The Effect of Drug Selection on Pediatric Rapid Sequence Induction Success: A Systematic Review and Meta-Analysis

The purpose of this systematic review is to evaluate the effect of drug selection on endotracheal intubation conditions, hemodynamic response, and time course of neuromuscular blockade in children undergoing rapid sequence intubation (RSI). We systematically searched databases with no time restrictions for studies related to pediatric RSI and induction agents, as well as neuromuscular blockers. The inclusion criteria consisted of randomized controlled trials (RCTs) that studied pediatric patients who had undergone RSI. Studies involving any number of adult patients were excluded, as were studies that included opioids as induction agents. Seven RCTs (520 participants) were included. Five of the studies reported primary outcomes related to endotracheal intubation conditions, with four of these using identical methods for recording jaw relaxation, vocal cord positioning, and diaphragmatic response. Subgroup meta-analysis of these four studies reported an odds ratio of 3.38 (95% confidence interval, 1.45-7.90) for excellent intubating conditions, favoring rocuronium over other neuromuscular blockers. This meant that patients given rocuronium were 3.38 times more likely to have excellent intubating conditions compared to other neuromuscular blockers, and that this result was not due to chance. Suxamethonium consistently had faster onset and recovery times. Our systematic review demonstrated that rocuronium provides superior intubating conditions, allowing for improved first-pass success rates in pediatric RSI. Future studies should evaluate the effect of different induction agents on endotracheal intubation conditions and whether the RSI procedure itself improves mortality compared to other intubation methods.