Catoire Pierre, Driver Brian, Prekker Matthew E, Freund Yonathan
Emergency Department, Hôpital Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris, Paris, France.
Improving Emergency Care (IMPEC) FHU, Sorbonne Université, Paris, France.
Acad Emerg Med. 2025 Feb;32(2):123-129. doi: 10.1111/acem.15031. Epub 2024 Oct 18.
Emergency tracheal intubation is associated with a risk of clinical adverse events, including the risk of first-attempt failure. Induction agents usually include a sedative and a neuromuscular blocking agent (i.e., paralytic). Whether the order of administration (i.e., sedative vs. paralytic given first) is associated with first-attempt failure or adverse events is unknown.
This study analyzed data from a single-center prospective cohort collected from 2021 to 2024 at Hennepin County Medical Center, which included all patients undergoing orotracheal intubation in the emergency department. Patients with no detail on administration sequence order were excluded. A Bayesian logistic regression analysis was used to measure the effect of drug sequence order (sedative first vs. paralytic first). The primary outcome was first-attempt failure. The key secondary outcome was peri-intubation hypoxemia (SpO < 90%). We estimated the odds ratio (OR), 95% credible interval (CrI), and the probability that the OR was inferior to 1 (existence of an effect) and inferior to 0.9 (significant effect). Frequentist analysis and reanalysis with various priors were performed as sensitivity analyses.
A total of 2216 patients were included for analysis. The most frequently used sedative and paralytic agents were etomidate (88.9%) and rocuronium (77.8%), respectively. The paralytic was given first to 56.6% of the patients. After adjustment for age, sex, body mass index, and sedative and paralytic agents, the OR for a paralytic-first strategy for first-attempt failure was 0.73 (95% CrI 0.46-1.02). The probability that the OR was less than 1 was estimated at 95.7% and less than 0.9 at 87.6%. There was a 33.5% and 8.0% probability that administering the paralytic first resulted in an OR < 1 and OR < 0.9 for the risk of hypoxemia, respectively. Sensitivity analyses were consistent with the main results.
In this Bayesian analysis a paralytic-first drug sequence was associated with reduced first-attempt failure during emergency tracheal intubation.
紧急气管插管与临床不良事件风险相关，包括首次尝试失败的风险。诱导药物通常包括镇静剂和神经肌肉阻滞剂（即麻痹剂）。给药顺序（即先给予镇静剂还是先给予麻痹剂）是否与首次尝试失败或不良事件相关尚不清楚。
本研究分析了2021年至2024年在亨内平县医疗中心收集的单中心前瞻性队列数据，其中包括急诊科所有接受口气管插管的患者。排除给药顺序细节缺失的患者。采用贝叶斯逻辑回归分析来衡量药物顺序（先给予镇静剂与先给予麻痹剂）的影响。主要结局是首次尝试失败。关键次要结局是插管期间低氧血症（SpO＜90%）。我们估计了比值比（OR）、95%可信区间（CrI）以及OR小于1（存在效应）和小于0.9（显著效应）的概率。进行频率分析和使用各种先验进行重新分析作为敏感性分析。
共有2216例患者纳入分析。最常用的镇静剂和麻痹剂分别是依托咪酯（88.9%）和罗库溴铵（77.8%）。56.6%的患者先给予麻痹剂。在调整年龄、性别、体重指数以及镇静剂和麻痹剂后，首次尝试失败的先给予麻痹剂策略的OR为0.73（95% CrI 0.46 - 1.02）。估计OR小于1的概率为95.7%，小于0.9的概率为87.6%。先给予麻痹剂导致低氧血症风险的OR＜1和OR＜0.9的概率分别为33.5%和8.0%。敏感性分析与主要结果一致。
在这项贝叶斯分析中，先给予麻痹剂的药物顺序与紧急气管插管期间首次尝试失败的减少相关。
