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Ramsey JT, Pache KM, Sayre MR, Maynard C, Johnson NJ, Counts CR. Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting. PREHOSP EMERG CARE 2023; 28:537-544. [PMID: 38019685 DOI: 10.1080/10903127.2023.2285399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades. METHODS We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events. RESULTS Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64-1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20-36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases. CONCLUSIONS Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.
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Affiliation(s)
- J T Ramsey
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Killian M Pache
- Department of Emergency Medicine, University of Washington, Seattle, Washington USA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, Washington USA
- Seattle Fire Department, Seattle, Washington, USA
| | - Charles Maynard
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington USA
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, Washington USA
- Seattle Fire Department, Seattle, Washington, USA
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2
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Fuller BM, Driver BE, Roberts MB, Schorr CA, Thompson K, Faine B, Yeary J, Mohr NM, Pappal RD, Stephens RJ, Yan Y, Johnson NJ, Roberts BW. Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial. Trials 2023; 24:753. [PMID: 38001507 PMCID: PMC10675941 DOI: 10.1186/s13063-023-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP. METHODS This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat. DISCUSSION The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Michael B Roberts
- Department of Institutional Research, Department of Psychology, Philadelphia College of Osteopathic Medicine, Rowland Hall, 514B, 4190 City Avenue, Philadelphia, PA, 19131, USA
| | - Christa A Schorr
- Cooper Research Institute, Cooper University Health Care, One Cooper Plaza, Dorrance, Camden, NJ, 08103, USA
| | - Kathryn Thompson
- Department of Emergency Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Ryan D Pappal
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care Medicine, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, 418E, 2Nd Floor, 600 South Taylor Ave., St. Louis, MO, 63110, USA
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, NJ, 08103, USA
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3
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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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Ender V, Leisten D, Zheng H, Dunn M, Frakes M, Cohen JE, Wilcox SR. Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization. Air Med J 2022; 41:287-291. [PMID: 35595336 DOI: 10.1016/j.amj.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. METHODS Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. RESULTS We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P < .001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. CONCLUSIONS Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.
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Affiliation(s)
- Vahé Ender
- Boston MedFlight, Bedford, Massachusetts
| | | | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Jason E Cohen
- Boston MedFlight, Bedford, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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5
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Bhoi S, Jishnu M, Sahu A, Suresh S, Aggarwal P. Airway management practices among emergency physicians: An observational study. Turk J Emerg Med 2022; 22:186-191. [DOI: 10.4103/2452-2473.357351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/24/2022] [Accepted: 05/28/2022] [Indexed: 11/04/2022] Open
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Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022; 26:108-113. [PMID: 35110853 PMCID: PMC8783236 DOI: 10.5005/jp-journals-10071-24086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS AND OBJECTIVES The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. MATERIALS AND METHODS For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and ClinicalTrials.gov between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. RESULTS Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31-0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95-1.36; I 2 = 16%). CONCLUSION The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. HOW TO CITE THIS ARTICLE Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108-113.
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Affiliation(s)
- Saurabh C Sharda
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandip S Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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7
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Li G, Cheng L, Wang J. Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China. Med Sci Monit 2021; 27:e928462. [PMID: 33441534 PMCID: PMC7814511 DOI: 10.12659/msm.928462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This retrospective study was conducted at a single center in China and aimed to compare rocuronium with succinylcholine for rapid sequence induction intubation in the Emergency Department of a hospital. MATERIAL AND METHODS An orotracheal intubation procedure was performed in a total of 267 patients by direct laryngoscopy using an intravenous bolus injection of 1 mg/kg of succinylcholine (n=141; SY group) or 1.2 mg/kg of rocuronium (n=126; RM group) for a rapid sequence induction in the emergency department. The success of orotracheal intubation was evaluated by a capnography curve. The modified Cormack-Lehane score was used to grade the direct laryngoscopy. RESULTS There was no statistically significant difference in numbers of patients with successful first-attempt orotracheal intubation between the groups (112 vs. 87, P=0.067). Fewer intubation failures under direct laryngoscopy were reported in the SY group than in the RM group (23 [16%] vs. 34 [27%], P=0.037). The number of intubation attempts was higher in the RM group than in the SY group (1.52±0.87 per patient vs. 1.27±0.60 per patient, P=0.032). CONCLUSIONS The findings from this study support results from previous studies, showing that even in the Emergency Department setting, rocuronium was equivalent to succinylcholine in achieving rapid sequence induction intubation, when the dose was appropriate. However, as current clinical guidelines highlight, succinylcholine has more contraindications and adverse effects, including hyperkalemia, which should be monitored, and rocuronium has a longer duration of action.
