Long-acting neuromuscular paralysis without concurrent sedation in emergency care

Chong, Ian; Sandefur, Benjamin J.; Rimmelin, Dorothy E.; Arbelaez, Christian; Brown, Calvin A.; Walls, Ron M.; Pallin, Daniel J.

doi:10.1016/j.ajem.2014.01.002

Cited by 16 publications

(26 citation statements)

References 17 publications

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“…The limited data on ED sedation for mechanically ventilated patients has focused on inadequate postintubation analgosedation, showing that up to 50% of mechanically ventilated ED patients received inadequate analgesia or sedation. [4][5][6] In the current study, although the rate was much lower, a significant minority of patients received no analgesia (14.3%) or sedation (15.2%) in the ED. However, there are multiple clinical factors that may influence the decision to withhold or minimize analgosedation; it is possible that patients were sedated prior to ED arrival or medications were withheld for clinical reasons (ie, neurologic examination).…”

Section: Discussionmentioning

confidence: 50%

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Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED

Stephens

Ablordeppey

Drewry³

et al. 2017

Chest

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Section: Discussionmentioning

confidence: 50%

“…The available data are up to a decade old and limited by study design, as well as lacking detail on medication administration, including dose and sedation depth. [3][4][5][6] No studies have examined the impact of EDbased sedation on clinically relevant outcomes.…”

mentioning

confidence: 99%

Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED

Stephens

Ablordeppey

Drewry³

et al. 2017

Chest

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“…This observation is likely related to hypotension and clinical instability described above, but hypotension should not preclude appropriate, carefully titrated sedation, and analgesia. With most sepsis patients receiving a neuromuscular blocking agent at the time of intubation and the increasing use of rocuronium, delaying or deferring sedation puts patients at risk for awareness during paralysis 34 . While awareness and inadequate pain control may increase blood pressure, choosing a strategy of appropriate preintubation resuscitation and stabilization, peri‐intubation vasoactive medications, and postintubation sedation and pain control is preferred.…”

Section: Discussionmentioning

confidence: 99%

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

Mohr

Pape

Runde

et al. 2020

Academic Emergency Medicine

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Objective: The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis. Methods: This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine. Results: A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed. Conclusions: Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis. E tomidate is commonly used as an induction agent for rapid sequence induction in critically ill patients in the emergency department (ED) because of its reliable sedation effect and stable hemodynamic profile. 1 Etomidate also inhibits adrenal steroidogenesis by its transient inhibition of 11 b-hydroxylase, 2-4 which has raised safety concerns in patients with sepsis. 3,5-8 Based on cohort studies and post hoc

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“…However, previous studies have reported that absence of concurrent sedation was common among patients receiving long-acting neuromuscular paralysis during transportation between hospitals and NMB-alone or inadequate sedation in non-comatose patients was an avoidable medical error [16–18]. One may argue that emergency airway management with NMB alone has advantages over that with RSI—e.g.…”

Section: Discussionmentioning

confidence: 99%

A comparison of emergency airway management between neuromuscular blockades alone and rapid sequence intubation: an analysis of multicenter prospective study

et al. 2017

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BackgroundAlthough airway management with neuromuscular blockade (NMB) alone is discouraged in the emergency department (ED), our previous study demonstrated that many patients were intubated using NMBs alone without sedatives. To refute this practice, we sought to compare the intubation success and adverse event rates between NMBs only and rapid sequence intubation (RSI).MethodsThis is a secondary analysis of the data from a prospective observational study of ED patients in 13 hospitals who underwent emergency airway management from April 2010 to August 2012. The primary outcome was intubation success rate on first attempt. The secondary outcomes were the intubation success rate in ≤2 attempts and the intubation-related adverse event rate. We compared these outcomes between intubation attempts using NMB alone and RSI. We fit multivariable logistic regression models adjusting for potential confounders (age, sex, weight, primary indication for intubation, and training level of intubators).ResultsOverall, 852 patients were eligible for this analysis, with 114 (13%) intubated with NMB alone and 738 (87%) with RSI. Between the NMB-alone and RSI groups, no significant differences were observed in the success rate on the first attempt (70 vs. 73%; P = 0.48) or in ≤2 attempts (89 vs. 91%; P = 0.46), or in the adverse event rate (11 vs. 12%; P = 0.58). Similarly, after adjusting for confounders, no significant differences were observed in any of these outcomes (all P > 0.05).ConclusionsIn this analysis of data from a large multicenter study of ED patients, we found no superior effectiveness of intubation with NMB alone when compared to RSI. Our data lend significant support to the concept that intubation with NMB alone should be avoided in the ED.

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Long-acting neuromuscular paralysis without concurrent sedation in emergency care

Cited by 16 publications

References 17 publications

Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED

Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

A comparison of emergency airway management between neuromuscular blockades alone and rapid sequence intubation: an analysis of multicenter prospective study

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