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November 25, 2024
Written by Jason Lesnick
This secondary analysis of 2 RCTs found no significant difference between rocuronium or succinylcholine on first attempt success or severe complications in critically ill patients undergoing endotracheal intubation.
Paralytic preference possibilities?
This was a secondary analysis of data from the DEVICE and PREOXI trials including 2,339 adult patients undergoing intubation in an ED or ICU. The authors used a generalized linear mixed-effects model with prespecified baseline covariates to examine the association between paralytic received, first attempt success (primary outcome), and severe complications (secondary outcome). The authors hypothesized that succinylcholine would have higher first attempt success rates with similar rates of severe complications. These were defined as severe hypoxemia (SpO2 <80%), severe hypotension (SBP <65 mmHg, new or increased use of vasopressors), or cardiac arrest occurring between induction and two minutes after intubation. 475 patients (20.3%) received succinylcholine while 1864 received rocuronium (79.7%). First-attempt success occurred in 78.9% of patients who received succinylcholine and 81.0% of patients who received rocuronium (aOR 0.87, 95%CI 0.65 to 1.15). Severe complications occurred in 67 patients (14.1%) who received succinylcholine and 456 (24.5%) who received rocuronium (aOR 0.88, 95%CI 0.62 to 1.26). I find it interesting that etomidate was used >80% of the time regardless of paralytic and that their data showed 83.6% of all intubations using succinylcholine occurred in the ED while only 40.9% of intubations that used rocuronium occurred in the ED.
How will this change my practice?
This study won’t change my practice but is an interesting study regarding a key EM procedure. I agree with the authors’ interest in an RCT.
Source
Association Between Neuromuscular Blocking Agents and Outcomes of Emergency Tracheal Intubation: A Secondary Analysis of Randomized Trials. Ann Emerg Med. 2024 Oct 8:S0196-0644(24)00962-4. doi: 10.1016/j.annemergmed.2024.08.509. Epub ahead of print. PMID: 39387758
