What are the premedication drugs used in intubation?

October 9, 2025 •

4 min read

According to a 2017 Cochrane review, using premedication drugs for rapid sequence intubation is associated with fewer intubation attempts and adverse events. Understanding what are the premedication drugs used in intubation is critical for effective airway management, mitigating physiological stress, and ensuring patient comfort and safety during the procedure.

Quick Summary

This article examines the various drugs utilized in intubation, detailing the purpose and types of analgesics, sedatives, and neuromuscular blockers involved. It covers drug selection criteria and special considerations for patient safety during the critical process of securing an airway.

Key Points

Analgesics are crucial for blunting the physiological stress response to intubation and providing pain relief. Fentanyl is a common opioid used for this purpose, particularly in patients with intracranial pressure concerns.
Sedative-hypnotics induce unconsciousness to facilitate the procedure safely. Etomidate and ketamine are frequently chosen for their minimal impact on blood pressure, making them suitable for hemodynamically unstable patients.
Neuromuscular blocking agents (paralytics) relax muscles for optimal intubating conditions. Succinylcholine offers a very fast onset but carries risks like hyperkalemia, while rocuronium is a safer, though longer-acting, alternative.
Drug selection is highly dependent on patient-specific factors. The patient's cardiac status, existing injuries (like head trauma), and other medical conditions dictate the best and safest medication choice.
Special populations, such as pediatrics, may require additional adjunctive medications. Atropine, for instance, is often used in infants and young children to prevent intubation-induced bradycardia.
Reversal agents for paralytics are crucial to have on hand. In the case of rocuronium, the availability of sugammadex allows for rapid reversal of neuromuscular blockade if necessary.
Proper post-intubation sedation is vital, especially with long-acting paralytics like rocuronium. Paralysis does not equal sedation, and patients can experience awareness unless appropriately managed.

The Role of Premedication in Intubation

Intubation is the process of inserting a tube into the trachea to maintain an open airway and to mechanically ventilate a patient. This procedure can be stressful and painful, triggering undesirable physiological responses such as hypertension, tachycardia, and a rise in intracranial pressure. Premedication involves administering a cocktail of drugs to reduce these risks and facilitate a smooth and controlled procedure. The specific combination of medications is carefully chosen based on the patient's underlying condition, health status, and the urgency of the intubation.

Core Components of Intubation Medications

The medication regimen for intubation is typically broken down into three phases: premedication, induction, and paralysis. While the term "premedication" can refer to specific agents given before induction, it is often used to describe the entire pharmacological process in a broader sense. In a standard Rapid Sequence Intubation (RSI), induction and paralytic agents are administered almost simultaneously after premedication and pre-oxygenation.

Analgesics: Providing Pain and Stress Relief

Pain and stress are significant components of the intubation process, and opioids are the primary class of drugs used to manage them. These agents bind to opiate receptors, producing analgesia and blunting the sympathetic nervous system's response to the noxious stimulus of laryngoscopy.

Fentanyl: This rapid-acting synthetic opioid is a common choice for premedication. It is highly effective at reducing the hypertensive and tachycardic response to intubation, making it particularly useful for patients with increased intracranial pressure or coronary artery disease. However, caution is required due to the risk of respiratory depression and, at high doses, chest wall rigidity.
Alfentanil and Sufentanil: These are other rapid-onset, short-duration opioids that are alternatives to fentanyl, offering similar effects.

Sedative-Hypnotics: Inducing Unconsciousness

Induction agents are given to induce a rapid state of unconsciousness, ensuring the patient is unaware of the procedure. The choice of agent depends heavily on the patient's hemodynamic status.

Etomidate: Historically a primary induction agent in the emergency department, etomidate provides rapid hypnosis with minimal effects on systemic blood pressure or heart rate, making it an excellent choice for hemodynamically unstable patients. It is also considered cerebropreotective. However, its use is sometimes controversial due to the potential for transient adrenal suppression after a single dose.
Ketamine: A dissociative anesthetic, ketamine has unique properties that can be beneficial in certain situations. It provides sedation, analgesia, and amnesia while preserving respiratory drive and causing bronchodilation, which is helpful for patients with reactive airway disease like asthma. Its sympathomimetic effects also make it suitable for hemodynamically unstable patients, although it can increase secretions and, rarely, cause emergence delirium.
Propofol: This powerful sedative-hypnotic has a rapid onset and short duration. However, its vasodilatory effects can cause significant cardiovascular depression and hypotension, making it a less-favorable option for critically ill or hypotensive patients. It is more commonly used in hemodynamically stable patients or for ongoing sedation post-intubation.
Midazolam: A benzodiazepine, midazolam provides anxiolysis and amnesia. Its slower onset and less predictable effects compared to other induction agents mean it is not a first-line agent for rapid sequence intubation, but can be used as an adjunct or in less urgent settings.

