2025 Southeastern Residency Conference

Title: Time to Sedation Initiation after Rapid Sequence Intubation in Various Hospital Settings 


Authors: Danielle Wilson, Christen Freeman, Megan Heath


Background: Rapid sequence intubation (RSI) is a procedure for emergency airway management. Proper administration of induction and paralytic agents leads to quicker airway control and increases the rate of first pass success with an endotracheal tube. An induction agent, such as etomidate, propofol, or ketamine, is used to sedate the patient prior to paralysis and the RSI procedure itself. Rocuronium and succinylcholine are both paralytic agents, however rocuronium has a much longer duration of action and almost always outlasts the induction agent. There should be an urgency to start adequate sedation as soon as possible following intubation to minimize wakefulness with paralysis. The purpose of this study is to assess the time to sedation initiation (in minutes) following the administration of induction and paralytic agents for RSI in different areas of the hospital at DCH Regional Medical Center, including the emergency department (ED), medical-surgical units, and intensive care units (ICUs).


Methods: Patients were screened for inclusion from August 1, 2023 to July 31, 2024. Eligible participants included those ≥ 19 years of age who underwent RSI in the ED, a medical-surgical unit, or an ICU. Retrospective chart reviews were completed for the 150 patients that were included.


Results: The median time to sedation initiation after RSI was 16.5, 58, and 23minutes in the ED, medical-surgical units, and ICUs, respectively. Etomidate was the induction agent used most commonly (91.3%), and rocuronium was the paralytic agent used most commonly (87.3%). Induction agents were dosed appropriately about 80% of the time, however paralytic agents were only dosed appropriately about 30% of the time. Appropriate post-RSI sedation was initiated 72% of the time with continuous fentanyl and propofol infusions used together most often.


Conclusion: Overall, there is a gap between RSI agent administration and post-intubation sedation in each of the hospital settings evaluated. This gap is greater in the medical-surgical units likely due to the fact that continuous sedation is not available in those areas. With etomidate and rocuronium used most often, the gaps between RSI and post-intubation sedation raise a greater concern for patients having wakefulness with paralysis. While induction agents were often dosed correctly, dosing for paralytic agents appears to be an area for significant improvement. Lastly, the majority of patients were initiated on appropriate post-intubation sedation, however all patients need to receive deep sedation following RSI while the paralytic agent is still in effect.