Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients

Bloomstone, Joshua A.; Eckhardt, William F.

doi:10.1001/jama.2021.8526

Cited by 47 publications

(119 citation statements)

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“…The proportion of rapid sequence intubations without major complications varied between 55% and 92% in recent studies. 4,25,[27][28][29] The intergroup difference used to power trials comparing successful intubation on the first attempt was between 5% and 9% in recent superiority trials. 25,30 We thus deemed it reasonable that 80% of patients in the neuromuscular blocker group would have tracheal intubation without major complications and therefore set a noninferiority margin of 7 percentage points (ie, a relative difference of 8.75%), which was similar to that defined in a noninferiority trial comparing neuromuscular blockers for out-of-hospital tracheal intubation.…”

Section: Sample Size Calculationmentioning

confidence: 99%

“…2,3 High variability in the modalities of rapid sequence intubation has been reported in national surveys and randomized clinical trials published between 2015 and 2020. [4][5][6][7][8] Rapid sequence intubation without neuromuscular blockers was performed in 25% to 75% of patients at risk of aspiration. [4][5][6][7][8] This observation is possibly explained by concerns about potential severe adverse effects of neuromuscular blockers, including anaphylaxis, 9 prolonged curarisation, 10 metabolic disturbance, 11 and postoperative respiratory complications.…”

mentioning

confidence: 99%

“…[4][5][6][7][8] Rapid sequence intubation without neuromuscular blockers was performed in 25% to 75% of patients at risk of aspiration. [4][5][6][7][8] This observation is possibly explained by concerns about potential severe adverse effects of neuromuscular blockers, including anaphylaxis, 9 prolonged curarisation, 10 metabolic disturbance, 11 and postoperative respiratory complications. 12 However, even if rapid sequence intubation without neuromuscular blockers is frequently performed in clinical practice, its noninferiority has not been demonstrated yet.…”

mentioning

confidence: 99%

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Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration

Grillot

Lebuffe

Huet

et al. 2023

JAMA

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ImportanceIt is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent.ObjectiveTo determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation.Design, Setting, and ParticipantsMulticenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for &lt;6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021.InterventionsPatients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic.Main Outcomes and MeasuresThe primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%.ResultsAmong 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, –6.1%; 95% CI, –11.6% to –0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, –5.7%; 2-sided 95% CI, –11.3% to –0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%).Conclusions and RelevanceAmong adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference.Trial RegistrationClinicalTrials.gov Identifier: NCT03960801

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Section: Sample Size Calculationmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration

Grillot

Lebuffe

Huet

et al. 2023

JAMA

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“…F rom 2014 to 2018, approximately 2 million critically ill adults underwent tracheal intubation each year in the US. 1 Hypotension occurs during 25% to 40% of tracheal intubations in the intensive care unit (ICU) 2,3 and can lead to cardiac arrest and death. 2,[4][5][6] Hypotension during tracheal intubation results, in part, from medication-induced vasodilation and decreased return of venous blood to the heart due to increased intrathoracic pressure from positive pressure ventilation.…”

mentioning

confidence: 99%

“…1 Hypotension occurs during 25% to 40% of tracheal intubations in the intensive care unit (ICU) 2,3 and can lead to cardiac arrest and death. 2,[4][5][6] Hypotension during tracheal intubation results, in part, from medication-induced vasodilation and decreased return of venous blood to the heart due to increased intrathoracic pressure from positive pressure ventilation. 7,8 The intravenous administration of a crystalloid solution (referred to as a fluid bolus) might counteract these effects by transiently increasing intravascular volume.…”

mentioning

confidence: 99%

Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation

Russell

Casey

Gibbs

et al. 2022

JAMA

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Key PointsQuestionIn critically ill adult patients undergoing tracheal intubation, does intravenous infusion of a crystalloid solution as a 500-mL fluid bolus decrease the incidence of severely low blood pressure, cardiac arrest, or death (referred to as cardiovascular collapse) during or shortly after the procedure?FindingsIn this randomized clinical trial that included 1065 critically ill adults, the incidence of cardiovascular collapse was 21.0% with administration of a fluid bolus vs 18.2% without administration of a fluid bolus, a difference that was not statistically significant.MeaningAmong critically ill adults undergoing tracheal intubation, administration of a fluid bolus did not significantly decrease the incidence of cardiovascular collapse.

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International Variation in Intubation and Extubation Practices and Adverse Events Among Critically Ill Patients Receiving Mechanical Ventilation

Gershengorn

2021

JAMA

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Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients

Cited by 47 publications

References 5 publications

Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration

Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration

Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation

International Variation in Intubation and Extubation Practices and Adverse Events Among Critically Ill Patients Receiving Mechanical Ventilation

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