PURPOSE: Rapid sequence induction (RSI) for emergency endotracheal intubation (EEI) by definition utilizes a paralytic agent and is standard practice in many critical care settings. Alternatively, EEI may be accomplished without use of a paralytic agent. We report on the safety of EEI performed with propofol without the use of a paralytic agent.
METHODS: We reviewed safety of 400 consecutive EEIs at two tertiary care hospitals performed by intensivists without anesthesiologist involvement. EEI was performed using a standard algorithmic approach that included a mandatory 40 point checklist, combined team function including simulation training, and emphasis on maintaining gas exchange and perfusion status. Critical care fellows were the primary intubators with backup by the attending physician. Propofol was the sole agent used for all EEI. Vasopressors were used to either preemptively block or treat hypotension. Safety data was collected prospectively as part of an ongoing quality improvement project.
RESULTS: Tracheal tube insertion was successful in all 400 cases. Complications were as follows: desaturation (SaO2< 80%) 44/400 (11%); hypotension (SBP< 80mmHg) 28/400 (7%); death 2/400 (0.5%); esophageal intubation 55/400 (14%); dental injury 4/400 (1%); difficult intubation (>2 attempts) 85/400 (21%).
CONCLUSION: Our results compare favorably with the complication rate of EEI reported in critical care and anesthesiology literature and indicate that the use of a paralytic agent is not necessary for safe EEI. Our complication rate reflects the difficult challenges inherent to intubating the unstable out of operating room in critically ill patient compounded by the need to train fellows in this difficult procedure.
CLINICAL IMPLICATIONS: The use of a paralytic agent may facilitate EEI but exposes the patient to complications such as 1. inability to perform BVM ventilation following a failed intubation or 2. lethal hyperkalemia secondary to unrecognized metabolic or neuromuscular disease. EEI maybe accomplished with acceptable safety using a sedative agent alone and the use of a paralytic agent is not mandatory.
DISCLOSURE: Viera Lakticova, No Financial Disclosure Information; No Product/Research Disclosure Information