Maximizing Success With Rapid Sequence Intubations

Pharmacotherapy optimization for rapid sequence intubation in the emergency department

PURPOSE

Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods.

SUMMARY

There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use.

AREAS FOR FUTURE RESEARCH

The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Comparison of aerosol box intubation with C-MAC video laryngoscope and direct laryngoscopy-A randomised controlled trial

Background and Aims:

Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is a highly infectious disease and healthcare workers are at constant risk for contracting it. Nowadays, aerosol box is used in conjunction with WHO-recommended safety kits, to avoid health workers from getting SARS-CoV-2 infection during aerosol-generating procedures. In our study, we compared the ease of oral intubation with C-MAC video laryngoscope and direct laryngoscopy, when the aerosol box was used. The secondary objectives were to compare the incidence of airway loss, haemodynamic changes, number of attempts, and time required for intubation between these two techniques.

Methods:

This prospective randomised controlled study was conducted on 60 non-coronavirus disease (COVID) patients presenting for elective surgery under general anaesthesia. Patients were randomly assigned into two groups:C and D using a computer-generated random sequence of numbers by closed envelope technique. In group D, laryngoscopy was performed with Macintosh blade and in group C, with Storz® C-MAC video laryngoscope.

Results:

The ease of intubation was better (grade 1) in group C than D (68.6% vs. 31.4% respectively) with a P value of < 0.001. 10% of patients required more than one intubation attempt in group D compared to none in group C, but this difference was not statistically significant. The intubation time was comparable between the two groups. There were no incidences of loss of airway or failure to intubate in both groups.

Conclusion:

The use of C-MAC video-laryngoscopy resulted in easier orotracheal intubation as compared to intubation with direct laryngoscopy when the aerosol box was used.

Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China

BACKGROUND This retrospective study was conducted at a single center in China and aimed to compare rocuronium with succinylcholine for rapid sequence induction intubation in the Emergency Department of a hospital. MATERIAL AND METHODS An orotracheal intubation procedure was performed in a total of 267 patients by direct laryngoscopy using an intravenous bolus injection of 1 mg/kg of succinylcholine (n=141; SY group) or 1.2 mg/kg of rocuronium (n=126; RM group) for a rapid sequence induction in the emergency department. The success of orotracheal intubation was evaluated by a capnography curve. The modified Cormack-Lehane score was used to grade the direct laryngoscopy. RESULTS There was no statistically significant difference in numbers of patients with successful first-attempt orotracheal intubation between the groups (112 vs. 87, P=0.067). Fewer intubation failures under direct laryngoscopy were reported in the SY group than in the RM group (23 [16%] vs. 34 [27%], P=0.037). The number of intubation attempts was higher in the RM group than in the SY group (1.52±0.87 per patient vs. 1.27±0.60 per patient, P=0.032). CONCLUSIONS The findings from this study support results from previous studies, showing that even in the Emergency Department setting, rocuronium was equivalent to succinylcholine in achieving rapid sequence induction intubation, when the dose was appropriate. However, as current clinical guidelines highlight, succinylcholine has more contraindications and adverse effects, including hyperkalemia, which should be monitored, and rocuronium has a longer duration of action.