Endotracheal intubation sedation in the intensive care unit

Abstract

Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.

Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study

“…Clinical and experimental studies examining the pharmacological effects of etomidate remain controversial. Besides suppression of adrenal production of cortisol for 24–72 h, 11 , 18 – 20 depression of sympathetic tone, 21 and myocardial depression, 22 a single-bolus etomidate injection has been associated with a postintubation increase in arterial compliance and decrease in arterial elastance. 23 , 24 These effects may be also responsible for the hemodynamic impairment and excess mortality in the ET group.…”

Telemedicine Protocols for the Management of Patients with Acute Spontaneous Intracerebral Hemorrhage in Rural and Medically Underserved Areas in Gangwon State : Recommendations for Doctors with Less Expertise at Local Emergency Rooms

“…Endotracheal intubation should be performed by an experienced doctor skillfully and quickly. The procedure sometimes requires rapid sequence intubation (RSI) with appropriate sedation and neuromuscular blockade [ 9 , 37 , 48 , 50 , 53 ]. If possible, an ultra-short-acting opioid such as fentanyl, alfentanil, or sufentanil, is considered to blunt the sudden ICP rise by adverse responses during RSI.…”

L’intubation chez l’adulte à l’urgence : une séquence à respecter (partie 1)

“…Les médicaments habituellement administrés lors de cette phase sont le Fentanyl, la Kétamine, le Midazolam, le Propofol ou l'Étomidate (23,31,32). Chacun de ces médicaments présente à la fois un effet thérapeutique et des effets secondaires à considérer en fonction de la condition de la personne traitée (voir Tableau 3) (33,34).…”