Neuromuscular Blocking Agents (Paralytics): Achieving Muscle Relaxation

Paralytics are used to achieve complete muscle relaxation, especially of the vocal cords and jaw, to facilitate a clear view for intubation and prevent the patient from resisting the breathing tube.

Succinylcholine: A depolarizing neuromuscular blocker, succinylcholine has a very rapid onset (under 60 seconds) and short duration of action (4–6 minutes). It is traditionally the agent of choice for RSI due to its speed. However, it is contraindicated in patients at risk for hyperkalemia (e.g., burn or crush injury) and can trigger malignant hyperthermia in susceptible individuals.
Rocuronium: As a non-depolarizing neuromuscular blocker, rocuronium has a fast onset at higher doses, comparable to succinylcholine, but a much longer duration of action (30–60 minutes). Its primary advantage is a superior safety profile regarding hyperkalemia and malignant hyperthermia. Its longer duration requires ensuring adequate post-intubation sedation. It can be rapidly reversed with the agent sugammadex if needed.

Other Premedications (Adjunctive Agents)

Some additional medications may be used in specific clinical scenarios to further optimize the conditions for intubation.

Atropine: An anticholinergic drug, atropine is sometimes used in pediatric patients to prevent reflex bradycardia induced by laryngoscopy, as infants and young children have a strong vagal response. It can also reduce excessive secretions.
Lidocaine: In patients with suspected traumatic brain injury, intravenous lidocaine can be administered 1–2 minutes before induction to help blunt the rise in intracranial pressure associated with intubation.

Comparison of Common Paralytics


Feature	Succinylcholine	Rocuronium
Class	Depolarizing Neuromuscular Blocker	Non-Depolarizing Neuromuscular Blocker
Mechanism	Competes with and mimics acetylcholine at the neuromuscular junction, causing initial fasciculations followed by paralysis.	Competitively inhibits acetylcholine at the neuromuscular junction without depolarization.
Onset	Very rapid, ~30–60 seconds.	Rapid (when using higher doses, e.g., >1.2 mg/kg), ~60 seconds.
Duration	Short, 4–6 minutes.	Long, ~30–60 minutes.
Key Side Effects	Hyperkalemia, malignant hyperthermia, fasciculations, bradycardia.	Rare anaphylaxis, prolonged paralysis, hepatotoxicity.
Contraindications	Hyperkalemia, major burns or trauma (>5 days old), neuromuscular disease, family history of malignant hyperthermia.	Known hypersensitivity.
Reversal	Wears off quickly, no specific antagonist for rapid reversal is typically needed.	Can be rapidly reversed with sugammadex.

Conclusion

Choosing the appropriate premedication drugs for intubation requires a thorough understanding of their mechanisms, pharmacokinetics, and potential side effects. The ideal combination varies significantly depending on the patient's clinical state, particularly their hemodynamic stability and any specific contraindications. While drugs like etomidate and ketamine are favored for their cardiovascular stability, alternatives like propofol are useful in select cases. The choice between succinylcholine and rocuronium as a paralytic depends on balancing the need for speed against the risk of contraindications and the availability of reversal agents. Ultimately, effective premedication is a cornerstone of safe airway management, demanding a high level of clinical judgment from healthcare providers.

Frequently Asked Questions

The primary purpose is to blunt the adverse physiological responses to intubation, such as increased blood pressure and heart rate, while providing analgesia, sedation, and muscle relaxation to create optimal and safe intubating conditions.

Etomidate is commonly used due to its rapid onset and minimal effect on hemodynamics, meaning it does not typically cause significant changes in blood pressure. This makes it particularly useful for critically ill patients who are hemodynamically unstable.

Ketamine is often preferred in patients who are hemodynamically unstable or have reactive airway disease, such as asthma. Its sympathomimetic and bronchodilatory effects are beneficial in these scenarios.

Major risks include the potential to trigger malignant hyperthermia in susceptible individuals and an increase in serum potassium, which can be dangerous for patients with conditions like crush injuries or certain neuromuscular diseases.

Atropine, an anticholinergic, is used to prevent vagally-mediated bradycardia that can occur during intubation, especially in pediatric patients. It can also help reduce secretions to improve airway visualization.

Post-intubation sedation is critical to ensure the patient remains comfortable and unaware, especially when long-acting paralytics like rocuronium have been used. Awareness while paralyzed is a significant risk that can cause extreme distress.

No, lidocaine is not always necessary. It is primarily considered for patients with a suspected traumatic brain injury to help mitigate the rise in intracranial pressure associated with the intubation process.