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Affiliation(s)
- Gui Li
- Department of Anesthesiology, Dangyang People's Hospital, Dangyang, Hubei, China (mainland)
| | - Lin Cheng
- Department of Anesthesiology, Yichang Central People's Hospital and The First College of Clinical Medical Science, China Three Gorges University, Yichang, Hubei, China (mainland)
| | - Jianke Wang
- Department of Anesthesiology, Dangyang People's Hospital, Dangyang, Hubei, China (mainland)
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Kurnutala LN, Rugnath N. Pseudocholinesterase Deficiency - Is Succinylcholine Still Needed to Facilitate Endotracheal Intubation? Cureus 2020; 12:e10721. [PMID: 33150117 PMCID: PMC7603876 DOI: 10.7759/cureus.10721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pseudocholinesterase (butyrylcholinesterase) deficiency is an inherited or acquired condition in which the serum pseudocholinesterase levels are absent or lower than normal. The enzyme is produced by the liver; decreased levels of the enzyme in an individual cause increased sensitivity to anesthetic agents, like succinylcholine and mivacurium. Pseudocholinesterase deficiency is caused by butyrylcholinesterase (BCHE) gene mutation, a gene that provides instructions for making the pseudocholinesterase enzyme. Succinylcholine is a depolarizing muscle relaxant that provides a quicker onset and a brief duration of muscle relaxation during general anesthesia. In this article, we would like to discuss a case report of prolonged intubation and ventilation in a patient with pseudocholinesterase deficiency and the necessity of succinylcholine during intubation in comparison to possible alternatives (rocuronium).
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Affiliation(s)
- Lakshmi N Kurnutala
- Anesthesiology and Perioperative Medicine, University of Mississippi Medical Center, Jackson, USA
| | - Nickhil Rugnath
- Anesthesiology, University of Mississippi Medical Center, Jackson, USA
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9
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Abstract
The high-risk airway is a common presentation and a frequent cause of anxiety for emergency physicians. Preparation and planning are essential to ensure that these challenging situations are managed successfully. Difficult airways typically present as either physiologic or anatomic, each type requiring a specialized approach. Primary physiologic considerations are oxygenation, hemodynamics, and acid-base, whereas anatomic difficulty is overcome using proper positioning and skilled laryngoscopy to ensure success. It is essential to be comfortable performing alternative techniques to address varying presentations. Ultimately, competence in airway management hinges on consistent training, deliberate practice, and a dedication to excellence.
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Affiliation(s)
- Jorge L Cabrera
- University of Miami Miller School of Medicine, 1600 NW 10th Ave, Miami, FL 33136, USA.
| | - Jonathan S Auerbach
- University of Miami Miller School of Medicine, 1600 NW 10th Ave, Miami, FL 33136, USA
| | - Andrew H Merelman
- Rocky Vista University College of Osteopathic Medicine, 8401 S. Chambers Rd, Parker, CO 80134, USA. https://twitter.com/amerelman
| | - Richard M Levitan
- Department of Medicine, Dartmouth Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, 853 Rt 25a, Orford, NH 03777, USA. https://twitter.com/airwaycam
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10
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Zhang Y, Guo X, Tan G, Zhao M, Huang Y, Chen W, Shi X, Pei L, Xing B. Neuromuscular Blockade Correlates with Hormones and Body Composition in Acromegaly. Int J Endocrinol 2020; 2020:2912839. [PMID: 33414825 PMCID: PMC7752264 DOI: 10.1155/2020/2912839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/17/2020] [Accepted: 10/25/2020] [Indexed: 12/17/2022] Open
Abstract
Tumor resection is the first-line therapy for acromegaly patients. In some cases, unsatisfactory intraoperative neuromuscular blockades (NMBs) lead to failed operations. The purpose of this study was to investigate and quantify the NMB status of acromegaly patients and explore the relationship between NMB status and hormone levels and body composition. Twenty patients with untreated acromegaly and seventeen patients with nonfunctioning pituitary adenomas as controls were enrolled in this study. NMB was assessed using the train-of-four (TOF) technique with TOF-Watch® SX. The onset time of NMB, deep neuromuscular blockade duration (DNMBD), and clinical neuromuscular blockade duration (CNMBD) were monitored. We found a significantly longer onset time (110.25 ± 54.90 vs. 75.00 ± 27.56, s, p=0.017), shorter DNMBD (21.99 ± 5.67 vs. 34.96 ± 11.04, min, p < 0.001), and shorter CNMBD (33.26 ± 8.09 vs. 46.21 ± 10.89, min, p < 0.001) in acromegaly patients compared with the controls. DNMBD and CNMBD decreased in patients with decreasing body fat percentage and increasing growth hormone (GH) level, insulin-like growth factor 1 (IGF-1) level, and GH and IGF-1 burden. The onset time increased with increasing IGF-1 level and GH and IGF-1 burden. Taken together, a unique NMB status was identified in acromegaly patients with the following characteristics: prolonged onset time and shortened DNMBD and CNMBD. Changes in the levels and burdens of GH and IGF-1 and body composition were linearly correlated with intraoperative NMB in acromegaly patients.
