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Background: The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated.Objective: We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt. Methods:We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model. Results:Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).Conclusion: Administration of either the neuromuscular blocking or the sedative agent first are both acceptable.Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.

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Background and objectivesWe sought to evaluate the effect of adult procedural sedation on cerebral oxygenation measured by near-infrared spectroscopy (rSo2 levels), and to assess whether respiratory depression occurring during procedural sedation was associated with decreases in cerebral oxygenation.MethodsWe performed a prospective, observational preliminary study on a convenience sample of adult patients (>18 years) undergoing unscheduled procedural sedation in the ED from August 2017 to September 2018 at Hennepin County Medical Center in Minneapolis, Minnesota. The primary outcome measures were rSo2 values by level of sedation achieved and the incidence of cerebral hypoxaemia during procedural sedation (absolute rSo2 ≤60 or decrease ≥20% from baseline). The secondary outcome is the decrease in rSo2 during episodes of respiratory adverse events (AEs), defined by respiratory depression requiring supportive airway measures.ResultsWe enrolled 100 patients (53% female). The median (IQR) rSo2 values (%) by each level of sedation achieved on the Observer Assessment of Alertness and Sedation (OAAS) scale 1–5, respectively, were 74 (69–79), 74 (70–79), 74 (69–79), 75 (69–80), 72 (68–76). The incidence of cerebral hypoxaemia at any point within the sedation (absolute rSo2 <60%) was 10/100 (10%); 2 out of 10 had rSo2 reduction more than 20% from baseline value; the median (IQR) observed minimum rSo2 in these patients was 58 (56–59). We observed respiratory depression in 65 patients via standard monitoring; of these, 39 (60%) required at least one supportive airway measure, meeting the definition of a respiratory AE. During these AEs, 15% (6/39) demonstrated cerebral hypoxaemia with a median (IQR) minimum rSo2 of 58 (57–59). Four patients (4%) had cerebral hypoxaemia without a respiratory AE.ConclusionCerebral oximetry may represent a useful tool for procedural sedation safety research to detect potential subclinical changes that may be associated with risk, but appears neither sensitive nor specific for routine use in clinical practice.