Rapid sequence intubation medication therapies: a review in light of recent drug shortages

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.

A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation

INTRODUCTION

Rapid sequence intubation is an airway rescue and protection technique in which different sedatives are used to perform orotracheal intubation. Etomidate, due to its pharmacokinetic and pharmacodynamic qualities, particularly hemodynamic stability, is the most widely used sedative in this scenario. However, its superiority over other sedatives is controversial.

MATERIALS AND METHODS

We performed a meta-analysis using a pre-designed protocol and PRISMA guidelines to evaluate the mean difference between systolic blood pressure before and after administration of the sedative. We also analyzed the relative risks of hypotension.

RESULTS

Ten studies were included. The incidence of hypotension in patients receiving etomidate ranged from 6.4% to 75.2%, and between 24.0% and 65.9% in patients receiving other sedatives. No significant differences were found in the mean difference in systolic blood pressure during pre-intubation 0.01 mm Hg (95% CI: -0.90; 0.92) or in post-intubation 0.98 mmHg (95% CI: -0.24; 2.20). The relative risk analysis showed that the risk of hypotension is equal to an RR of 1.19 (95% CI: 0.92-1.54) between those who received etomidate and those who received the other sedatives.

CONCLUSIONS

The risk of hypotension after rapid intubation sequence with etomidate does not differ significantly compared to other sedatives. However, the studies included in this review were heterogeneous.

Despite Federal Legislation, Shortages Of Drugs Used In Acute Care Settings Remain Persistent And Prolonged

Early evidence suggests that provisions of the Food and Drug Administration Safety and Innovation Act of 2012 are associated with reductions in the total number of new national drug shortages. However, drugs frequently used in acute unscheduled care such as the care delivered in emergency departments may be increasingly affected by shortages. Our estimates, based on reported national drug shortages from 2001 to 2014 collected by the University of Utah's Drug Information Service, show that although the number of new annual shortages has decreased since the act's passage, half of all drug shortages in the study period involved acute care drugs. Shortages affecting acute care drugs became increasingly frequent and prolonged compared with non-acute care drugs (median duration of 242 versus 173 days, respectively). These results suggest that the drug supply for many acutely and critically ill patients in the United States remains vulnerable despite federal efforts.

Awake emergency endotracheal intubation using sheath-assisted technique for patients having malignant tracheal stenosis under fluoroscopy guidance: a retrospective study

Background For patients having a severe larynx or tracheal stenosis, emergency endotracheal intubation (EEI) may be needed due to respiratory failure. Purpose To evaluate the feasibility and effectiveness of awake EEI using a fluoroscopy-guided sheath-assisted technique for adult patients having a malignant tracheal stenosis. Material and Methods From October 2009 to May 2015, 219 patients having a malignant tracheal stenosis causing dyspnea or asphyxia required EEI. Of these, 32 patients who experienced intubation difficulties or failure were included in this study. Data on the technical success, procedure time, complications, and clinical outcome were collected. The pulse oxygen saturation (SpO₂) and Hugh-Jones classification were used to evaluate the respiratory function before and after EEI. Results Awake fluoroscopy-guided EEI was technically successful in 15 ± 4 min and acute dyspnea was resolved in all patients. The SpO₂ and Hugh-Jones classification increased after EEI ( P < 0.05). Subsequent treatments included tracheal stents (n = 15), surgical resection (n = 10), and palliative tracheotomy (n = 7), which were performed within 72 h after EEI. Conclusion Awake EEI using a sheath-assisted technique for adult patients having a malignant tracheal stenosis is a safe and effective procedure.

Emergency endotracheal intubation under fluoroscopy guidance for patients with acute dyspnea or asphyxia

OBJECTIVE

To evaluate the feasibility and effectiveness of emergency endotracheal intubation (EEI) under fluoroscopy guidance for patients with acute dyspnea or asphyxia.

METHODS

From October 2011 to October 2014, of 1521 patients with acute dyspnea or asphyxia who required EEI in 6 departments, 43 patients who experienced intubation difficulty or failure were entered into this study. Data on technical success, procedure time, complications, and clinical outcome were collected. The pulse oxygen saturation and Hugh-Jones classification changes were analyzed.

RESULTS

Fluoroscopy-guided EEI was technically successful in all patients. Acute dyspnea had resolved in all patients with clinical success rate 100% after the procedure. There were no serious complications during or after the procedure. The pulse oxygen saturation and Hugh-Jones classification showed significant increase after EEI (P < .05). Further treatments, including tracheal stents (n = 21), surgical resection (n = 16), palliative tracheotomy (n = 4), and bronchoscopic treatment (n = 2), were performed 1 to 72 hours after EEI. During a mean follow-up period of 13.2 months, 13 patients had died and 30 patients remained alive without dyspnea.

CONCLUSIONS

Fluoroscopy-guided EEI is a safe and feasible procedure, and may serve as an alternative treatment option for patients when traditional EEI is unsuccessful.

Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department

OBJECTIVES

Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED). The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication.

METHODS

A matched case-control study with a case to control ratio of 1:3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities.

RESULTS

Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7%) had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%). Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001). Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤ 90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58-8.55], p = 0.01).

CONCLUSION

Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation.