In this episode, I’ll discuss the time to delivery of sedation and analgesia after RSI using rocuronium vs succinylcholine.
A new retrospective study looking at the timing of first-dose sedation and analgesia after rapid sequence intubation (RSI) in patients induced with etomidate and paralyzed with rocuronium or succinylcholine has been published in AJHP. More than 2000 patients were analyzed who received rocuronium over succinylcholine in a 3:1 ratio. The median time to first dose of sedation was 2 minutes longer in the rocuronium group at 12 minutes vs 10 minutes for succinylcholine. In addition, the median time to first dose of analgesia was 3 minutes longer for rocuronium at 24 vs 21 minutes. On top of that, the receipt of rocuronium was also associated with lower rates of sedation and analgesia with an adjusted hazard ratio of about 0.75 each.
Use of rocuronium for RSI was associated with reduced likelihood of timely post-RSI sedation and analgesia. Coupled with low initial sedative dosing, our findings suggest that patients intubated with rocuronium are at increased risk of being awake during paralysis.
This is not the first time the issue of being awake during paralysis has come up with rocuronium. I have previously discussed it in episodes 754, 867, and 873. If you’ve ever been present for an emergent intubation of a critically ill patient it is not hard to figure out what is happening: A patient’s airway is often just one concern out of many during the acute phase of a critical illness and the care team is also focusing on supporting the circulatory system as well as figuring out and reversing the cause of the critical illness. Due to rocuronium’s extended duration of paralysis compared to succinylcholine, it is likely that patients who have received rocuronium take longer to display physical signs that they are in need of sedation and analgesia, and this is the reason for delay.
Thankfully, there is an evidence-based way to improve the rates of analgesia and sedation in patients who received rocuronium for RSI that the authors of this and previous studies have identified: A pharmacist at the bedside. In this study, the bedside presence of an ED pharmacist was associated with an improvement in sedation with an adjusted hazard ratio of 1.14 which was statistically significant. A pharmacist in the ED is well suited to ensuring the prompt provision of analgosedation after RSI and thereby prevent awareness with paralysis from occurring. While the rest of the care team is confirming tube placement, CO2 exchange, and stabilizing the patient, the pharmacist can remain focused on pharmacotherapy needs including the continued sedation and comfort of the patient.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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