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Chapter 12: Pharmacologic Adjuncts to Intubation

Ned F. Nasr; David W. Boldt; Isam F. Nasr

INTRODUCTION

Reserve oral endotracheal intubation without pharmacologic assistance for the unresponsive and apneic patient. Intubate unconscious patients capable of resisting laryngoscopy or those with spontaneous respiratory effort with the assistance of pharmacologic adjuncts. Rapid sequence intubation (Chapter 16) optimizes conditions while minimizing the risk of aspiration. It can be performed with a high rate of success and minimal complications.1 Rapid sequence intubation requires the use of several pharmacologic adjuncts (Tables 12-1, 12-2, and 12-3). This includes a potent anesthetic agent to induce unconsciousness and a neuromuscular blocking agent to produce paralysis.

TABLE 12-1Recommended Anesthetic Doses of Pharmacologic Agents Used for Rapid Sequence Intubation
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TABLE 12-1 Recommended Anesthetic Doses of Pharmacologic Agents Used for Rapid Sequence Intubation
Medication Adult dose (mg/kg) Pediatric dose (mg/kg) Onset (sec) Duration (min)
Dexmedetomidine 0.001 0.0005–0.0010 15–45 12–20
Etomidate 0.2–0.3 0.2–0.3 15–45 3–12
Fentanyl 0.005–0.015 0.005–0.015 15–45 30–60
Ketamine 1–2 1–3 45–60 10–20
Methohexital 1–3 1–2 < 30 5–10
Midazolam 0.2–0.4 0.5–1.0 30–90 10–30
Propofol 1.5–2.5 2.5–3.5 15–45 5–10
Thiopental 2–5 2–6 < 30 5–10
TABLE 12-2Recommended NMB Agents for Intubation and Rapid Sequence Intubation
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TABLE 12-2 Recommended NMB Agents for Intubation and Rapid Sequence Intubation
Medication Histamine release Active metabolites Adult dose (mg/kg) Pediatric dose (mg/kg) Time to maximum onset (min) Duration (min) Infusion (mcg/kg-min) Elimination Action
Atracurium Yes No 0.5 0.5 3 20–35 5–20

Hoffman,

5–10% renal

 Intermediate
Pancuronium No Yes 0.05–0.1 0.07–0.10 2–3 40–100 0.8–1.7

40–70% renal

15% hepatic

 Long
Rocuronium No No 0.6 1.0 4–6 15–85 8–12

33% renal

< 75% hepatic

 Intermediate
Rocuronium for RSI No No 0.9–1.2 1.0–1.2 1.0–1.5 30–110 N/A

33% renal

< 75% hepatic

 Intermediate
Succinylcholine No No 0.6–1.0 1–2 1 2–3 N/A Plasma cholinesterase Short
Succinylcholine for RSI No No 1.5 2 1 3–5 N/A Plasma cholinesterase Short
Vecuronium No Yes 0.1 0.05–0.10 3 30–40 0.8–1.7

10–50% renal

35–50% hepatic

 Intermediate
Vecuronium for RSI No Yes 0.3–0.5 0.3–0.5 1 45–60 N/A

10–50% renal

35–50% hepatic

 Intermediate

N/A, not applicable; RSI, rapid sequence intubation.

TABLE 12-3Drug Interactions of NMB Agents
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TABLE 12-3 Drug Interactions of NMB Agents

Causes NMB prolongation

Aminoglycosides

Beta-blockers

Calcium channel blockers

Clindamycin

Corticosteroids

Cyclosporine

Enflurane

Furosemide

Halothane

Isoflurane

Lithium

Local anesthetics

Magnesium

Methylxanthines

Methoxyflurane

Nitrous oxide

Potassium

Procainamide

Quinidine

Tetracycline

Vancomycin

Causes NMB resistance

Caffeine

Calcium

Carbamazepine

Phenytoin

Ranitidine

Theophylline

INDUCTION AGENTS

The ideal induction agent has an extremely rapid onset of action, produces predictable deep anesthesia, has a short duration of action, and has no adverse effects.2 Such an agent does not yet exist. There are at least six drugs that can safely be used for induction of anesthesia and intubation (e.g., etomidate, fentanyl, ketamine, methohexital, midazolam, propofol, and thiopental). ...

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