and the aminosteroids may cause more typical allergic reaction; sux > benzylisos > aminosteroids.

 

[deleted875186]

Anesthesiologist
Typically versed and fentanyl, followed by a large dose of roc 1.2 mg/kg. More commonly, small annestic dose of prop, 30-50 mg, plus or minus a vasopressors, followed by roc. I will also use ketamine occasionally which works excellent, very stable, will typically give 50 mg or less in a very sick patient, ketamine actually works the fastest of any of these hypnotics. If the patient is sick, intubations conditions will typically be ok in 10 seconds or so, but as noted above I will typically wait at least 30 seconds for optimal relaxation with the roc. Helps to use a glide scope, less suspension needed for laryngoscopy. Helps if there is a CVC and the meds are given and flushed, they tend to work very quickly.

 

[lymphocyte]

It really just depends. I've intubated with scopolamine, midaz/fent, lignocaine with head/eye injuries (controversial), ketamine, etc. You need higher-dose roc in shock, closer to 1.6mg/kg (NOT 1.2 mg/kg). I like using sux in status epilepticus to follow motor activity, but appropriate doses of rocuronium outperforms sux in terms of safe apnoea time and has about the same time to muscle relaxation (as posted above).

Our institution does NOT routinely use propofol to intubate sick patients. It can be safe in the right hands, but it often adds an unnecessary haemodynamic variable. We also use ketamine infusions liberally for analgosedation with as few opioids as possible.

If I had to pick one intubation regimen, it would be LOW-dose ketamine 0.5mg-1.0mg/kg and HIGH-dose rocuronium 1.5mg/kg. I round the numbers only because the calculations are faster/easier when **** hits the fan.

We also have Sugammadex on stand by, but if a patient NEEDS a tube they're getting a tube one way or another.

 

[Robotic Wis-Hipple]

Let's make this interesting.

Except for the novices and those who are uncomfortable with recovery requiring LMA or a cric, is there any reason to not use 2 per kg roc over any dose of sucks?

HH

The suga is only tested/dosed for rescue of 1.2mg/kg……😉

But otherwise no.

The best view is your first view. And the best view is a relaxed one.

And as most have said, the sedative/hypnotic isn’t that important in critically I’ll pts, and you don’t need anywhere near the “induction dose”. I put a lot of people to sleep with 60-80mg of prop (cardiac surgical pts) and they aren’t “crashing” or as critically ill as your intubations (typically).

 

[The kitchen sink]

Thanks for all the responses. Very helpful!

 

[Arch Guillotti]

septic shock with BPs in the 60s etc

Propofol

Bad combo.

 

[cchoukal]

Anesthesia Critical Care here... underappreciated is the role of the un-induced intubation. Why is an RSI being chosen?

Severe hypoxemia? Why not maintain spontaneous ventilation on HFNC while you intubate?

Full stomach or propensity to aspirate? Why not maintain consciousness and airway reflexes while intubating?

Perceived difficult mask ventilation? Why mask at all if the patient continues ventilating during intubation?

 

[Siggy]

Anesthesia Critical Care here... underappreciated is the role of the un-induced intubation. Why is an RSI being chosen?

Severe hypoxemia? Why not maintain spontaneous ventilation on HFNC while you intubate?

Full stomach or propensity to aspirate? Why not maintain consciousness and airway reflexes while intubating?

Perceived difficult mask ventilation? Why mask at all if the patient continues ventilating during intubation?

I mentioned that I do most of my tubes with just etomidate in a different thread and people were outright horrified at my malpractice of not paralyzing.

If I’m intubating from a bipap I’ll go straight from bipap to an ETT. The bipap doesn’t come off until relaxed enough to intubate.

 

[SurfingDoctor]

RSI is pretty unheard of in pediatrics. In the PICU, you can usually tell who maybe buying a ETT, so they are usually NPO for quite a period of time anyway.

But somewhat related, as soon as a kid is sedated, I throw in a decompressive NG. That has saved me (and the kids) too many times to count.

 

[Radetzky]

Anesthesia Critical Care here... underappreciated is the role of the un-induced intubation. Why is an RSI being chosen?

Severe hypoxemia? Why not maintain spontaneous ventilation on HFNC while you intubate?

Full stomach or propensity to aspirate? Why not maintain consciousness and airway reflexes while intubating?

Perceived difficult mask ventilation? Why mask at all if the patient continues ventilating during intubation?

Because most people that sick have crappy spont efforts after just the induction agent that are more of a hindrance than a help

Because aspiration is less likely when the pt is paralysed

Because mask ventilation is easiest with the pt paralysed and true difficult mask ventilation with two hands and an OPA is exceedingly rare

 

[cchoukal]

Because most people that sick have crappy spont efforts after just the induction agent that are more of a hindrance than a help

Because aspiration is less likely when the pt is paralysed

Because mask ventilation is easiest with the pt paralysed and true difficult mask ventilation with two hands and an OPA is exceedingly rare

Right, but I'm not talking about inducing without paralysis; I'm talking about not inducing at all. HFNC or bipap, topical, glide.

 

[Robotic Wis-Hipple]

Right, but I'm not talking about inducing without paralysis; I'm talking about not inducing at all. HFNC or bipap, topical, glide.

If the pt is so obtunded, encephalopathic, or they have 1/2 MAC of CO2 I think that’s completely reasonable. Why burn a bridge you don’t have to. In these scenarios their medical/metabolic condition is the anesthetic.

Not completely sure DL-ing a known full stomach critically ill pt ensures no aspiration risk though. If their pharyngeal reflexes all work the blade and manipulation is likely to cause a gag/reflux of stomach contents into the mouth. Sure you can suction and hope glottic reflexes protect the airway but if you’ve got a blade in there, have their epiglottis retracted or obstructed in any way and they take a spontaneous breath that succus is now in their lungs.

And if you think they have a “propensity to aspirate” when awake or at baseline I fail to see how performing an awake DL is less risk than paralyzing them.