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Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
- China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Mengyun Zhao
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Wei Chen
- Department of Parenteral & Enteral Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Xiaodong Shi
- Department of Parenteral & Enteral Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
- Outcomes Research Consortium, 9500 Euclid Ave, Cleveland 44195, Ohio, USA
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
- China Pituitary Disease Registry Center, China Pituitary Adenoma Specialist Council, No. 1 Shuaifuyuan, Dongcheng, Beijing 100730, China
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11
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Guihard B, Chollet-Xémard C, Lakhnati P, Vivien B, Broche C, Savary D, Ricard-Hibon A, Marianne dit Cassou PJ, Adnet F, Wiel E, Deutsch J, Tissier C, Loeb T, Bounes V, Rousseau E, Jabre P, Huiart L, Ferdynus C, Combes X. Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. JAMA 2019; 322:2303-2312. [PMID: 31846014 PMCID: PMC6990819 DOI: 10.1001/jama.2019.18254] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium. OBJECTIVE To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations. DESIGN, SETTING AND PARTICIPANTS Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016. INTERVENTIONS Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624). MAIN OUTCOMES AND MEASURES The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis. RESULTS Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group. CONCLUSIONS AND RELEVANCE Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02000674.
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Affiliation(s)
- Bertrand Guihard
- Department of Emergency, CHU de la Réunion, Allée des Topazes, Saint Denis, Réunion, France
| | - Charlotte Chollet-Xémard
- Groupe Hospitalo-Universitaire Henri Mondor, SAMU 94, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | | | - Benoit Vivien
- Department of Anesthesia & Critical Care - SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Claire Broche
- Département d'Anesthésie-Réanimation-SMUR, Hôpital Universitaire Lariboisière, AP-HP, Paris, France
| | - Dominique Savary
- Emergency Department, General Hospital of Annecy, Annecy, France
| | | | | | - Frédéric Adnet
- AP-HP, Urgences-SAMU 93, Unité Recherche-Enseignement-Qualité, Hôpital Avicenne, Bobigny, France
| | - Eric Wiel
- Univ Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
- French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
- Emergency Medicine Department and SAMU 59, Lille University Hospital, Lille, France
| | - Juliette Deutsch
- Department of Emergency Medicine, Groupe Hospitalier Broca Cochin Hôtel-Dieu, Paris, France
| | - Cindy Tissier
- Department of Emergency Medicine, University Hospital Dijon, Dijon, France
| | - Thomas Loeb
- Raymond Poincaré Hospital (APHP), SAMU 92, Paris, France
| | - Vincent Bounes
- Pôle Médecine d'Urgence, Hôpital Universitaire de Purpan, Toulouse, France
- INSERM UMR 1027, Université Paul Sabatier, Toulouse, France
| | - Emmanuel Rousseau
- Services de Médecine d’Urgence et de Réanimation, Pôle Urgence Réanimation, SAMU 77, Melun, France
| | - Patricia Jabre
- AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
| | - Laetitia Huiart
- INSERM CIC 1410 Clinical and Epidemiology/ CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
- Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Cyril Ferdynus
- Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Xavier Combes
- Department of Emergency, CHU de la Réunion, Université de la Réunion, Réunion, France
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Sakles JC, Augustinovich CC, Patanwala AE, Pacheco GS, Mosier JM. Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program. West J Emerg Med 2019; 20:610-618. [PMID: 31316700 PMCID: PMC6625676 DOI: 10.5811/westjem.2019.4.42343] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/06/2019] [Accepted: 04/20/2019] [Indexed: 01/06/2023] Open
Abstract
Introduction Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period. Methods An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means. Results EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = −7.9%, 95% CI −13.4% to −2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%). Conclusion The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events.
