Elsevier

Journal of Critical Care

Volume 45, June 2018, Pages 65-70
Journal of Critical Care

Sedation/Delirium
Current practices and safety of medication use during rapid sequence intubation

https://doi.org/10.1016/j.jcrc.2018.01.017Get rights and content

Highlights

  • Rapid sequence intubation medication practices vary amongst providers throughout the United States

  • Medications are often used inappropriately based on patient hemodynamics and contraindications

  • Ketamine was associated with hypotension post-RSI

  • Succinylcholine was given to 67% with baseline bradycardia and was significantly associated with bradycardia post-RSI

  • Sedation practices post-RSI were not consistent with national guidelines in the majority of patients

Abstract

Purpose

Characterize medication practices during and immediately after rapid sequence intubation (RSI) by provider/location and evaluate adverse drug events.

Materials and methods

This was a multicenter, observational, cross-sectional study of adult and pediatric intensive care unit and emergency department patients over a 24-h period surrounding first intubation.

Results

A total of 404 patients from 34 geographically diverse institutions were included (mean age 58 ± 22 years, males 59%, pediatric 8%). During RSI, 21%, 87%, and 77% received pre-induction, induction, and paralysis, respectively. Significant differences in medication use by provider type were seen. Etomidate was administered to 58% with sepsis, but was not associated with adrenal insufficiency. Ketamine was associated with hypotension post-RSI [RR = 1.78 (1.36–2.35)] and use was low with traumatic brain injury/stroke (1.5%). Succinylcholine was given to 67% of patients with baseline bradycardia and was significantly associated with bradycardia post-RSI [RR = 1.81 (1.11–2.94)]. An additional 13% given succinylcholine had contraindications. Sedation practices post-RSI were not consistent with current practice guidelines and most receiving a non-depolarizing paralytic did not receive adequate sedation post-RSI.

Conclusions

Medication practices during RSI vary amongst provider and medications are often used inappropriately. There is opportunity for optimization of medication use during RSI.

Introduction

Rapid sequence intubation (RSI) is a series of steps that include simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for endotracheal intubation. The goals of RSI are to facilitate intubation quickly, reduce complications, and improve the overall success rate. The success rate of intubation is improved when RSI medications are used [1]. The pharmacotherapy related steps of RSI include pre-induction (or pre-treatment), induction (or sedation), and paralysis. In general, the goals of pre-induction are to blunt the “pressor response” (catecholamine release resulting in hypertension and tachycardia) from stimulation of the airway with the laryngoscope and endotracheal tube or to prevent an adverse drug event from a medication administered during the remainder of the sequence. The goals of induction and paralytic medication administration are to facilitate the intubation itself. When discussing the pharmacotherapy of RSI it is also important to consider post-intubation practices related to pain control, sedation, and delirium since this can impact the long-term outcomes of patients.

Several controversies regarding medication selection and dose for each step of RSI exist [[2], [3], [4]]. Medications used for RSI are often given based on theoretical benefits or avoided based on potential adverse effects without sufficient literature support. Without clear consensus, RSI medication practices likely vary between intubating providers. Therefore, the primary goal of this study was to characterize medication practices during and immediately after RSI in wards, intensive care units (ICU), and emergency departments (ED) across the United States (US). Secondary goals were to compare prevalence of use of RSI agents based on intubation provider, post-RSI sedation and analgesia practices based on intubating location, and understand the incidence of adverse effects between RSI agents.

Section snippets

Materials and methods

This was a multicenter, observational, cross-sectional study of adult and pediatric ICU and ED patients over a 24-h period. Recruitment of study sites occurred between September 18, 2014 and October 31, 2015 via electronic mail, newsletter, and business meeting announcements to several pharmacy and critical care organizations (Critical Care Pharmacotherapy Trials Network [CCPTN], Clinical Pharmacy and Pharmacology Section of the Society of Critical Care Medicine [SCCM], American College of

Institution, study population, and intubation demographics

A total of 404 patients from 34 geographically diverse institutions were included in the study. Institution, patient, and intubation demographics are included in Table 1, Table 2, Table 3 respectively.

RSI medication practices

During RSI, 21%, 87%, and 77% of patients received pre-induction, induction, and paralysis, respectively. Most common medications used can be found in Table 4. Most patients (89%) achieved successful intubation with one attempt. Of those requiring multiple attempts, very few required additional

Discussion

Literature supporting or refuting medication use during RSI is sparse and inconclusive leading to clinical controversies and significant variability in practice. This cross-sectional study confirms variability in medication choice for all steps of RSI amongst different provider types. It also highlights deviations from best practice are often found leading to potentially harmful situations from inappropriate medication use.

There are several medications used for RSI that are given as

Conclusions

We identified medication practices during RSI vary amongst intubation provider throughout the US. Our data indicate that medications in the sequence are often used inappropriately based on hemodynamics or contraindications, which may cause harm to patients. Best practices for medication use during RSI have not been established, which likely contributed to the inconsistencies and inappropriateness in medication use that we found. We feel there is room for optimization, selection, and

Declarations of interest

None.

Financial support

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Non-financial support was provided by the Critical Care Pharmacotherapy Trials Network (CCPTN)/DISCOVERY.

Acknowledgements

We thank the Critical Care Pharmacotherapy Trials Network for their participation with data collection in this study. The participants are as follows: May Hormese, Pharm.D., Neal Lyons, Pharm.D., Branka Milicev, Pharm.D., Robert K. Mokszycki, Pharm.D., Linda Peich, Pharm.D., Poovi Shah, Pharm.D., Christine Steffensen, Pharm.D., Rolla Sweis, Pharm.D., Renata Taylor, Pharm.D., Advocate Christ Medical Center, Oak Lawn, IL; Billie Bartel, Pharm.D., Elizabeth Gau, Pharm.D., Emily Sass, Pharm.D.,

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