Drug choice during intubation

Verbatim · Nov 21, 2011

So I have witnessed quite a few intubations during my brief experience so far working in ICU, and the drugs I am requested to push are always different. Almost always we will give Fentanyl in some combination with either etomidate, succinylcholine, vecuronium or rocuronium.
Just wondering if anyone can give me any relevant differences between the various paralytics and why a doc would want one over another besides strictly preference? I ask because the last person we intubated the MD wanted roc- but for some reason we are not able to override the pyxis to get roc out immediately- only vecuronium. When offered vec, the MD said no and decided on etomidate instead.
Someone enlighten me please :)
I certainly can't enlighten you on the matter. However, I'll share some of my experience.
Succs, although short acting, has a lot of untoward side effects. If your patient needs to be intubated, he already has problems. No need for more. Roc. does not cause the untoward problems that Succs can. I'm certain that Roc. can be used w/ people liver disease. Point is, the intubator is looking at a bigger picture than the patient simply needs an airway. I hope that I did not minimize the importance of an airway.
In my unit, they perform Rapid Sequence Intubations quite often. This involves sedating and using a rapid acting NMBA and immediately inserting the ett. This is some times performed using fluoroscopy. So, I'm more familiar with giving Etomidate or Versed and some Roc.

meandragonbrett · Nov 26, 2011

Provider preferences. Patient's hemodynamic status or anticipated hemodynamic issues....ie. are they a severe aortic stenosis that propofol will cause issues?

Etomidate has been shown to cause adrenal suppression and that's certainly what is not needed for most ICU patients.

Succs vs. rocuronium vs. vecuronium......... Succs is shorter acting..is a depolarizing NMB. causes the patient to fasiculate. Can have post-use myalgias, can cause issues with hyperkalemia....especially in burn patients/bed ridden patients/etc. Vec vs Rocc.....>Vec is a little more predictable on timing when compared to rocuronium. With Roc you just never know what you're going to get sometimes depending on manufacturer.

After the airway is secured.....ask your provider what their decision path was for choosing their drugs for intubation. Most should be happy to share with you.

CraigB-RN, MSN, RN · Nov 27, 2011

There are a couple of factors that play into it. One is when your in an ICU who is doing the intubation. If your program has a CC fellowship then you might have anesthesia doing the intubation or a surgeon or a pulmonologist, all have a different approach.

In induction there are a couple of steps that are the same.

The first is an induction agent. This is what puts the patient out. It can be an opiate, a benzo, or Etomidate, or even a medication like Ketamine. each has it's own pro's and Con's and as such shuold be choosen based on the patients condition, need for intubation AND the skill level of the provider. If you use a med that you can't reverse or has a long half life, and then can't get the patient intubated, your in trouble.

The paralytic choice follow the same pathway. If you're not an every day intubator, you might want to choose a shorter activing paralytic like Succs. It does have it's problems, If your patient is a hyperkalemic pt, from either trauma/burn or other reason, you have to be carefull not to make it worse. Succs can also cause malignant hyperthermia. Never actually seen it, but it can. The othere paralytics have different times of onset and length of use. Succs also won't stop your patient from seizing, only stop the muscle activity.

Now that the studies are showing that there MAY be a problem iwth etomidate in septic patients, we're begining to get to the stage were we've gone from the same thing cor everyone, to a more focused approach.

getoverit, BSN, RN, EMT-P · Nov 29, 2011

My personal experience: I usually use etomidate on a medical intubation (copd exacerbation, resp failure, CVA etc). I haven't seen etomidate work well on a trauma patient, esp a closed head injury. A caveat is that it can cause adrenal suppression.

Anectine (or sux) is a great agent and I've used it on the majority of RSIs. I have used it on a child who had a hx of malignant hyperthermia (long story and I wish we had that information prior to administering the medication). He did just fine and had no untoward effects from it. Of course it goes along with a sedative and an analgesic (usually versed and fenanyl or mso4 based on their BP).

I would never give a full loading dose of a non-depolarizing agent (vec/roc/pav, etc) without the airway secured. meandragonbrett gives some good advice, once the ETI is done ask the MD or CRNA why they chose the medication.

