Outcomes of Succinylcholine and Rocuronium for Rapid Sequence Intubation in the Emergency Department.

92 Comparison of Early Versus Late Sedative Interventions After Rapid Sequence Intubation Using Rocuronium in the Emergency Department

Succinylcholine and rocuronium are neuromuscular blocking agents used in the emergency department (ED) during rapid sequence intubation (RSI). Very few studies have been conducted to determine which agent is preferred for children. This study analyzed outcomes of death, post-traumatic stress disorder (PTSD) and malignant hyperthermia for children administered succinylcholine versus rocuronium for RSI in the ED. This retrospective, propensity-matched study utilized the TriNetX database. Cohorts included children less than or equal to 17 years of age, given a paralytic agent plus etomidate or ketamine during intubation in the ED from 2004 to 2024. Cohorts were further stratified by the administration of succinylcholine or rocuronium. The outcomes measured were death, PTSD, and malignant hyperthermia. Propensity matching was done for demographics and pre-existing conditions. Before propensity matching, 2095 pediatric patients were identified. After propensity matching, 706 patients were identified in each cohort. After propensity matching, children administered succinylcholine had a lower rate of death (5.7% vs. 8.9%, RR: 0.65, 95% CI [0.43-0.93], P =0.019) but no significant difference in PTSD (2.6% vs. 3.7%, RR: 0.71, 95% CI [0.32-1.68], P =0.399). There was no significant difference in malignant hyperthermia. Subgroup analysis suggests that succinylcholine and etomidate were the best combination of drugs for RSI. Mortality rates were lower for children administered succinylcholine for RSI when compared with rocuronium. This study demonstrates a potential association between succinylcholine use and favorable RSI outcomes in the ED, though further prospective studies are needed.

Rocuronium for rapid sequence intubation of emergency department patients

Comparison of time to sedation after rapid sequence intubation using long-acting neuromuscular blockers between the ED and ICU.

Etomidateis a sedative-hypnotic used for intubation in children. Its use in airway management has been controversial since etomidate may induce adrenal insufficiency. Ketamine is frequently used for intubation in children and has not been reported to be associated with adrenal insufficiency. We evaluated the risk of death and adrenal suppression after rapid sequence intubation (RSI) with either etomidate or ketamine. This retrospective study was performed using the TriNetX database in the United States from 61 healthcare organizations (HCOs). The final cohort after propensity matching included 1,191 patients who were ≤17 years of age and were given etomidate or ketamine for RSI but not both. The time frame was from December 22, 2003, to October 22, 2022. After propensity matching, the etomidate and ketamine groups each contained 565 patients, and there was a significantly lower risk of adrenal suppression with etomidate (1.8%) compared to ketamine (4.2%) (RR=0.43, 95% CI=0.21-0.90, p=0.02).There were similar results regarding adrenal insufficiency when no propensity matching was performed. There were no differences in mortality when comparing intubation with etomidate or ketamine with and without propensity matching. There was not an increased risk of adrenal insufficiency for etomidate administered as a single dose in children undergoing RSI in the emergency department (ED) when compared with ketamine. Additionally, there was no difference in mortality for those intubated with ketamine or etomidate.

Early invasive versus ischaemia-guided strategies in the management of non-Q wave myocardial infarction patients with and without prior myocardial infarction; results of Veterans Affairs Non-Q Wave Infarction Strategies in Hospital (VANQWISH) trial.

