Impact of Paralytic Agent Choice on Time to Post-Intubation Sedation in the Emergency Department

Background/Objectives: Rapid sequence intubation (RSI) involves nearly simultaneous administration of a rapid-acting induction agent and a neuromuscular blocking agent (NMBA) to facilitate ideal intubation conditions. The NMBAs most commonly used for RSI are succinylcholine and rocuronium, which cause paralysis for 5-15 minutes and 45-70 minutes, respectively. Awareness with paralysis can occur in patients given longer-acting NMBAs with delayed initiation of post-intubation sedation or insufficient sedation depth. Previous literature has associated the use of rocuronium with a significantly longer time to sedation and analgesia. However, a recent study found no difference. The purpose of this study was to assess the association between paralytic agent choice and time to initiation of analgesia and/or sedation after RSI in the emergency department (ED) of a large tertiary care hospital. Methods: This study was an institutional review board-approved, single center, retrospective cohort evaluation of adult patients (≥ 18 years of age) who received succinylcholine or rocuronium following administration of an induction agent in the ED for RSI during the study time period. The primary outcome was time to initiation of post-intubation analgesia and/or sedation. Continuous data was analyzed using Mann Whitney U or student’s T-test, and categorical data was analyzed using Chi Square test or Fisher’s Exact test. Results: A total of 400 patients were included in this study. The median time to sedation with succinylcholine was 9 minutes compared to 14 minutes with rocuronium (p<0.01). No significant differences were identified in baseline characteristics or secondary outcomes related to induction agent choice or ED length of stay. Conclusions: The results of this study further support that the use of rocuronium for RSI is associated with a significantly longer time to sedation and/or analgesia, making emergency medicine provider awareness essential towards minimizing the risks associated with inadequate post-intubation sedation.