In this episode I’ll:
1. Discuss an article that found an increase in mortality when succinylcholine was used for rapid sequence intubation in patients with traumatic brain injury.
2. Answer the drug information question “Do antibiotics need to be stopped prior to fecal microbiota transplantation (FMT) to treat clostridium difficile infection?”
3. Share a resource I use during in-hospital medical emergencies.
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Article
Lead author: Asad Patanwala
Published in the journal Pharmacotherapy January 2016
Background
The “Sux vs Roc” debate over whether to use succinylcholine or rocuronium in the setting of rapid sequence intubation (RSI) has been going on for a long time. I gave my opinion on the matter back in episode 14.
Purpose
The purpose of this article was to compare mortality in patients with traumatic brain injury (TBI) who received either succinylcholine or rocuronium for rapid sequence intubation.
Methods
The study examined a retrospective cohort in an academic emergency department (ED) in the United States. The cohort consisted of adult patients with TBI who underwent rapid sequence intubation (RSI) in the ED with rocuronium or succinylcholine between October 2010 and October 2014. The main outcome of interest was in-hospital mortality. Subjects were stratified based on severity of injury using head abbreviated injury scores. The high-severity group had a severe or critical head injury (score 4 or higher); the low-severity group had a less than severe head injury (score lower than 4).
Results
A total of 233 patients were studied; 149 received succinylcholine and 84 received rocuronium. In patients who received rocuronium, mortality was 22% and 23% in the low-severity and high-severity categories, respectively. In patients who received succinylcholine, mortality was 14% and 44% in the low-severity and high-severity categories, respectively. In the multivariate analysis after adjusting for important confounders, there was no significant association between succinylcholine and mortality in the low-severity category. In patients in the high-severity category, succinylcholine was associated with increased mortality compared with rocuronium (OR 4.10, 95% CI 1.18–14.12).
Conclusion
The authors concluded that in severely brain-injured patients undergoing RSI in the ED, succinylcholine was associated with increased mortality compared with rocuronium.
Discussion
Succinylcholine may cause a transient increase in intracranial pressure, which could be detrimental to patients with traumatic brain injury. It is possible that the increased mortality in the high-severity succinylcholine group resulted from this increase in intracranial pressure.
Rocuronium’s longer duration of action compared with succinylcholine makes neurologic assessments after intubation difficult to perform. This may delay decisions to perform neurosurgical intervention but did not appear to affect mortality in this study.
The study authors did an excellent job explaining the limitations of their study. One interesting limitation was the difference between groups in the incidence of hypotension:
Patients in the succinylcholine group were more likely to have hypotension suggesting higher severity of illness. However, this was not verified by other measures of severity such as injury severity scores. Nonetheless, we acknowledge that this is an important imbalance between the groups. Hypotension has been shown to be an important predictor of mortality after TBI. Even a single episode of hypotension in these patients may double the risk of mortality. We adjusted for both of these variables in our multivariate and sensitivity analyses.
As with any retrospective cohort study, a prospective trial is needed to confirm the findings. In the meantime I think it is reasonable to use rocuronium over succinylcholine for RSI in severely injured head trauma patients if the excess duration of action of rocuronium will not affect significant patient care decisions.
Drug information question
Q: Do antibiotics need to be stopped prior to fecal microbiota transplantation (FMT) to treat clostridium difficile infection?
A: Yes, nearly all protocols involve stopping antibiotics prior to FMT.
A 2012 review article in the journal Therapeutic Advances in Gastroenterology examined published protocols for fecal microbiota transplantation and concluded:
The decision to eliminate antibiotics prior to FMT was almost universal, however there were variances in the timeframe prior to the procedure, most commonly 1–3 days.
Resource
The resource I’d like to share in this episode is simple and free but makes a big difference in responding to medical emergencies – a stop watch app for your (android or apple) smartphone or tablet. There are two main emergencies when a stopwatch comes in handy:
The first is during code blue calls (discussed in episode 1). I will set a timer after each dose of epinephrine. Time seems to stand still during a code; if it weren’t for the timer I’d be asked for epinephrine about every 40-60 seconds.
The second is during endotracheal intubation. I will set a timer after the induction agent is given. This is how I know how much time I’ve got before the induction agent wears off and further sedation is going to be needed.
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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