Impact of paralytic choice on postintubation sedation and analgesia in the emergency department

Purpose We describe the timing of first-dose sedation and analgesia after rapid sequence intubation (RSI) in patients induced with etomidate and paralyzed with rocuronium or succinylcholine.Methods This was a retrospective study of adult patients undergoing RSI in 3 emergency departments (EDs). We evaluated the time to administration of analgesia and sedation using a Cox proportional hazard model controlling for choice of paralytic, post-RSI hypotension (nadir systolic blood pressure of less than 100 mm Hg in the first hour), bedside presence of an ED pharmacist, and practice site. We also describe the first doses of post-RSI analgesia and sedation.Results A total of 2,059 adult patients were included in the study, of whom 1,532 received rocuronium and 527 received succinylcholine. The median time to first dose of sedation was 12 minutes (interquartile range [IQR], 7-26 minutes) in patients given rocuronium and 10 minutes (IQR, 6-19 minutes) in those given succinylcholine. The median time to analgesia was 24 minutes (IQR, 10-78 minutes) and 21 minutes (IQR, 10-60 minutes), respectively. Administration of rocuronium was associated with lower rates of sedation (adjusted hazard ratio [aHR], 0.75; 95% confidence interval [CI], 0.67-0.85) and analgesia (aHR, 0.73; 95% CI, 0.62-0.87). Hypotension was also predictive of decreased sedation (aHR, 0.67; 95% CI, 0.54-0.80), while bedside presence of an ED pharmacist was associated with improvement (aHR, 1.14; 95% CI, 1.03-1.27). Overall, the median post-RSI initial propofol infusion rate was low at 20 mu g/kg/min (IQR, 10-30 mu g/kg/min).Conclusion Use of rocuronium for RSI was associated with reduced likelihood of timely post-RSI sedation and analgesia. Coupled with low initial sedative dosing, our findings suggest that patients intubated with rocuronium are at increased risk of being awake during paralysis.