Rapid Sequence Induction and Intubation
Induction agents Muscle relaxants Post - intubation sedation Anaesthetic and sedative medication may be administered only by medical practitioners trained and experienced in their use. Sound theoretical and practical training followed by supervised experience in the administration of anaesthetic and sedative medication is essential. Even within the recommended dosage range, anaesthetic agents can
Anaesthetic and sedative medication may be administered only by medical practitioners trained and experienced in their use. Sound theoretical and practical training followed by supervised experience in the administration of anaesthetic and sedative medication is essential. Even within the recommended dosage range, anaesthetic agents can cause death when inappropriately used.
Medicines and equipment for resuscitation should be functional and immediately available whenever general anaesthesia, regional anaesthesia, or sedation is administered.
The doses of the medicines given are those recommended for healthy adults. Patients who are acutely or chronically sick, and/or elderly, may require substantial reductions in the doses given otherwise life-threatening adverse effects may ensue.
Patients at risk of aspiration require a rapid sequence intubation. An IV induction agent is given through an IV line with fast running fluids, immediately followed by a rapidly acting muscle relaxant. The rapid onset of action enables the time to intubation to be short enough to avoid mask ventilation, as this can result in gastric insufflation and aspiration of gastric contents.
INDUCTION AGENTS
ICD-10 code: Z99.1
Respiratory depression occurs following induction of anaesthesia and ventilation should be supported as required. Administer at appropriate doses, after consideration of patient factors and contraindications:
- Propofol is the most widely used IV induction agent but can produce hypotension.
- Etomidate or ketamine is preferred in haemodynamically unstable patients.
- Propofol, IV, 1.5–2.5 mg/kg.
- Etomidate, IV, 0.3 mg/kg (0.2–0.6 mg/kg)
- Ketamine, IV, 1–2 mg/kg.
MUSCLE RELAXANTS
ICD-10 code: Z99.1
- Suxamethonium, 1–1.5 mg/kg, IV. (See section 12.3.1: Depolarising muscle relaxants).
- Preferred agent as, in the event of a failed intubation, it wears off quickly enabling spontaneous respiration to resume.
- Contraindications to suxamethonium
- Congenital and acquired medical conditions associated with severe, potentially lethal suxamethonium-induced hyperkalaemia.
- Malignant hyperthermia.
If suxamethonium is contra-indicated, consider:
- Rocuronium, 0.9 mg/kg, IV.
- Duration +/- 60 minutes.
Prolonged effect can be problematic in the event of a difficult or failed intubation and if the procedure is short.
POST-INTUBATION SEDATION
ICD-10 code: Z99.1
Sedation requirements fluctuate rapidly and warrant regular review. Individualised sedation objectives should be clearly defined, and level of sedation regularly recorded. Sedation protocols that recognise the need for dose minimisation, weaning, and sedation interruptions probably improve outcomes.
Adequate pain control is often more efficacious than sedatives for reducing agitation. The doses listed apply to ventilated patients in whom short term respiratory depression is not a concern.
Sedation
Short term sedation (less than 24 hours)
- Midazolam, IV infusion, 0.05–0.2 mg/kg/hour.
OR
- Propofol, IV infusion, 0.5 mg/kg/hour.
Note:
Propofol has cardiovascular effects; benzodiazepines are preferred.
Longer term sedation (expected 72 hours or more)
- Midazolam, IV, 0.2 mg/kg/hour.
OR
- Lorazepam, IV, 0.1 mg/kg/hour.
Note:
Lorazepam (0.1 mg/kg/hour) is as effective (and as easy to wean) as midazolam 0.2 mg/kg/hour) but is more difficult to titrate. Due to high fat solubility, midazolam also becomes ‘long acting’ after infusions of more than 24 hours.
Supplemental analgesia:
ADD an analgesic to any of the above regimens:
- Morphine, IV infusion, 0.1–0.2 mg/kg/hour.
OR
- Fentanyl, IV infusion, 1 mcg/kg/hour (also becomes long acting after prolonged infusion due to fat solubility).
OR
- Ketamine, IV infusion, 0.5–1 mg/kg/hour.
Note:
If haemodynamically unstable, use adjunctive ketamine for analgosedation.
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Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level, 2020-4_Version 1_June 2024
Chapter 20: Emergencies and Injuries