Wilson Jason W, Gillen James P, Maute Tucker
Division of Emergency Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida.
Department of Emergency Medicine, Orlando Health, Orlando, Florida.
J Emerg Trauma Shock. 2020 Oct-Dec;13(4):264-268. doi: 10.4103/JETS.JETS_92_18. Epub 2020 Dec 7.
Succinylcholine is a depolarizing agent used for rapid sequence intubation (RIS). While the agent is the most widely used drug of choice in most emergency departments (EDs), the adverse effect profile is lengthy compared to nondepolarizing paralytic agents included rocuronium and vecuronium.
Our objective in this analysis is to detect potential safety signals and differences in safety related outcomes between patients that received succinylcholine compared to those that received rocuronium or vecuronium when undergoing RSI. Specifically, we asked whether there was a difference in all-cause mortality, whether succinylcholine was used in patient later found to have contraindications to the medication, as well as differences in the rates of rescue airway or difficult airway algorithms utilized.
We utilize two clinical cases as a framework to review adverse events among ED patients undergoing RSI when using succinylcholine compared to nondepolarizing agents over a 7 years' period at our institution as part of a quality review project. The review is retrospective and does not allow us to link adverse events specifically with drug but, instead, considers aggregate level event frequency.
From January 31, 2013, to January 31, 2018, there were 36,059 intubations with paralytics in the ED (75.39% with succinylcholine and 24.61% with rocuronium or vecuronium). There was no evidence of death or associated adverse events in 98.49% of patients. Of 36,059 intubations, 14 patients expired, representing 0.039% of all RSI encounters. There were 39/100,000 total deaths during RSI events. There was a higher rate of mortality in the combined vecuronium/rocuronium group (90/100,000) compared to the sample of patients intubated with succinylcholine (22/100,000).
While the succinylcholine adverse effect profile is concerning, data from our institution does not support removal of the agent as an available option for RSI as the mortality rate among patients receiving succinylcholine was lower than that of patients receiving non-depolarizing agents. Patient level data will be needed in future work to further understand why the all-cause mortality rate was higher in the group receiving rocuronium or vecuronium and whether those patients had increased risk of mortality from underlying disease at time of presentation.
琥珀酰胆碱是一种用于快速顺序诱导插管（RIS）的去极化剂。虽然该药物是大多数急诊科（ED）最广泛使用的首选药物，但与包括罗库溴铵和维库溴铵在内的非去极化麻痹剂相比，其不良反应谱更长。
我们本次分析的目的是检测接受琥珀酰胆碱的患者与接受罗库溴铵或维库溴铵的患者在接受快速顺序诱导插管时潜在的安全信号以及安全相关结局的差异。具体而言，我们询问全因死亡率是否存在差异，琥珀酰胆碱是否用于后来被发现对该药物有禁忌证的患者，以及使用抢救气道或困难气道处理流程的比率是否存在差异。
作为质量审查项目的一部分，我们以两个临床病例为框架，回顾了在我们机构7年期间接受快速顺序诱导插管的急诊患者中使用琥珀酰胆碱与非去极化剂相比的不良事件。该审查是回顾性的，不允许我们将不良事件具体与药物联系起来，而是考虑总体事件频率。
从2013年1月31日至2018年1月31日，急诊科有36059例使用麻痹剂进行的插管（75.39%使用琥珀酰胆碱，24.61%使用罗库溴铵或维库溴铵）。98.49%的患者没有死亡或相关不良事件的证据。在36059例插管中，14例患者死亡，占所有快速顺序诱导插管病例的0.039%。快速顺序诱导插管事件期间的总死亡率为39/100000。与使用琥珀酰胆碱插管的患者样本（22/100000）相比，维库溴铵/罗库溴铵联合组的死亡率更高（90/100000）。
虽然琥珀酰胆碱的不良反应谱令人担忧，但我们机构的数据不支持将该药物从快速顺序诱导插管的可用选项中去除，因为接受琥珀酰胆碱的患者死亡率低于接受非去极化剂的患者。未来的工作将需要患者层面的数据，以进一步了解接受罗库溴铵或维库溴铵的组中全因死亡率为何更高，以及这些患者在就诊时是否因基础疾病而有更高的死亡风险。
