50 Short Term Use of Neuromuscular Blocking Agents in Post Rapid Sequence Intubation Patients Are Not Harmful, and May Be Beneficial

Abstract

Study Objectives: Neuromuscular blocking agents (NMBA) are commonly used in post rapid sequence intubation (RSI) patients in the emergency department (ED). Short-term or bolus doses of NMBA are often use in post RSI ED patients to facilitate ventilation or for immobilization during procedures or tests. Long term continuous use of NMBA have been shown to increase length of intensive care unit (ICU) and hospital stay and have been associated with increase in mortality. Despite the potential adverse outcomes with long term use, there are little to no data on the effects of short-term or bolus dose use of NMBA. Since limited data exists, we sought to determine any difference in ED, ICU, and hospital length of stay (LOS), ventilator days, and mortality in post RSI patients given bolus dose of NMBA versus patients given no NMBA in the ED post RSI.Methods: We conducted a retrospective study in an urban, academic ED (100,000 visits annually) in Detroit, MI. Eligible patients were patients >18 years who were intubated in our ED from January 2009 to December 2009. Patients were excluded if they were pregnant, died within 48 hrs of admission, intubated outside of our ED (eg, out-of-hospital). Intubated patients who received bolus dose of NMBA were compared with patients who received no NMBA. We analyzed the 2 groups for differences in ED, ICU and hospital LOS, ventilator days, and mortality. Descriptive analysis was used for demographics; medians and proportions were compared using t-test and Chi-square test as appropriate.Results: The study included 158 patients intubated in the ED. Patients were 55.7% male, primarily black (82.3%) with a mean age of 53.3 ± 17.9 years. The mean Glasgow Coma Score (GCS) was 10.1 ± 4.7 and Sequential Organ Failure Assessment (SOFA) score was 4.7 ± 2.8. Of these intubated patients, 87.3% received sedative(s), 62.7% received post RSI NMBA, 29.7% received analgesic(s), and 4.4% received none of these. Some (24.7%) received both sedative(s) and analgesic(s), while some did not receive either (7.6%). In 3.2% of cases (n = 5), patients received post RSI NMBA without a sedative or analgesic. 21.5% of patients died during hospital stay and on average patients had a mean ED LOS of 8.4 hrs, mean ICU LOS of 8 days, and mean hospital LOS of 11.7 days. Contrary to our hypothesis, patients that received a post RSI NMBA were significantly less likely to die than those that received no post RSI NMBA (32% versus 15.2%, p = 0.016). Group differences were examined to determine if other factors could account for this difference in mortality. The NMBA and no NMBA groups did not differ significantly in diagnosis, sex, race, SOFA score, GCS, age, or weight. Additionally, patients that received the NMBA, had significantly lower number of days on the ventilator (mean 5.4 versus 9.0 days, p =0.01). Patients that received the NMBA had lower LOS in the ED, ICU, and hospital, but these numbers were not significant.Conclusion: In this urban ED population, we found significantly higher mortality rate and longer number of days spent on the ventilator in patients who received no NMBA post RSI than those who received bolus dose(s) of NMBA, but no difference in the ED, ICU and hospital LOS were observed. This study demonstrates no negative impact and possibly a benefit with the use of NMBA as bolus dose(s) in post-intubated patients; however, further investigation is warranted. Study Objectives: Neuromuscular blocking agents (NMBA) are commonly used in post rapid sequence intubation (RSI) patients in the emergency department (ED). Short-term or bolus doses of NMBA are often use in post RSI ED patients to facilitate ventilation or for immobilization during procedures or tests. Long term continuous use of NMBA have been shown to increase length of intensive care unit (ICU) and hospital stay and have been associated with increase in mortality. Despite the potential adverse outcomes with long term use, there are little to no data on the effects of short-term or bolus dose use of NMBA. Since limited data exists, we sought to determine any difference in ED, ICU, and hospital length of stay (LOS), ventilator days, and mortality in post RSI patients given bolus dose of NMBA versus patients given no NMBA in the ED post RSI. Methods: We conducted a retrospective study in an urban, academic ED (100,000 visits annually) in Detroit, MI. Eligible patients were patients >18 years who were intubated in our ED from January 2009 to December 2009. Patients were excluded if they were pregnant, died within 48 hrs of admission, intubated outside of our ED (eg, out-of-hospital). Intubated patients who received bolus dose of NMBA were compared with patients who received no NMBA. We analyzed the 2 groups for differences in ED, ICU and hospital LOS, ventilator days, and mortality. Descriptive analysis was used for demographics; medians and proportions were compared using t-test and Chi-square test as appropriate. Results: The study included 158 patients intubated in the ED. Patients were 55.7% male, primarily black (82.3%) with a mean age of 53.3 ± 17.9 years. The mean Glasgow Coma Score (GCS) was 10.1 ± 4.7 and Sequential Organ Failure Assessment (SOFA) score was 4.7 ± 2.8. Of these intubated patients, 87.3% received sedative(s), 62.7% received post RSI NMBA, 29.7% received analgesic(s), and 4.4% received none of these. Some (24.7%) received both sedative(s) and analgesic(s), while some did not receive either (7.6%). In 3.2% of cases (n = 5), patients received post RSI NMBA without a sedative or analgesic. 21.5% of patients died during hospital stay and on average patients had a mean ED LOS of 8.4 hrs, mean ICU LOS of 8 days, and mean hospital LOS of 11.7 days. Contrary to our hypothesis, patients that received a post RSI NMBA were significantly less likely to die than those that received no post RSI NMBA (32% versus 15.2%, p = 0.016). Group differences were examined to determine if other factors could account for this difference in mortality. The NMBA and no NMBA groups did not differ significantly in diagnosis, sex, race, SOFA score, GCS, age, or weight. Additionally, patients that received the NMBA, had significantly lower number of days on the ventilator (mean 5.4 versus 9.0 days, p =0.01). Patients that received the NMBA had lower LOS in the ED, ICU, and hospital, but these numbers were not significant. Conclusion: In this urban ED population, we found significantly higher mortality rate and longer number of days spent on the ventilator in patients who received no NMBA post RSI than those who received bolus dose(s) of NMBA, but no difference in the ED, ICU and hospital LOS were observed. This study demonstrates no negative impact and possibly a benefit with the use of NMBA as bolus dose(s) in post-intubated patients; however, further investigation is warranted.