In this episode, I’ll discuss what happens if you add fentanyl to ketamine+rocuronium for rapid sequence intubation?
Rapid sequence intubation includes providing sedation, analgesia, and paralysis to achieve adequate intubating conditions and to ensure the patient tolerates the procedure.
When ketamine is used for rapid sequence intubation, some clinicians rely on ketamine’s inherent analgesic properties and use it only with rocuronium while others add fentanyl for additional analgesia.
One of the primary concerns when performing rapid sequence intubation is the patient’s ability to maintain a normal blood pressure in spite of the procedure and medications used. Ketamine is generally expected to have a neutral to slightly positive effect on blood pressure while fentanyl is expected to have a neutral to slightly negative effect.
Therefore a group of researchers studied the effects of adding fentanyl to ketamine+rocuronium vs using ketamine and rocuronium without fentanyl for RSI in emergency department patients. This study was published recently in Academic Emergency Medicine.
290 patients in 5 different emergency departments were randomized to receive either fentanyl or placebo in combination with ketamine and rocuronium for RSI. The amount of fentanyl given was always matched to the amount of ketamine given at a ratio of 1 mcg fentanyl for every 1 mg of ketamine. This ratio was arbitrarily chosen based on the expert opinion of the investigators.
The order of administration was fentanyl/placebo first, then ketamine, then rocuronium, followed by a 60 second pause before intubation was attempted.
After a 10 minute interval passed, continuous sedation was provided with fentanyl and propofol.
The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the pre-specified range of 100-150mmHg. An adjustment to this range was made if the patient had a baseline abnormal systolic blood pressure.
While there was no difference in the primary outcome of systolic blood pressure outside of the 100-150 range, there were differences between groups on each side of this range.
Systolic BP below 100 mmHg was significantly more common in the fentanyl group at 29% vs 16% for an absolute difference of 13% and a 95% confidence interval of 3-23%.
Systolic BP above 150 mmHg was significantly more common in the placebo group at 69% vs 55% for an absolute difference of 14% and a 95% confidence interval of 3-24%.
There were no differences in safety outcomes such as first-pass intubation success, 30-day mortality, or ventilator-free days.
The authors concluded that since lower blood pressure was more common with fentanyl, baseline hemodynamics and post-intubation blood pressure targets should be considered before adding fentanyl to ketamine+rocuronium for RSI.
Members of my Hospital Pharmacy Academy have access to practical training on airway pharmacology and the use of ketamine in critical care from a pharmacist’s point of view, along with many other resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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