ObjectiveThe present study aimed to evaluate the impact of 1.5 mg/kg succinylcholine or 1.2 mg/kg rocuronium, vs. 1.0 mg/kg succinylcholine on apnea duration in patients underwent rapid sequence induction (RSI).MethodsThis prospective cohort study was conducted in the Department of Anesthesiology in Shanghai General Hospital from July 2020 to November 2020. Apnea duration was defined as the time from apnea prompted by the PETCO2 waveform to the time the point of oxygen saturation declined to 90% (T90) and 95% (T95) after succinylcholine or rocuronium administration. The primary outcome included T90 and T95 changes in 1.5 mg/kg vs. 1.0 mg/kg succinylcholine groups and 1.5 mg/kg succinylcholine vs. 1.2 mg/kg rocuronium groups.ResultsA total of 265 participants were subjected for analysis. The succinylcholine (1.0 mg/kg) group had a significantly longer T90 (50.72, 95% confidence interval [CI, 7.60, 94.38], P = 0.015) and T95 (48.09, 95% CI [7.11, 89.07], P = 0.012) than the succinylcholine (1.5 mg/kg) group. In addition, significantly longer T90 (56.84, 95% CI [16.24, 97.44], P = 0.003) and T95 (50.57, 95% CI [12.58, 88.57], P = 0.003) were observed in the rocuronium (1.2 mg/kg) group than those in the succinylcholine (1.5 mg/kg) group. No severe side events were observed during the operation.ConclusionRocuronium and the lower dose of succinylcholine may be recommended to patients underwent RSI.

Analgosedative interventions after rapid sequence intubation with rocuronium in the emergency department

While recent studies have demonstrated an overall increase in psychiatric visits in the emergency department (ED), none have focused on a nationally representative pediatric population. Understanding trends in pediatric psychiatric ED visits is important because of limited outpatient availability of pediatric specialists, as well as long wait times for psychiatric appointments. The study aim was to evaluate the trends in ED psychiatric visits for children between 2001 and 2010 with comparison by sociodemographic characteristics. This was a retrospective, cross-sectional analysis of ED psychiatric visits for children<18years of age using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes. Outcome measures included frequency of visits for children with psychiatric diagnosis codes and odds and adjusted odds of psychiatric visits controlling for temporal, demographic, and geographic factors. From 2001 to 2010, an average of 28.3 million pediatric visits to EDs occurred annually. Among those, an approximately 560,000 (2% of ED visits) were psychiatric visits each year. Pediatric psychiatric ED visits increased from an estimated 491,000 in 2001 to 619,000 in 2010 (p=0.01). Teenagers (adjusted odds ratio [AOR]= 3.92, 95% confidence interval [CI]=3.37 to 4.57) and publicly insured patient visits (AOR= 1.47, 95% CI=1.25 to 1.74) had increased odds of psychiatric ED visits. Pediatric ED psychiatric visits are increasing. Teenagers and children with public insurance appear to be at increased risk. Further investigation is needed to determine what the causative factors are.

Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge. This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.

The recommended rocuronium dose for rapid sequence intubation is 1.0mg/kg; however, the optimal dose for emergency airway management is not clear. We assessed the relationship between rocuronium dose and first-attempt success among emergency department (ED) patients undergoing rapid sequence intubation. This is a secondary analysis of the National Emergency Airway Registry (NEAR), an observational 25-center registry of ED intubations. Ninety percent recording compliance was required from each site for data inclusion. We included all patients > 14years of age who received rocuronium for rapid sequence intubation from 1 Jan 2016 to 31 Dec 2018. We compared first-attempt success between encounters using alternative rocuronium doses (< 1.0, 1.0-1.1, 1.2-1.3 and ≥1.4mg/kg). We performed logistic regressions to control for predictors of difficult airways, indication, pre-intubation hemodynamics, operator, body habitus and device. We also performed subgroup analyses stratified by device (direct vs. video laryngoscopy). We calculated univariate descriptive statistics and odds ratios (OR) from multivariable logistic regressions with cluster-adjusted 95% confidence intervals (CI). 19,071 encounters were recorded during the 3-year period. Of these, 8,034 utilized rocuronium for rapid sequence intubation. Overall, first attempt success was 88.4% for < 1.0mg/kg, 88.1% for 1.0-1.1mg/kg, 89.7% for 1.2-1.3mg/kg, and 92.2% for ≥1.4mg/kg. Logistic regression demonstrated that when direct laryngoscopy was used and when compared to the standard dosing range of 1.0-1.1mg/kg, the adjusted odds of a first attempt success was significantly higher in ≥1.4mg/kg group at 1.9 (95% CI 1.3-2.7) relative to the other dosing ranges, OR 0.9 (95% CI 0.7-1.2) for < 1.0mg/kg and OR 1.2 (95% CI 0.9-1.7) for the 1.2-1.3mg/kg group. First-attempt success was similar across all rocuronium doses among patients utilizing video laryngoscopy. Patients who were hypotensive (SBP < 100mmHg) prior to intubation had higher first-attempt success 94.9% versus 88.6% when higher doses of rocuronium were used. The rates of all peri-intubation adverse events and desaturation were similar between dosing groups, laryngoscope type utilized and varying pre-intubation hemodynamics. Rocuronium dosed ≥1.4mg/kg was associated with higher first attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension with no increase in adverse events. We recommend further prospective evaluation of the dosing of rocuronium prior to offering definitive clinical guidance.

