In this episode, I’ll discuss paralytic first vs sedative first RSI and the chance of first attempt success.
One of the most significant contributors to a positive outcome for a patient undergoing emergency tracheal intubation is that the first attempt at placing the airway is a success.
The purpose of the paralytic and sedative used during emergency intubation is to provide the optimal conditions for placing the airway and to ensure the patient can tolerate the procedure.
One decision clinicians are faced with is which medication to give first – the paralytic or the sedative?
Each class of medication has slightly different onset times, and waiting for each medication to take effect can consume a significant portion of the safe apnea time, making it even more crucial that the airway is placed successfully on the first attempt.
Back in episode 386 I discussed a secondary analysis of a trial that examined giving the paralytic vs sedative first in emergency endotracheal intubation, and concluded that either strategy was acceptable for achieving first pass success.
Recently, authors published in Academic Emergency Medicine A Bayesian analysis of a prospective cohort looking at the effect of administration sequence of induction agents on first-attempt failure during emergency intubation.
More than 2000 patients were included in the analysis. The vast majority of patients received rocuronium for paralysis and etomidate for sedation. The paralytic was given first for just over half of the patients. After adjustments, the odds ratio for first attempt failure was 0.73 in patients who were given the paralytic first. The 95% confidence interval for this odds ratio was 0.46–1.02. When bayesian analysis was applied, the probability that the odds ratio for first attempt failure was less than 1 (in favor of giving the paralytic first) was estimated at 95.7% and less than 0.9 at 87.6%.
Hypoxemia, which was defined as a pulse oximetry lower than 90% occurring from induction to 1 min after the completion of intubation occured at similar rates no matter which medication was given first.
The authors concluded that a paralytic-first drug sequence was associated with reduced first-attempt failure during emergency tracheal intubation. Their study had a larger sample size and used adjustment for potential confounding factors compared to the one from Episode 386, which may explain their results.
Unfortunately, their study did not include data on data on awake paralysis and whether it is affected by the order of administration of medications during emergency intubation. However the authors feel that previously published data does not suggest that giving the paralytic before the sedative increases the chance of awake paralysis and therefore they consider a paralytic-first strategy to be a safe practice.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on airway pharmacology, code blue and rapid response participation, along with over 200 practical trainings and other resources to help in your practice. 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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