Comparison of rocuronium and succinylcholine on postintubation sedative and analgesic dosing in the emergency department

Abstract

Patients who receive rocuronium are more likely to receive lower doses of sedative and analgesic infusions after intubation. This may place them at risk of being awake under paralysis.

Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department

“…However, succinylcholine's duration of effect is only 6 minutes because it is rapidly hydrolyzed by plasma pseudocholinesterases . This has implications for postintubation care, such as provision of sedation and analgesia . In one study, patients who were intubated with rocuronium had a greater delay in receiving sedatives after intubation because of the appearance of sedation .…”

“…However, rocuronium has a long duration of effect that leads to sustained paralysis for more than an hour postintubation, preventing the possibility of repeat neurologic assessments during this time period . Patients receiving rocuronium have also been shown to receive less sedation and analgesia in the immediate postintubation phase because their pharmacologically induced paralysis may make it appear as if they are calm and sedated . This has implications for patient comfort but may be ameliorated by the presence of pharmacists during resuscitation .…”

Protocol for a prospective, observational cohort study of awareness in mechanically ventilated patients admitted from the emergency department: the ED-AWARENESS study

“…OR-based studies demonstrate that some critical risk factors for awareness include: (1) a total intravenous anaesthetic approach (as opposed to inhaled); (2) underdosing of anaesthesia; (3) neuromuscular blocker (NMB) use and (4) a lack of protocolled monitoring of sedation depth 1. Critically ill ED patients requiring mechanical ventilation almost exclusively receive intravenous medications, and are frequently underdosed 6–8. Further, a significant percentage (up to 45%) of ED patients have been documented in previous literature to receive no analgesia or sedation after intubation 8.…”

“…Further, a significant percentage (up to 45%) of ED patients have been documented in previous literature to receive no analgesia or sedation after intubation 8. Approximately 90% of patients receive an NMB for intubation in the ED, with a recent trend of increased use of long-acting NMB for intubation (ie, rocuronium vs succinylcholine), and up to 25% receive a long-acting NMB after intubation 7–10. In the ED, these paralysed patients typically receive less analgesia and sedation, lower doses and in a delayed fashion 7.…”

“…Approximately 90% of patients receive an NMB for intubation in the ED, with a recent trend of increased use of long-acting NMB for intubation (ie, rocuronium vs succinylcholine), and up to 25% receive a long-acting NMB after intubation 7–10. In the ED, these paralysed patients typically receive less analgesia and sedation, lower doses and in a delayed fashion 7. These practice patterns are completely discordant to recommendations for reducing the incidence of awareness, and suggest that patients mechanically ventilated in the ED are at higher risk for this complication.…”