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Affiliation(s)
- John C Sakles
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
| | | | - Asad E Patanwala
- University of Sydney, Faculty of Medicine and Health, Sydney, Australia
| | - Garrett S Pacheco
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
| | - Jarrod M Mosier
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona.,University of Arizona College of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Tucson, Arizona
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13
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Kilber E, Jarrell DH, Sakles JC, Edwards CJ, Patanwala AE. Analgosedative interventions after rapid sequence intubation with rocuronium in the emergency department. Am J Emerg Med 2018; 36:1129-1133. [DOI: 10.1016/j.ajem.2017.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 12/20/2022] Open
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Groth CM, Acquisto NM, Khadem T. Current practices and safety of medication use during rapid sequence intubation. J Crit Care 2018; 45:65-70. [DOI: 10.1016/j.jcrc.2018.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 10/17/2022]
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Abstract
Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.
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Affiliation(s)
- Nicholas Kramer
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Lebowitz
- Office of Faculty and Academic Affairs, University of Central Florida College of Medicine, Orlando, USA
| | - Michael Walsh
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Latha Ganti
- Clinical Sciences, University of Central Florida College of Medicine, Orlando, USA
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Shoenberger JM, Mallon WK. Rocuronium Versus Succinylcholine Revisited: Succinylcholine Remains the Best Choice. Ann Emerg Med 2018; 71:398-399. [DOI: 10.1016/j.annemergmed.2017.07.478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Indexed: 02/08/2023]
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Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2017; 120:323-352. [PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021] [Citation(s) in RCA: 437] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
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Affiliation(s)
- A Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8).
| | - B A McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9)
| | - C Goddard
- Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8)
| | - J Rangasami
- Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8)
| | - G Suntharalingam
- Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10)
| | - R Gale
- Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11)
| | - T M Cook
- Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12)
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West JR, Lott C, Donner L, Kanter M, Caputo ND. Peri-intubation factors affecting emergency physician choice of paralytic agent for rapid sequence intubation of trauma patients. Am J Emerg Med 2017; 36:1151-1154. [PMID: 29162438 DOI: 10.1016/j.ajem.2017.11.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION No study has assessed predictors of physician choice between the succinylcholine (Succ) and rocuronium (Roc) for rapid sequence intubation (RSI) during the initial resuscitation of trauma patients in the emergency department (ED). METHODS We retrospectively evaluated of the use of Succ and Roc for adult trauma patients undergoing RSI at a Level 1 trauma center. The primary outcome was to identify factors affecting physician choice of paralytic agent for RSI analyzed by cluster analysis using pre-intubation vital signs and early mortality. The secondary outcome was to identify factors influencing physician choice of paralytic agent using a logistic regression model reported as adjusted odds ratios (aOR). RESULTS The analysis included 215 patients, including 148 receiving Succ and 67 receiving Roc. The two groups were similar in regard to age, provider level of training, mean GCS (10 vs. 10) and median ISS (27 vs. 27). Cluster analysis using peri-intubation patient vital signs and early mortality indicates that patients with predominantly abnormal vital signs and early mortality were more likely to receive Roc (74%) than those without abnormal vital signs prior to intubation or early mortality (24%). Hypoxemia prior to RSI (aOR 12.3 [2.5-60.9]) and the use of video laryngoscopy (VL) (aOR 5.5 [1.2-24.6]) were associated with the choice to use Roc. CONCLUSIONS Roc was more frequently chosen for paralysis in the patient cluster with predominantly abnormal peri-intubation vital signs and higher rate of early ED mortality. The use of Roc was associated with hypoxemia prior to RSI and VL.
