In other words, use a neuromuscular blocker – as if we didn’t already know that. However, since the upper 95%CI was also negative (–0.5%), this showed it was, in fact, inferior. Rocuronium (usually 0.61.2 mg kg 1) reversed in the event of failed tracheal intubation with sugammadex up to 16 mg kg 1. But it was –11.6%, which means it was not non-inferior. Suxamethonium or rocuronium for rapid sequence induction of anaesthesia Suxamethonium (usually 12 mg kg 1) and await spontaneous reversal of NMB in the event of failed tracheal intubation. Do you think 7% is the right number? Reasonable people could disagree. But this is just the opinion of the authors. They established up front that if the lower 95%CI was greater than (more positive than) –7%, this would indicate non-inferiority. *Nerd’s Corner: Non-inferiority trials are tricky to interpret. Although the authors leave the door open to future investigations, I will proceed with a sedative and paralytic during my next RSI.Įffect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial. Overall, remifentanil is not ready for prime time, particularly for ED-specific RSI. ileus, bowel obstruction) versus other risk factors, each demonstrated a similar trend for inferiority of remifentanil, without intergroup statistically significant differences. Importantly, the subgroup analyses between both video and direct laryngoscopy, as well as digestive occlusion (i.e. They found first pass success without major complication in 66.1% of patients in the remifentanil group and 71.6% in the neuromuscular blocker group: adjusted difference –6.1% (95%CI –11.6% to –0.5%, P = 0.37 for noninferiority), which means remifentanil was inferior*. The authors also included various secondary outcomes including time to intubation, rescue therapies for difficult intubation, and several others. The primary outcome was successful tracheal intubation on the first attempt without major complications such as aspiration, hypoxemia, or hemodynamic instability, and the non-inferiority margin was set at -7%.
#Rapid sequence intubation history trial
This multicenter, parallel-group, open-label, randomized non-inferiority clinical trial included 1,150 patients at-risk for aspiration (pre-op fasting 98%). Are rapid-onset opioids, such as remifentanil, a safe and effective alternative to paralytics? These are real considerations in the current climate of prolonged ED boarding. Adverse effects of neuromuscular blockers include metabolic derangements and prolonged paralysis with awareness. However, no studies to date effectively challenge this practice.
In patients at risk of aspiration, RSI with a combination of a sedative/hypnotic agent and paralytic is standard of care.
#Rapid sequence intubation history plus
This randomized, non-inferiority trial found that remifentanil plus hypnotics were inferior to neuromuscular blocking agents plus hypnotics for rapid sequence intubation (RSI) of patients at risk of aspiration in the operating room setting.
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