Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.
Acad Emerg Med. 2019 Sep;26(9):1014-1021. doi: 10.1111/acem.13723. Epub 2019 Mar 19.
The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated.
We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.
We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model.
Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).
Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.
在快速序贯插管（RSI）中，药物给药的最佳顺序（镇静剂先给还是神经肌肉阻滞剂先给）存在争议。
我们旨在确定 RSI 药物顺序是否与从给予第一剂 RSI 药物到首次插管成功结束之间的时间有关。
我们对一项接受紧急经口气管插管的成人 ED 患者的随机试验进行了计划的二次分析，该试验表明使用引导管与气管导管+管芯相比，首次尝试的成功率更高。未规定药物选择、剂量以及镇静剂和神经肌肉阻滞剂的给药顺序。我们分析了在彼此 30 秒内接受了镇静剂和神经肌肉阻滞剂且首次尝试插管成功的试验患者。主要结局是从第一剂 RSI 药物完全给予到首次插管尝试结束的时间，这是呼吸暂停时间的替代结局。我们使用混合效应广义线性模型进行了多变量分析。
在最初的 757 例试验患者中，有 562 例（74%）符合分析标准；153 例患者先给予镇静剂，409 例患者先给予神经肌肉阻滞剂。与先给予镇静剂相比，先给予神经肌肉阻滞剂与从 RSI 给药到插管尝试结束的时间减少 6 秒（95%置信区间= 0 至 11 秒）相关。
先给予神经肌肉阻滞剂或镇静剂均可接受。先给予神经肌肉阻滞剂可能会使插管时间略有加快。目前，医生继续以他们最舒适的方式进行 RSI 是合理的。如果未来的研究确定药物给药顺序与神经肌肉阻滞的意识无关，那么先给予神经肌肉阻滞剂可能是一种合理的默认给药方法，试图尽量减少插管期间的呼吸暂停时间。
