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.

Keywords: Critically ill; Endotracheal intubation; Etomidate; Hypotension; Intensive care unit; Ketamine; Ketofol; Propofol; Sedation

Core Tip: Intensive care unit endotracheal intubations are associated with a higher risk of complications such as hypotension, hypoxemia, and cardiac arrest when compared to non-intensive care unit endotracheal intubations. A necessity of endotracheal intubations, sedation, is a modifiable risk factor in the pathway to cardiovascular instability. The goal of this review is to present the pros and cons of each sedative agent used for endotracheal intubation while comparing the outcomes. This will help the reader to make an informed decision when choosing a sedative agent for endotracheal intubation in the intensive care unit.