Background. Succinylcholine and rocuronium are the predominant neuromuscular blocking agents (NMBAs) used for rapid sequence intubation (RSI) in the emergency department (ED). Prior studies have found reduced first‐attempt intubation success (FAIS) with rocuronium compared to succinylcholine. Recent large registry data have shown no difference in intubating conditions or FAIS. Objectives. The objective of this study was to compare FAIS rates for rocuronium and succinylcholine when used for RSI in a high‐acuity academic ED. Methods. This was a single‐center retrospective study. Patients were included if they received either succinylcholine or rocuronium for RSI in the ED from January 2016 to August 2020. The primary endpoint was FAIS. Subgroup analyses were performed evaluating the impact of weight‐based dosing on FAIS for each agent, and multivariate analysis was conducted to evaluate the impact of baseline characteristics on the primary outcome. Results. There were 448 patients who received rocuronium and 183 patients who received succinylcholine. No difference was observed in unadjusted FAIS between patients receiving rocuronium (median weight‐based dose: 1.22 mg/kg) or succinylcholine (median weight‐based dose: 1.43 mg/kg) (361 (80.6%) vs. 150 (82.0%), p = 0.69). There were no differences in FAIS between the weight‐based dose categories for rocuronium and for succinylcholine. Conclusions. These findings were consistent with those from recent studies indicating no difference in FAIS between rocuronium and succinylcholine, although the median dose of rocuronium used in this study was higher than traditionally recommended. Larger prospective studies are warranted to further evaluate the effect of weight‐based paralytic dosing on FAIS.

Analysis of Emergency Department Visits for Palpitations (from the National Hospital Ambulatory Medical Care Survey)

380 Emergency Airway Management in Japan: Interim Analysis of a Multi-Center Prospective Observational Study

Young adults with sickle-cell disease have increased emergency department (ED) utilization and increased risk of mortality for unclear reasons. Emergency Department Reliance (EDR) differentiates excessive ED use due to increased need in chronic illness from increased use due to limited access to outpatient care. A higher EDR has been used to define excessive reliance on the ED and thus access to care issues leading to increased ED utilization. We conducted a retrospective cohort study of sickle-cell disease patients within the Wisconsin Medicaid database over a 5-year period to examine EDR during the transition period from childhood to adulthood. The study population included four distinct groups: (1) children, (2) patients transitioning from pediatric to adult providers, (3) young adults, and (4) adults age 31-45. Rates of visits per year were calculated for ED visits and outpatient visits for all diagnoses and sickle-cell disease-related diagnoses. Overall, we found increased EDR among the transition group and young adults compared to children and adults for sickle-cell disease-related diagnoses. These findings suggest access to care issues play a significant role in the increased ED utilization seen during the transition period from pediatric to adult providers in sickle-cell disease.