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Affiliation(s)
- Jason R West
- Lincoln Medical and Mental Health Center, Department of Emergency Medicine, Weill Cornell Medicine of Cornell University, Bronx, NY, United States.
| | - Catherine Lott
- Lincoln Medical and Mental Health Center, Department of Emergency Medicine, Weill Cornell Medicine of Cornell University, Bronx, NY, United States
| | - Lee Donner
- Lincoln Medical and Mental Health Center, Department of Emergency Medicine, Weill Cornell Medicine of Cornell University, Bronx, NY, United States
| | - Marc Kanter
- Lincoln Medical and Mental Health Center, Department of Emergency Medicine, Weill Cornell Medicine of Cornell University, Bronx, NY, United States
| | - Nicholas D Caputo
- Lincoln Medical and Mental Health Center, Department of Emergency Medicine, Weill Cornell Medicine of Cornell University, Bronx, NY, United States
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Patanwala AE, Sakles JC. Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department. Emerg Med J 2017; 34:739-743. [DOI: 10.1136/emermed-2017-206762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/05/2017] [Accepted: 07/21/2017] [Indexed: 11/03/2022]
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20
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Tran DTT, Newton EK, Mount VAH, Lee JS, Mansour C, Wells GA, Perry JJ. Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia 2017; 72:765-777. [DOI: 10.1111/anae.13903] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 12/16/2022]
Affiliation(s)
- D. T. T. Tran
- Division of Cardiac Anesthesiology; Department of Anesthesiology and Pain Medicine; School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
- School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - E. K. Newton
- Division of Cardiac Anesthesiology; Department of Anesthesiology and Pain Medicine; School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - V. A. H. Mount
- Department of Family Medicine; Queen's University; Kingston
| | - J. S. Lee
- Emergency Department; Sunnybrook and Women's College Health Sciences Centre; Toronto
| | - C. Mansour
- Division of Cardiac Anesthesiology; Department of Anesthesiology and Pain Medicine; School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - G. A. Wells
- School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - J. J. Perry
- School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
- Clinical Epidemiology Programme; Department of Emergency Medicine; The Ottawa Hospital; Ottawa Canada
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Welch JL, Seupaul RA. Update: Does Rocuronium Create Better Intubating Conditions Than Succinylcholine for Rapid Sequence Intubation? Ann Emerg Med 2017; 69:e55-e56. [DOI: 10.1016/j.annemergmed.2016.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Indexed: 12/17/2022]
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Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med 2016; 34:1705-6. [PMID: 27241569 DOI: 10.1016/j.ajem.2016.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 04/26/2016] [Accepted: 05/18/2016] [Indexed: 12/17/2022] Open
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NYU School of Medicine, New York, NY 10003.
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Patanwala AE, Erstad BL, Roe DJ, Sakles JC. Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy 2016; 36:57-63. [DOI: 10.1002/phar.1683] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Asad E. Patanwala
- Department of Pharmacy Practice & Science; College of Pharmacy; The University of Arizona; Tucson Arizona
| | - Brian L. Erstad
- Department of Pharmacy Practice & Science; College of Pharmacy; The University of Arizona; Tucson Arizona
| | - Denise J. Roe
- Department of Epidemiology and Biostatistics; Mel and Enid Zuckerman College of Public Health; The University of Arizona; Tucson Arizona
| | - John C. Sakles
- Department of Emergency Medicine; College of Medicine; The University of Arizona; Tucson Arizona
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Tran DTT, Newton EK, Mount VAH, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015; 2015:CD002788. [PMID: 26512948 PMCID: PMC7104695 DOI: 10.1002/14651858.cd002788.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015. OBJECTIVES To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation. SEARCH METHODS In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations. SELECTION CRITERIA We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg. DATA COLLECTION AND ANALYSIS Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model. MAIN RESULTS The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action. AUTHORS' CONCLUSIONS Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.
