Medication practices during and immediately after rapid sequence intubation (RSI) show wide variation among ICUs and emergency departments (EDs) across the United States, a new study has found.
There were clear differences in choice of medication, based on patient location and type of intubating provider. “Practices likely vary because there are several controversies regarding medication selection and dose for each step of RSI, which include preinduction, induction and paralysis, as well as postintubation sedation and analgesia practices,” said Christine Groth, PharmD, critical care clinical pharmacy specialist at the University of Rochester Medical Center, in New York, who was the lead researcher of the study, which was presented during the 2016 Society of Critical Care Medicine’s Critical Care Congress (abstract 582).
The multicenter, observational, cross-sectional study was sponsored by the Critical Care Pharmacotherapy Trials Network (ccptn.org), a collaborative group of critical care practitioners dedicated to the study and development of pharmacotherapy for critically ill patients through high-level, multicenter research.
One-Day Snapshot Study
On March 12, 2015, all participating sites reviewed their current adult and pediatric ICU and ED census and included all patients intubated during admission. A 24-hour data collection around the time of first intubation was performed to capture all data related to the patient, provider, location and RSI procedure.
A total of 404 patients were included; minimal adverse effects were found, although this was a small representation of patients who received medications for RSI. The researchers concluded that there were areas in which pharmacist intervention could improve the procedure. Interventions might include avoiding succinylcholine in patients with or who were at risk for hyperkalemia, substituting ketamine for etomidate in septic patients, or clarifying the lack of literature supporting increased intracranial pressure with ketamine in traumatic brain injury/stroke.
The researchers also found a high incidence of continuous infusion sedation and analgesia and use of sedation alone after RSI, which is not consistent with current literature. In addition, many patients did not receive appropriate sedation after administration of a nondepolarizing neuromuscular blocking agent. In the first 24 hours post-RSI, a majority of patients were not screened for delirium in the ICU.
When asked about the role of a pharmacist during RSI, Dr. Groth said, “Pharmacists can ensure safe and effective medication use during RSI by helping to clarify some of the existing controversies and make recommendations on choice of medication, as well as dose.”
Dr. Groth and her co-investigator Nicole Acquisto, PharmD, who is also at the University of Rochester Medical Center, thought that clinical practice guidelines that scientifically evaluate the current literature and give evidence-graded recommendations or expert opinion on appropriate medication use during RSI would help standardize RSI medication selection in different populations and improve post-RSI management.
“Consensus guidelines that clarify all the controversies surrounding medication use during RSI could be used by critical care and emergency medicine clinicians to streamline care at the institutional level,” said Dr. Groth.