Association Between Neuromuscular Blocking Agents and Outcomes of Emergency Tracheal Intubation: A Secondary Analysis of Randomized Trials - 09/10/24

Doi : 10.1016/j.annemergmed.2024.08.509

Stephanie C. DeMasi, MD ^a,^⁎ , Wesley H. Self, MD, MPH ^a,^b, Neil R. Aggarawal, MD, MHSc ⁱ, Michael D. April, MD ^m, Luke Andrea, MD ⁿ, Christopher R. Barnes, MD ^o, Jason Brainard, MD ^j, Veronika Blinder, DO ⁿ, Alon Dagan, MD ^p, Brian Driver, MD ^r, Kevin C. Doerschug, MD ^s, Ivor Douglas, MD ^t, Matthew Exline, MD, MPH ^u, Daniel G. Fein, MD ⁿ, John P. Gaillard, MD ^v, Sheetal Gandotra, MD ^x, Kevin W. Gibbs, MD ^w, Adit A. Ginde, MD, MPH ^k, Stephen J. Halliday, MD, MSCI ^z, Jin H. Han, MD ^a,^c,^aa, Taylor Herbert, MD, PhD ^b,^bb, Kevin High, RN, MPH, MHPE ^a, Christopher G. Hughes, MD, MS ^d, Akram Khan, MBBS ^c,^cc, Andrew J. Latimer, MD ^d,^dd, Amelia W. Maiga, MD, MPH ^c,^e,^f, Steven H. Mitchell, MD ^d,^dd, Amelia L. Muhs, MD ^g, Amira Mohamed, MD ⁿ, Ari Moskowitz, MD, MPH ⁿ, David B. Page, MD, MSPH ^e,^ee, Jessica A. Palakshappa, MD, MS ^w, Matthew E. Prekker, MD, MPH ^q, Edward T. Qian, MD, MSc ^d,^g, Dan Resnick-Ault, MD, MBA ^k, Todd W. Rice, MD, MSc ^g, Derek W. Russel, MD ^ee,^ff, Steven G. Schauer, DO, MS ^l, Kevin P. Seitz, MD ^g, Nathan I. Shapiro, MD, MPH ^p, Lane M. Smith, MD, PhD ^g,^gg, Peter Sottile, MD ⁱ, Susan Stempek, MBA, MMSc, PA-C ^h,^hh, Stacy A. Trent, MD, MPH ^k,ⁱⁱ, Derek J. Vonderhaar, MD ^j,^jj, James E. Walker, MD, PhD ^k,^kk, Li Wang, MS ^h, Micah R. Whitson, MD ^x,^y, Jonathan D. Casey, MD, MSc ^b,^g, Matthew W. Semler, MD, MSc ^b,^g
for the
Pragmatic Critical Care Research Group
^a Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
^b Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
^c Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN
^d Anesthesia Critical Care Medicine Division, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
^e Division of Acute Care Surgery, Department of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN
^f Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
^g Division of Allergy, Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
^h Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
ⁱ Division of Pulmonary Sciences and Critical Care Medicine, Fort Stewart, GA
^j Department of Anesthesiology, Fort Stewart, GA
^k Department of Emergency Medicine, Fort Stewart, GA
^l Departments of Anesthesiology & Emergency Medicine, Center for Combat and Battlefield Research, Fort Stewart, GA
^m University of Colorado School of Medicine, Aurora, CO; 14^th Field Hospital, Fort Stewart, GA
ⁿ Division of Pulmonary & Critical Care Medicine, Montefiore Medical Center, Bronx, NY
^o Department of Anesthesiology & Critical Care Medicine, Harborview Medical Center, Seattle, WA
^p Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
^q Division of Pulmonary, Allergy, and Critical Care, Department of Emergency Medicine, and Department of Medicine, Minneapolis, MN
^r Hennepin County Medical Center, Minneapolis, MN
^s Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
^t Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, University of Colorado, Anschutz, Aurora, CO
^u Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH
^v Department of Anesthesiology, Section on Critical Care, Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
^w Wake Forest University School of Medicine, Wake Forest School of Medicine, Winston-Salem, NC
^x Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
^y Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
^z Division of Allergy, Pulmonary & Critical Care Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI
^aa Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare Center, Nashville, TN
^bb Division of Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
^cc Division of Pulmonary, Allergy & Critical Care Medicine, Oregon Health & Science University, Portland, OR
^dd Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
^ee Division of Pulmonary, Allergy & Critical Care Medicine, UAB Heersink School of Medicine, Birmingham, Alabama
^ff Pulmonary Section, Birmingham Veteran’s Affairs Medical Center, Birmingham, Alabama
^gg Pulmonary and Critical Care Associates, Atrium Carolinas Medical Center, Charlotte, NC
^hh Division of Pulmonary & Critical Care Medicine, Department of Medicine, Lahey Hospital & Medical Center, Burlington, MA
ⁱⁱ Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
^jj Department of Pulmonary & Critical Care, Ochsner Health, New Orleans, LA
^kk Department of Pulmonary & Critical Care Medicine, Louisiana State University Health Sciences Center, Baton Rouge, LA