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Affiliation(s)
- Diem TT Tran
- The University of Ottawa Heart InstituteDivision of Cardiac Anesthesiology, Department of Anesthesia40 Ruskin StOttawaONCanadaK1Y 4W7
| | - Ethan K Newton
- The University of Ottawa Heart InstituteDivision of Cardiac Anesthesiology, Department of Anesthesia40 Ruskin StOttawaONCanadaK1Y 4W7
| | | | - Jacques S Lee
- Sunnybrook and Women's College Health Sciences CentreEmergency DepartmentTorontoONCanada
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
| | - Jeffrey J Perry
- The Ottawa HospitalClinical Epidemiology Programme1053 Carling AvenueF6 Clinical Epidemiology ProgrammeOttawaONCanadaK1Y 4E9
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Shaw I, Trueger NS, Pirotte MJ. What Is the Time to Muscle Relaxation After Intramuscular Administration of Neuromuscular Blockers? Ann Emerg Med 2015; 66:390-3. [DOI: 10.1016/j.annemergmed.2015.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Indexed: 10/23/2022]
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Johnson EG, Meier A, Shirakbari A, Weant K, Baker Justice S. Impact of Rocuronium and Succinylcholine on Sedation Initiation After Rapid Sequence Intubation. J Emerg Med 2015; 49:43-9. [PMID: 25797938 DOI: 10.1016/j.jemermed.2014.12.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 12/03/2014] [Accepted: 12/21/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rapid sequence intubation (RSI) involves a rapidly acting sedative plus a neuromuscular blocking agent (NMBA) to facilitate endotracheal intubation. Rocuronium and succinylcholine are NMBAs commonly used in RSI with drastically different durations of action. OBJECTIVES Evaluate whether patients receiving RSI with a longer-acting NMBA had a greater delay in sedation or analgesia than patients that received a short-acting NMBA. METHODS This was a retrospective review of patients presenting to the emergency department requiring endotracheal intubation. Exclusions included age < 18 years, pregnancy, prior intubation, and contraindication to sedation and analgesia. Primary endpoint was time to continuous sedation or analgesia after RSI in patients receiving rocuronium or succinylcholine. Secondary endpoints included hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), and impact of an emergency medicine pharmacist (EPh). RESULTS A total 106 patients met inclusion criteria, 76 patients receiving rocuronium and 30 receiving succinylcholine. Mean time to sedation or analgesia was longer in the rocuronium group when compared to the succinylcholine group at 34 ± 36 min vs. 16 ± 21 min (p = 0.002). In the presence of an EPh, the mean time to sedation or analgesia was 20 ± 21 min, vs. 49 ± 45 min (p < 0.001). Time spent on ventilator, HLOS, and ICU LOS were not significantly different between groups. CONCLUSIONS Patients receiving rocuronium in RSI had a significantly longer time to sedation or analgesia when compared to patients receiving succinylcholine. The presence of an EPh significantly decreased the time to administration of sedation or analgesia after RSI.
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Affiliation(s)
- Eric G Johnson
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Alex Meier
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Alicia Shirakbari
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Kyle Weant
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
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Rocuronium Versus Suxamethonium: A Survey of First-line Muscle Relaxant Use in UK Prehospital Rapid Sequence Induction. Prehosp Disaster Med 2015; 30:184-6. [PMID: 25627032 DOI: 10.1017/s1049023x15000047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Prehospital anaesthesia in the United Kingdom (UK) is provided by Helicopter Emergency Medical Service (HEMS) and British Association for Immediate Care (BASICS), a road-based service. Muscle relaxation in rapid sequence induction (RSI) has been traditionally undertaken with the use of suxamethonium; however, rocuronium at higher doses has comparable intubating conditions with fewer side effects. HYPOTHESIS/PROBLEM The aim of this survey was to establish how many prehospital services in the UK are now using rocuronium as first line in RSI. METHODS An online survey was constructed identifying choice of first-line muscle relaxant for RSI and emailed to lead clinicians for BASICS and HEMS services across the UK. If rocuronium was used, further questions regarding optimal dose, sugammadex, contraindications, and difference in intubating conditions were asked. RESULTS A total of 29 full responses (93.5%) were obtained from 31 services contacted. Suxamethonium was used first line by 17 prehospital services (58.6%) and rocuronium by 12 (41.4%). In 11 services (91.7%), a dose of 1 mg/kg of rocuronium was used, and in one service, 1.2 mg/kg (8.3%) was used. No services using rocuronium carried sugammadex. In five services, slower relaxation time was found using rocuronium (41.7%), and in seven services, no difference in intubation conditions were noted (58.3%). Contraindications to rocuronium use included high probability of difficult airway and anaphylaxis. CONCLUSION Use of rocuronium as first-line muscle relaxant in prehospital RSI is increasing. Continued auditing of practice will ascertain which services have adopted change and identify if complications of failed intubation increase as a result.
