Ketamine and Roc: The Batman and Robin of RSI
Joshua Fountain, ASN, CFRN, CCRN, TCRN
Like Batman, Ketamine is a kick-ass kind of drug that not only is an upscale, suave, pain management drug by day, but also a swift, bat-like induction agent by night. Ketamine also has a boy wonder paralytic sidekick named Rocuronium. Ketamine and Roc are the dynamic duo of rapid sequence intubation, which is the rapid induction and paralysis of a patient with the intent to perform endotracheal intubation (King, 2016). Rapid sequence intubation is used to perform endotracheal intubation without having to risk inflating the stomach through excessive bagging, which can result in regurgitation and blocking of the airway (King, 2016).
Ketamine is a triple threat agent that has dissociative properties, pain management properties and also acts as an anesthetic agent that allows the patient to remain free from pain and awareness during potentially painful and unpleasant procedures, such as RSI (Merelman, et al., 2019). Ketamine has a mildly positive effect on the sympathetic response, resulting in increased tissue perfusion and cardiac output due to a catecholamine surge (King, 2016). Ketamine has been shown to result in fewer episodes of hypotension during the peri-intubation phase as compared to other induction agents such as propofol, fentanyl, or versed. Peri-intubation hypotension directly correlates with an increased risk of mortality (Merelman, et al. 2019). Ketamine should be the induction drug of choice in unstable sepsis patients and patients with asthma or other reactive airway disease Ketamine also has a longer duration of action than other induction agents, approximately 10-20 minutes (King, 2016), thus allowing for additional time to stabilize the patient before additional sedation is needed. Ketamine should be administered at 1-2mg/kg as an induction agent, or per company protocol (Merelman, et al., 2019).
Rocuronium (roc) is a non-depolarizing paralytic agent that results in relaxation of muscles to assist with RSI (Jain, et al. 2019).. Roc has minimal contraindications, the only one being documented allergy to the drug. This lack of contraindications is a refreshing turn from its widely used counterpart, succinylcholine, that has several contraindications, such as glaucoma, burns, hyperkalemia, renal and liver failure, strokes lasting longer than 72 hours, and history of malignant hyperthermia (Hager & Burns, 2019). Roc is also shown to be cardiovascularly stable and does not result in a decrease in cardiac output or hypotension. Roc has a relatively rapid onset (1-2 minutes) and a moderate duration of action (20-30 minutes). Dosing is typically 1mg/kg when used for RSI, or per company protocol (Jain, et al., 2019).
Ketamine and Roc are the perfect combination of drugs for RSI as they both have little to no contraindications for use. They also provide cardiovascular stability and prevent hypotension during the peri-intubation phase. Preventing hypotension during the peri-intubation phase is paramount in increasing the survival rate of the procedure (Merelman, et al., 2019) The best part is that dose calculation for these drugs is easy as they both can be given at 1mg/kg, which can be easily calculated during a potentially stressful situation.
- Hager, H., Burns, B., (2019). Succinylcholine chloride. StatPearls. retrieved from https://www.ncbi.nlm.nih.gov/b…
- Jain, et al. (2019). Rocuronium. StatPearls. retrieved from https://www.ncbi.nlm.nih.gov/b…
- King, A., (2016). Rapid sequence intubation: Basics for medical students. EM Resident. Retrieved from https://www.emra.org/emresiden…
- Merelman, et al., (2019). Alternatives to rapid sequence intubation: Contemporary airway management with ketamine. West Journal of Emergency Medicine. 20(3). 466-471. Retrieved from https://www.ncbi.nlm.nih.gov/p…
Big thank you to Jay’s Brick Blog for the photo!