Impact of Paralytic Agent on Postintubation Sedation

Neuromuscular Blocking Agent Use in Critical Care Transport Not Associated With Intubation

OBJECTIVE

Variable indications exist for neuromuscular blocking agents (NMBAs) in the critical care transport setting beyond facilitation of intubation.

METHODS

This retrospective cohort study included adult patients (≥ 18 years) who underwent critical care transport from July 1, 2020, to May 2, 2023, and received NMBAs during transport that was not associated with intubation. The primary outcome was the indication for NMBA administration. Secondary outcomes included the characterization of NMBA use, mean Richmond Agitation Sedation Scale score before NMBA administration, sedation strategy used, and continuation of NMBAs within 48 hours of hospital admission.

RESULTS

One hundred twenty-six patients met the inclusion criteria. The most common indication for NMBA administration was ventilator dyssynchrony (n = 71, 56.4%). The majority of patients received rocuronium during transport (n = 113, 89.7%). The mean pre-NMBA Richmond Agitation Sedation Scale score was -3.7 ± 2.4. The most common sedation strategy was a combination of continuous infusion and bolus sedatives (76.2%). One hundred (79.4%) patients had sedation changes in response to NMBA administration. Seventy-two (57.1%) received NMBAs during the first 48 hours of their intensive care unit admission.

CONCLUSION

NMBAs were frequently administered for ventilator dyssynchrony and continuation of prior therapy. Optimization opportunities exist to ensure adequate deep sedation and reassessment of NMBA indication.

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

RATIONALE

Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI).

OBJECTIVES

To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI.

DESIGN

A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process.

METHODS

Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist.

RESULTS

From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence.

CONCLUSIONS

Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

Prehospital Ketamine Use for Rapid Sequence Intubation: Are Higher Doses Associated With Adverse Events?

OBJECTIVE

Ketamine for rapid sequence intubation (RSI) is typically dosed at 1 to 2 mg/kg intravenously. The need to ensure dissociation during RSI led some to administer ketamine at doses greater than 2 mg/kg. This study assessed associations between ketamine dose and adverse events.

METHODS

This multisite, retrospective study included adult subjects undergoing RSI with intravenous ketamine. Subjects were categorized into 2 groups: a standard ketamine dose (≤ 2 mg/kg intravenously) or a high dose (> 2 mg/kg intravenously). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for adverse events.

RESULTS

Eighty subjects received standard-dose ketamine, and 50 received high-dose ketamine. The high-dose group had a significantly (P < .05) higher proportion of trauma patients, were younger, and had higher predose blood pressure compared with the standard-dose group. High-dose ketamine was associated with greater odds of adverse events including hypotension (OR = 7.0; 95% CI, 3.0-16.6), laryngospasm (OR = 10.8; 95% CI, 1.3-93.4), bradycardia (OR = 7.5; 95% CI, 1.5-36.6), repeat medications (OR = 12.9; 95% CI, 1.5-107.9), oxygen desaturation (OR = 6.0; 95% CI, 1.8-19.9), multiple attempts (OR = 3.2; 95% CI, 1.5-6.8%), and failed airway (OR = 3.6; 95% CI, 1.0-12.7).

CONCLUSION

Ketamine at higher doses was associated with increased odds of adverse events. Studies assessing adverse events of ketamine at lower than standard doses in shock patients are needed.