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Yan F, Chen G, Yang L, He R, Gu L, Wang F. A reduction technique of arthroplasty without subtrochanteric femoral shortening osteotomy for the treatment of developmental high dislocation of hip: a case series of 28 hips. J Arthroplasty 2014; 29:2289-93. [PMID: 24412147 DOI: 10.1016/j.arth.2013.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 09/24/2013] [Accepted: 11/23/2013] [Indexed: 02/01/2023] Open
Abstract
In total hip arthroplasty for the treatment of developmental dysplasia of the hip (DDH) with high hip dislocation, it can be technically challenging to locate the true acetabulum and restore limb length without subtrochantric femoral shortening osteotomy. We explored and described total hip arthroplasty without subtrochanteric femoral shortening osteotomy in 28 hips with Crowe type III and IV dislocation by intravenous injection of rocuronium at 0.9mg/kg 1minute before reduction and hip reduction combined with continuous strong traction of the affected limb with patients in a position with hip and knee flexion. All patients did not show dislocation, prosthesis loosening, and other severe complications. It is thus a safe and feasible reduction technique for arthroplasty of Crowe type III or IV dislocation of DDH.
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Affiliation(s)
- Fei Yan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Guangxing Chen
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Liu Yang
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Rui He
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Lingchuan Gu
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Fuyong Wang
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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Varndell W, Elliott D, Fry M. Emergency nurses practices in assessing and administering continuous intravenous sedation for critically ill adult patients: a retrospective record review'. Int Emerg Nurs 2014; 23:81-8. [PMID: 25449551 DOI: 10.1016/j.ienj.2014.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/16/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
Abstract
AIM To generate an initial profile of emergency nurses' practices in and factors influencing the assessment and administration of continuous intravenous sedation and analgesia for critically ill mechanically ventilated adult patients. BACKGROUND Emergency nurses are relied upon to assess and manage critically ill patients, some of whom require continuous intravenous sedation. Balancing sedation is a highly complex activity. There is however little evidence relating to how emergency nurses manage continuous intravenous analgesia and sedation for the critically ill intubated patients. DESIGN Descriptive study. METHOD A 12-month retrospective medical record review was undertaken from January to December 2009 of patients (>16 years) administered continuous intravenous sedation in ED. RESULTS Fifty-five patients received ongoing intravenous sedation within the ED during a median length of stay of 3.4 h. Assessment of patient depth/quality of sedation and pain-relief varied and were rarely documented. Adverse events were documented, majority (16%) drug administration related. Thematic analysis identified three themes: 'Maintaining sedation', 'Directionless-directions', and 'Navigating the balance'. CONCLUSION Emergency nurses provide continuity of patient care and optimisation of analgesia and sedation for critically ill sedated patients. The safety and effectiveness of continuous intravenous sedation for the critically ill adult patient in ED are dependent on the expertise and decision-making abilities of the nurse.
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Affiliation(s)
- Wayne Varndell
- Prince of Wales Hospital Emergency Department, Faculty of Health, University of Technology, Sydney, Australia.
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology, Sydney, Australia
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Shashank DS, Singh NR, Singh LK. Effects of pretreatment with different neuromuscular blocking agents on facilitation of intubation with rocuronium: A prospective randomized comparative study. Indian J Anaesth 2014; 58:303-8. [PMID: 25024474 PMCID: PMC4090997 DOI: 10.4103/0019-5049.135043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS Priming principle refers to administration of a small dose of non-depolarising blocker, which when followed by a large intubating dose produces a relatively rapid and profound blockade to ensure suitable conditions for endotracheal intubation. We aimed to compare the effects of rocuronium, vecuronium, and atracurium as "pretreatment" drugs on intubating conditions with rocuronium facilitated endotracheal intubation. METHODS This double-blinded, randomised controlled prospective study was carried out at a tertiary health care hospital on patients undergoing surgical procedures under general anaesthesia. They were randomly allocated into three groups (n = 35) by computer generated randomisation chart to receive either rocuronium (0.06 mg/kg body weight) (Group A); vecuronium (0.01 mg/kg body weight) (Group B) or, atracurium (0.05 mg/kg body weight) (Group C), followed by intubating dose (0.6 mg/kg body weight) of rocuronium. The haemodynamic parameters and intubating conditions were studied and statistically analysed by ANOVA test and Student's t-test as applicable using statistical package for the social sciences 16.0 for windows (SPSS Inc., Chicago, IL, USA). RESULTS Excellent intubating conditions were noted in maximum number of patients in Group C (97.41%). No significant differences were observed in the systolic blood pressure in all the three groups at all-time intervals. The mean arterial pressure rose significantly from baseline value to maximum, at '0' min in all the groups; however, no significant difference was observed amongst the groups (P > 0.05). CONCLUSION Pretreatment with rocuronium bromide can facilitate endotracheal intubation in 60 s irrespective of non-depolarising muscle relaxants used for priming; however, it cannot attenuate haemodynamic changes associated with laryngoscopy and intubation.
