Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport...

Area of Science:

• Emergency Medicine
• Anesthesiology
• Critical Care Transport

Background:

• Rocuronium is a frequently used neuromuscular blocker (NMB) for rapid sequence intubation (RSI) by transport teams.
• Previous research indicates a potential delay in postintubation sedation with rocuronium compared to succinylcholine.

Purpose of the Study:

• To compare the time to sedation and fentanyl administration following RSI using rocuronium versus succinylcholine in a critical care transport setting.
• To identify potential areas for optimizing sedation and analgesia protocols after rocuronium-facilitated intubation.

Main Methods:

• Retrospective review of 264 intubations performed by Boston MedFlight critical care transport teams between January 2017 and December 2019.
• Analysis of data comparing patients intubated with succinylcholine (n=92) versus rocuronium (n=172).
• Assessment of time from NMB administration to first sedation dose and total hourly weight-adjusted fentanyl dose post-intubation.

Main Results:

• The mean time from NMB administration to the first dose of sedation was significantly longer for rocuronium (14.8 minutes) compared to succinylcholine (9.2 minutes) (P < .001).
• Patients intubated with rocuronium received a significantly lower total hourly weight-adjusted fentanyl dose post-neuromuscular blockade compared to those intubated with succinylcholine.
• Ketamine and etomidate were the most common induction agents used in both groups.

Conclusions:

• Rocuronium administration for RSI was associated with a prolonged interval to sedation and reduced post-blockade fentanyl use compared to succinylcholine.
• Findings highlight opportunities to enhance sedation and analgesia strategies in critical care transport following rocuronium-based RSI.