Primary Outcome: A paralytic-first strategy was associated with reduced risk of first-attempt failure after adjustment, with an estimated OR of 0.73 (95% CrI 0.46–1.02).
Secondary Outcome: OR estimates for risk of hypoxemia during the procedure was 0.99 (0.78–1.22)
Discussion
This is a retrospective study at one centre, with a large sample. The results differ from previous studies (1) which may be a result of its retrospective nature resulting in data collection bias.
The first attempt failure, although associated with a potential for worse outcomes, is not the outcome measure I'm interested in. I want to know about clinical outcomes. Was there harm to the patient, when one strategy was used over the other? We don't know this. This study wont change my practice very much.
I tend to use Rocuronium almost exclusively as my paralytic agent. I use it at a higher dose of 1.2mg/kg, to ensure rapid onset. For the very sick patients, especially those that can't lie down due to rapid desaturation, I might use a 'sandwich' approach ie., a little Ketamine and then all the Rocuronium and a more Ketamine. In my mind this takes care of the 'awareness' issue, (although there is no significant finding of awareness if paralytics are given first (1)) and ensures early paralysis effect.
References
