critical care medicine
Drugs to Aid Intubation
Pretreatment before intubation
Pretreatment typically includes 100% oxygen Lidocaineand/orfentanyl Sometimesatropine, a neuromuscular blocker, or both If time permits, patients should be placed on 100% oxygen for 3 to 5 minutes; this measure may maintain satisfactory oxygenation in previously healthy patients for up to 8 minutes. Noninvasive ventilation (NIV) or high-flow nasal cannula (HFNC) can be used to aid preoxygenation ( General references ). Even in apneic patients, such preoxygenation has been shown to improve arterial oxygen saturation and prolong the period of safe apneic time ( Laryngoscopy can stimulate coughing and causes a sympathetic-mediated pressor response with an increase in heart rate, blood pressure, and possibly intracranial pressure. When time permits, some practitioners givelidocaine1.5 mg/kg IV 1 to 2 minutes before sedation and paralysis to decrease coughing and possibly to decrease the sympathetic-mediated pressor response, although the evidence is mixed.Fentanyl(eg, 3 to 5 mcg/kg IV), also given 1 to 2 minutes prior to intubation, may also blunt the increase sympathetic-mediated pressor response. Children and adolescents often have a vagal response (marked bradycardia) in response to intubation and are givenatropine0.02 mg/kg IV (minimum: 0.1 mg in infants, 0.5 mg in children and adolescents) at the same time. Some physicians include a small dose of a neuromuscular blocker, such asvecuronium0.01 mg/kg IV, in patients>4 years to prevent muscle fasciculations caused by full doses ofsuccinylcholine. Fasciculations may result in muscle pain on awakening and cause transient hyperkalemia; however, the actual benefit of such pretreatment is unclear. 