Study objective: To compare thiopental, fentanyl, and midazolam for rapid-sequence induction and intubation (RSI).
Methods: Eighty-six patients undergoing RSI in the emergency department were randomly assigned in a double-blind fashion to receive either thiopental (5 mg/kg), fentanyl (5 microg/kg), or midazolam (.1 mg/kg) before paralysis was induced. Outcome measures were mortality, speed and ease of intubation, and hemodynamics.
Results: Of the patients who received thiopental, 93% were intubated within 2 minutes of paralysis (P=.037), but systolic blood pressure fell an average of 38 mm Hg in this group (P=.045). The midazolam group had a greater number of delayed intubations (31%) and an average heart rate increase of 17 beats/minute (P=.008). Mortality (24% inhospital) was unaffected by drug assignment. In all three groups, patients with pulmonary edema had the greatest decrease in blood pressure during RSI, and patients exposed to multiple attempts at intubation manifested pronounced hypertension.
Conclusion: Fentanyl provided the most neutral hemodynamic profile during RSI, although factors other than choice of sedative can play a more significant role in determining hemodynamic response. Depth of sedation may influence the speed of RSI.