Also I give 1mg/kg of lidocaine to blunt increased ICP in a known head injury. and premedicate peds with atropine to avoid bradycardia when passing the tube and stimulating the larynx.

CRNA1982 · Nov 30, 2011

My personal experience: I usually use etomidate on a medical intubation (copd exacerbation, resp failure, CVA etc). I haven't seen etomidate work well on a trauma patient, esp a closed head injury. A caveat is that it can cause adrenal suppression.
Anectine (or sux) is a great agent and I've used it on the majority of RSIs. I have used it on a child who had a hx of malignant hyperthermia (long story and I wish we had that information prior to administering the medication). He did just fine and had no untoward effects from it. Of course it goes along with a sedative and an analgesic (usually versed and fenanyl or mso4 based on their BP).
I would never give a full loading dose of a non-depolarizing agent (vec/roc/pav, etc) without the airway secured. meandragonbrett gives some good advice, once the ETI is done ask the MD or CRNA why they chose the medication.
Also I give 1mg/kg of lidocaine to blunt increased ICP in a known head injury. and premedicate peds with atropine to avoid bradycardia when passing the tube and stimulating the larynx.

Nothing wrong with what you said about giving a non-depolarizer without airway secured; you can never be too safe. Therefore, you can never go wrong with Succs (As long as it is not contraindicated). As far as Lido, I always give 100 mg to any pt. prior to induction; with any drug.

As far as Etomidate causing adrenocortical suppression, I would take that with a grain of salt. I use the drug regularly and have never had any issues.....Of course, there have been case reports of this. When dealing with a sick pt. with no blood pressure or an EF

CraigB-RN, MSN, RN · Nov 30, 2011

Listened to a podcast yesterday between an ED physician and an Intensivist.

ED Doc pro paralytic, ICU Doc pro sedation, no paralytic. Now obviously different pt population.

I've done more "awake" intubations here recently. The DKA pt with reps rate of 56, the Upper GI bleed with BP 74 systolic. A 400+lb with no neck. All pt's with serious complications and poss neg reactions to things going bad. Used some sedation, some neb lidocaine, and a good glidescope to make sure I had good visualization. Kind of like the old nasal intubations but with visualization. If I can't bag them when they are awake, I'm prob not going to be able to bag them paralyzed. But it is interesting to have pt looking at you while your intubating them. Actually had a Pt Nod their head and give me a thumbs up after an intubation. But then again this pt had been tubed many times. Took him to CT with him bagging himself.

I like the concept of planning the care of the patient, based on that patients needs. I tend to use more opiates in trauma patients. Remember propofol and Amidate have no analgesic properties, planning for the patients needs after the intubation. I also keep some neo available for that transient drop in BP, But try to avoid that drop if I can help it.

If your looking for need information, check out the EMCRIT podcast, by Scott Weingart, MD. You'll have to search but he's got a couple of podcast on the topic, with some pretty good reasoning and evidence to support it.

IheartICUnursing · Dec 1, 2011

Thank you all for your great responses! I will definitely be asking after intubations about why the particular drugs were chosen!

fiveofpeep · Dec 4, 2011

My personal experience: I usually use etomidate on a medical intubation (copd exacerbation, resp failure, CVA etc). I haven't seen etomidate work well on a trauma patient, esp a closed head injury. A caveat is that it can cause adrenal suppression.
Anectine (or sux) is a great agent and I've used it on the majority of RSIs. I have used it on a child who had a hx of malignant hyperthermia (long story and I wish we had that information prior to administering the medication). He did just fine and had no untoward effects from it. Of course it goes along with a sedative and an analgesic (usually versed and fenanyl or mso4 based on their BP).
I would never give a full loading dose of a non-depolarizing agent (vec/roc/pav, etc) without the airway secured. meandragonbrett gives some good advice, once the ETI is done ask the MD or CRNA why they chose the medication.
Also I give 1mg/kg of lidocaine to blunt increased ICP in a known head injury. and premedicate peds with atropine to avoid bradycardia when passing the tube and stimulating the larynx.

Thank you for sharing! Very informative :)

BelgianRN · Jan 1, 2012

The adrenal suppresion by etomidate is seen more frequently when administered as a continuous sedative. That's why it's contra-indicated as a long term sedative. Adrenal suppresion from one or occasional administration of etomidate is much rarer.