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Affiliation(s)
- DS Shashank
- Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - N Ratan Singh
- Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - L Kameshwar Singh
- Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
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Amini A, Faucett EA, Watt JM, Amini R, Sakles JC, Rhee P, Erstad BL, Patanwala AE. Effect of a pharmacist on timing of postintubation sedative and analgesic use in trauma resuscitations. Am J Health Syst Pharm 2014; 70:1513-7. [PMID: 23943183 DOI: 10.2146/ajhp120673] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Pharmacists' impact in reducing the time interval from intubation to sedative and analgesic use during trauma patient resuscitations is investigated. METHODS A retrospective cohort study was conducted at a level 1 trauma center to compare medication-use outcomes in consecutive cases in which trauma patients underwent rocuronium-assisted rapid-sequence intubation (RSI) and subsequent sedation and analgesia with or without a pharmacist's participation on the resuscitation team. The primary and secondary outcomes were, respectively, the time to sedative provision and the time to analgesic provision after intubation. RESULTS Relative to resuscitation cases not involving a pharmacist, the presence of the pharmacist during RSI was associated with decreased mean times to provision of postintubation sedation (9 minutes versus 28 minutes, p = 0.007) and analgesia (21 minutes versus 44 minutes, p = 0.057). The cumulative proportions of patients receiving appropriate sedation 5, 10, and 15 minutes after intubation were 11%, 26%, and 41% in the pharmacist-absent group and 33%, 53%, and 63% in the pharmacist-present group (p = 0.009, 0.008, and 0.045, respectively); for postintubation analgesic use, the corresponding figures were 9%, 14%, and 23% in the pharmacist-absent group and 17%, 30%, and 43% in the pharmacist-present group (p = 0.236, 0.066, and 0.039, respectively). CONCLUSION The presence of a pharmacist during RSI procedures was associated with decreased times to postintubation sedative and analgesic use, indicating that pharmacist participation in trauma-resuscitation responses can facilitate appropriate drug therapy.
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Affiliation(s)
- Albert Amini
- Department of Surgery, College of Medicine, University of Arizona (UA), Tucson, AZ, USA
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Patanwala AE, McKinney CB, Erstad BL, Sakles JC. Retrospective analysis of etomidate versus ketamine for first-pass intubation success in an academic emergency department. Acad Emerg Med 2014; 21:87-91. [PMID: 24552528 DOI: 10.1111/acem.12292] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/02/2013] [Accepted: 08/02/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective of this study was to compare first-pass intubation success between patients who received etomidate versus ketamine for rapid sequence intubation (RSI) in the emergency department (ED). METHODS This was a retrospective analysis of prospectively collected data recorded in a quality improvement database between July 1, 2007, and December 31, 2012. The study was conducted in an academic ED in the United States. All patients who received etomidate or ketamine as part of RSI were included. The primary outcome measure was first-pass success. A multivariate analysis was conducted to determine if sedative type was associated with first-pass success, after adjusting for potential confounders and baseline differences. RESULTS The final cohort consisted of 2,098 RSI procedures using either etomidate (n = 1,983) or ketamine (n = 115). First-pass success occurred in 77.0% of patients in the etomidate group and 79.1% of patients in the ketamine group (difference = -2.1%; 95% CI = -5.5% to 9.8%). In the multivariate analysis, after adjusting for potential confounders, sedative type was not associated with first-pass success (odds ratio = 0.89; 95% CI = 0.5 to 1.5; p = 0.632). CONCLUSIONS Etomidate and ketamine are associated with equivalent first-pass success when used in RSI. Ketamine may be an appropriate alternative to etomidate for RSI in the ED.
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Affiliation(s)
- Asad E Patanwala
- The Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ
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Rapid sequence intubation in the intensive care unit☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341010-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Watt JM, Amini A, Traylor BR, Amini R, Sakles JC, Patanwala AE. Effect of paralytic type on time to post-intubation sedative use in the emergency department. Emerg Med J 2012; 30:893-5. [DOI: 10.1136/emermed-2012-201812] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Strayer RJ. Rocuronium Versus Succinylcholine: Cochrane Synopsis Reconsidered. Ann Emerg Med 2011; 58:217-8. [DOI: 10.1016/j.annemergmed.2011.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 01/10/2011] [Accepted: 01/10/2011] [Indexed: 11/16/2022]
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