^∗Corresponding Author.

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Abstract

Study objective

To examine the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt and severe complications during tracheal intubation of critically ill adults in an emergency department (ED) or ICU.

Methods

We performed a secondary analysis of data from 2 multicenter randomized trials in critically ill adults undergoing tracheal intubation in an ED or ICU. Using a generalized linear mixed-effects model with prespecified baseline covariates, we examined the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt (primary outcome) and severe complications during tracheal intubation (secondary outcome).

Results

Among the 2,440 patients in the trial data sets, 2,339 (95.9%) were included in the current analysis; 475 patients (20.3%) received succinylcholine and 1,864 patients (79.7%) received rocuronium. Successful intubation on the first attempt occurred in 375 patients (78.9%) who received succinylcholine and 1,510 patients (81.0%) who received rocuronium (an adjusted odds ratio of 0.87; 95% CI 0.65 to 1.15). Severe complications occurred in 67 patients (14.1%) who received succinylcholine and 456 patients (24.5%) who received rocuronium (adjusted odds ratio, 0.88; 95% CI 0.62 to 1.26).

Conclusion

Among critically ill adults undergoing tracheal intubation, the incidences of successful intubation on the first attempt and severe complications were not significantly different between patients who received succinylcholine and patients who received rocuronium.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Methods

Study Design and Setting

Selection of Participants

Measurements and Outcomes

Primary Analysis

Results

Characteristics of Patients, Operators, and Intubation Procedure

Main Results

Limitations

Discussion

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Nicholas M. Mohr, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: SCD, WHS, JDC, and MWS conceived and helped design the study. SCD drafted the manuscript. All authors critically revised the manuscript for important intellectual content. LW helped with statistical analysis. SCD helped with final approval and held accountability for integrity. SCD takes responsibility for the paper as a whole.
	Data sharing statement: The entire deidentified data set for the PREOXI and DEVICE trials are available on request from the date of each respective article publication by contacting Matthew Semler at matthew.w.semler@vumc.org.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: This work was supported in part by grants from the National Institutes of Health (NIH) and the Department of Defense; MWS was supported in part by grants from the NIH/National Center for Advancing Translational Sciences (5UL1TR002243). JDC was supported in part by NIH (K23HL153584). SCD was supported in part by NIH (5T32GM108554). KPS was supported in part by NIH (5T32HL087738). TWR was supported in part by NIH/National Center for Advancing Translational Sciences (UL1TR002243) and NIH/National Heart, Lung, and Blood Institute (UO1 HL123033). NRA was supported in part by grants from NIH and the Department of Defense. AWM is supported by NIH (1K23GM150110) and the American College of Surgeons (C. James Carrico, MD, FACS; Faculty Research Fellowship for the Study of Trauma and Critical Care). DWR was supported in part by NIH/ National Heart, Lung, and Blood Institute (1K08HL148514). The Direct versus Video Laryngoscope and the Pragmatic Trial Examining Oxygenation Prior to Intubation trials were supported by the United States Department of Defense through Defense Health Agency Restoral Funding in collaboration with the 59^th Medical Wing (59MDW) of the United States Air Force. The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components.
	SGS has received funding from the Department of Defense in the form of grants to his institution. CGH has received consulting fees for trial steering committee participation from Sedana Medical. AAG receives funding from Seastar and Biomeme unrelated to the present work. ETQ received a teaching fee for teaching bronchoscopy in the ICU for Karl Storz Endoscopy. SHM received travel-related funding support for a research trial from SharpMed.