In reply:

Abstract

We thank Dr. Kendall for his letter related to our study comparing first-pass intubation success with rocuronium versus succinylcholine, using data from the National Emergency Airway Registry.1April M.D. Arana A. Pallin D.J. et al.NEAR InvestigatorsEmergency department intubation success with succinylcholine versus rocuronium: a National Emergency Airway Registry study.Ann Emerg Med. 2018; (https://doi.org/10.1016/j.annemergmed.2018.03.042)Abstract Full Text Full Text PDF Scopus (39) Google Scholar The issue of rocuronium dosing is important. A commonly cited Cochrane review of randomized controlled trials from the anesthesia literature comparing succinylcholine with rocuronium concluded that succinylcholine resulted in superior intubating conditions. However, this superiority disappeared at rocuronium doses exceeding 1.2 mg/kg, suggesting that higher doses of this medication may optimize outcomes.2Tran D.T. Newton E.K. Mount V.A. et al.Rocuronium versus succinylcholine for rapid sequence induction intubation.Cochrane Database Syst Rev. 2015; 10: CD002788Google Scholar In our study, the mean dose of rocuronium administered was 1.2 mg/kg (median 1.1 mg/kg). These relatively high doses might have contributed to our finding of no significant difference in first-attempt intubation success between succinylcholine and rocuronium. However, we also found no difference in first-attempt intubation success when comparing intubations using greater than or equal to 1.2 mg/kg versus less than 1.2 mg/kg of rocuronium in subgroup analyses included as a supplementary appendix to our main article. One exception was our finding of higher odds of first-attempt intubation success with greater than or equal to 1.2 mg/kg versus less than 1.2 mg/kg doses of rocuronium among patients without any difficult airway characteristics (odds ratio 2.2; 95% confidence interval 1.2 to 3.4).1April M.D. Arana A. Pallin D.J. et al.NEAR InvestigatorsEmergency department intubation success with succinylcholine versus rocuronium: a National Emergency Airway Registry study.Ann Emerg Med. 2018; (https://doi.org/10.1016/j.annemergmed.2018.03.042)Abstract Full Text Full Text PDF Scopus (39) Google Scholar Future prospective emergency department (ED)–based studies will be necessary to further clarify the role and importance of rocuronium dose for optimizing emergency airway management outcomes. In regard to the role of intubator experience, it is undeniable that this plays a critical role in intubation success.3Brown 3rd, C.A. Blair A.E. Pallin D.J. et al.NEAR III InvestigatorsTechniques, success, and adverse events of emergency department adult intubations.Ann Emerg Med. 2015; 65: 363-370Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 4April M.D. Schauer S.G. Brown 3rd, C.A. et al.A 12-month descriptive analysis of emergency intubations at Brooke Army Medical Center: a National Emergency Airway Registry study.US Army Med Dep J. 2017; 3-17: 98-104Google Scholar We did not specifically solicit each intubator’s number of previous intubations because we believed these self-reported numbers would be unreliable for a registry study. Nevertheless, the National Emergency Airway Registry does capture intubator experience as an ordinal variable related to operator level of training: emergency physician postgraduate year 1, 2, and 3/4; fellow; attending physician; or other (nonemergency physician). We believe this variable provides a reasonable depiction of each intubator’s level of airway management experience and we did control for this variable in our study’s regression and subgroup analyses. Finally, in regard to the issue of predictors of difficult airway characteristics, we based the National Emergency Airway Registry variables and definitions on those characteristics widely discussed in the emergency medicine literature as associated with challenging airways.5Brown 3rd, C.A. Sakles J.C. Mick N.W. The Walls Manual of Emergency Airway Management. 5th ed. Wolters Kluwer, Philadelphia, PA2018Google Scholar We agree that not all of these variables have undergone rigorous validation studies in the literature. We further concede that the prognostic value of these variables may well differ in the ED compared with the operating room setting. Nevertheless, we believe they are important considerations in the research and clinical practice of ED airway management, given their widespread use in the emergency medicine literature and difficult airway curricula. Although acknowledging these limitations, we did incorporate the difficult airway characteristic variables into our regression and subgroup analyses in an effort to control for potential confounding. Further refinement and validation of the myriad difficult airway characteristics reported in the emergency medicine literature represents another important area for future investigations. Can Successful Intubation Be Attributed to the Specific Use of Neuromuscular Agent?Annals of Emergency MedicineVol. 72Issue 4PreviewI read with great interest the article by April et al.1 The authors performed a retrospective multicenter study on 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium and concluded that there was no association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events. I congratulate the authors for performing a well-designed study in an important topic of emergency airway management.2,3 The current emphasis to minimize adverse events after emergency airway management makes the topic relevant in emergency medicine. Full-Text PDF Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry StudyAnnals of Emergency MedicineVol. 72Issue 6PreviewAlthough both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium. Full-Text PDF