Impact of Rocuronium/Succinylcholine on Sedation post-RSI

From Wiki Journal Club
Jump to: navigation, search
Johnson E.G. et al. "Impact of Rocuronium and Succinylcholine on Sedation Initiation After Rapid Sequence Intubation". The Journal of Emergency Medicine. 2015. 49(1):43-49.
PubMedFull text

Clinical Question

In patients intubated in the Emergency Department (ED) via Rapid Sequence Intubation (RSI), is there a difference in time to post-intubation sedation or analgesia between patients that received rocuronium or succinylcholine as their neuromuscular blocking agent (NMBA)?

Bottom Line

Patients that received rocuronium, the longer acting NMBA as a paralytic for RSI, had a statistically significant longer period of time following intubation without sedation/analgesia. This longer time mirrors that of the duration of the NMBA. This delay of inadequate sedation while paralyzed puts those patients at risk of extreme discomfort, pain, and panic. Presence of a pharmacist will decrease this delay but not eliminate it entirely.

Major Points

Adding to the trauma of receiving acute medical care, a patient being paralyzed and fully aware of their surroundings would be a further trumatizing event. This trial demonstrated that increased vigilance is required to ensure that patients that are paralyzed using a long acting NMBA are adequately sedated prior to the wearing off of the initial RSI sedation. A Pharmacist being present may help to increase this vigilance.

Design

  • Single-centre, retrospective chart review
  • N=106
    • Rocuronium (n=76)
    • Succinylcholine (n=30)
  • Setting: 650 bed tertiary care, academic, level 1 trauma centre, with Pharmacist in ED from 13:00-22:00hrs
  • Enrollment: October 2009-December 2012
  • Primary outcome:
    • Time to initiation of continuous sedation or analgesia after RSI
  • Secondary Outcome:
    • Sedatives used
    • Intubation attempts
    • Continuous sedatives and analgesics used
    • Analgesics or anxiolytics received while in transit to the ED
    • Duration of mechanical ventilation
    • Intensive Care Unit length of stay
    • Hospital length of stay

Population

Inclusion Criteria

  • Patients intubated in the ED

Exclusion Criteria

  • <18 years old
  • pregnancy
  • intubation prior to arrival
  • those with incomplete medical records
  • patients who did not receive sedation or analgesia after RSI due to contraindication.
  • did not receive NMBA during intubation

Baseline Characteristics

Presented as Rocuronium (n=76) vs. Succinylcholine (n=30), P-value

  • Chief complaint, n(%)
    • Motor vehicle crash: 37(48.7) vs. 16(53.3), NS
    • Motorcycle crash: 14(18.4) vs. 4(13.3), NS
    • Gun shot wound: 8(10.5) vs. 1(3.3), NS
    • Other: 17(22.4) vs. 9(30), NS
  • Female, n(%): 19(25) vs. 17(56.6), 0.004
  • Age, mean(SD): 19(25) vs. 17(56.6), NS
  • Pharmacist present, n(%): 49(64.5) vs. 23(76.6), NS
    • Rocuronium Patients: 49(46.2)
    • Succinylcholine Patients: 23(21.7)
  • Indication for intubation, n(%)
    • Altered mental status: 1(1.3) vs. 3(10), NS
    • Airway protection: 53(69.7) vs. 12(40), 0.021
    • Combative: 5(6.6) vs. 4(13.3), NS
    • Other: 17(22.4) vs. 11(36.7), NS
  • Glasgow Coma Scale(IRQ): 13(6-14) vs. 13(7-15), NS
  • Weight, kg, mean(SD): 81.2(16.5) vs. 81.2(18.7), NS

Medications Used:

Presented as Rocuronium (n=76) vs. Succinylcholine (n=30), P-value

  • Sedative in RSI, n(%)
    • Ketamine: 6(7.9) vs. 2(6.6), NS
    • Etomidate: 58(76.3) vs. 24(80), NS
    • Propofol: 3(3.9) vs. 2(6.6), NS
    • None: 0(0) vs. 1(3.3), NS
    • Midazolam: 9(11.8) vs. 1(3.3), NS
  • Intubation attempts, mean(SD): 1.1(0.39) vs 1.3(0.53), NS
  • Continuous sedation agent, n(%)
    • Propofol: 41(53.9) vs. 18(60), NS
    • Midazolam: 28(36.8) vs. 8(30), NS
    • None: 6(7.9) vs. 2(6.6), NS
    • Lorazepam: 1(1.3) vs. 2(6.6), NS
  • Continuous analgesia agent, n(%)
    • Fentanyl: 22(28.9) vs. 10(30), 0.897
    • Morphine: 19(25) vs. 5(16.7), NS
    • None: 35(46) vs. 15(50), NS

Interventions

Patients who received Rocuronium vs. Succinylchoine for RSI

Outcomes

  • ED Patients Evaluated for Intubation: n=626
    • Excluded: <18 yrs old: n=82
    • Excluded: Incomplete Medical Records: n=333
    • Excluded: Paralytics Prior to Arrival: n=62
    • Excluded: No sedation or Analgesia Post-Intubation: n=43
  • Met inclusion: n=106

Primary Outcomes

Presented as mean of Rocuronium (n=76) vs. Succinylcholine (n=30), P-value

Time to initiation of continuous sedation/analgesia after RSI, min
34 +/- 36 vs. 16 +/- 21, P=0.002

Secondary Outcomes

Presented as Rocuronium (n=76) vs. Succinylcholine (n=30), P-value

Time to initiation of sedation/analgesia in presence of a Pharmacist, min
with RPh: 23 +/- 22 vs. 12 +/- 14, P=0.024
without RPh: 55 +/- 46 vs. 28 +/- 33, P=0.132

Presented as mean of with Pharmacist Present vs. Pharmacist Absent, P-value

Any NMBA agent
Time to sedation/analgesia, min
20 +/- 21 vs. 49 +/- 45, P<0.001
Rocuronium group
Time to sedation/analgesia, min
23 +/- 22 vs. 55 +/- 46, P=0.002
Succinylcholine group
Time to sedation/analgesia, min
13 +/- 14 vs. 28 +/- 3, NS

Presented as Rocuronium (n=76) vs. Succinylcholine (n=30), P-value

Time on ventilator, days, mean(SD)
8.2(16.9) vs. 5.0(5.6), NS
Hospital Length of Stay (LOS), days, mean(SD)
20.6(24.7) vs. 20.5(23.7), NS
ICU LOS, days, mean(SD)
9.8(13.5) vs. 8.3(8.6), NS

Criticisms

  • Retrospective Chart Review, selection bias of ED records
    • n=333 excluded for incomplete medical records
    • Even those that were "complete" may be missing key details
  • likely not powered to find differences for secondary outcomes (Vent Time, LOS)
  • no assessment of how healthcare team assessed patients’ requirement for sedation/analgesia
  • Did not assess affect of inadequate sedation on patients
  • Mean GCS was 13 so patients were likely conscious once the initial RSI sedation/analgesia wore off

Funding

Not stated in manuscript

Further Reading