Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study

Abstract

Objective Greater Sydney Area Helicopter Emergency Medical Service encouraged an increased dose of rocuronium for rapid sequence intubations (RSIs) from 1.5 mg/kg to 2.0 mg/kg from the end of 2017 in response to a number of inadequately paralysed patients identified by our airway audit processes. Subsequent protocol change incorporated 2.0 mg/kg rocuronium. This retrospective observational study was undertaken to see if doses over 1.5 mg/kg rocuronium were associated with a reduction in the number of inadequately paralysed patients. Methods Retrospective review of patient prehospital notes and airway database records from 2017 to 2018 for all cases using rocuronium for RSI. Primary outcome of interest was physician notes describing skeletal muscle activity at laryngoscopy. Patients with tissued vascular access were excluded. Dose of rocuronium, estimated patient actual weight and grade of laryngoscopy were recorded. Comparisons were made between rocuronium doses ≤1.5 mg/kg and >1.5 mg/kg by estimated weight. Results From 211 patients receiving rocuronium ≤1.5 mg/kg, five cases were inadequately paralysed, compared with two cases from 384 patients receiving >1.5 mg/kg rocuronium. Conclusions Although there were fewer inadequately paralysed patients with rocuronium doses >1.5 mg/kg, this did not reach statistical significance, presumably because of the low event rate. Further investigation into rocuronium dose for RSI is warranted.

Cardiorespiratory consequences of attenuated fentanyl and augmented rocuronium dosing during protocolised prehospital emergency anaesthesia at a regional air ambulance service: a retrospective study

“…The increased dosing regimen in the new SOP aligns with the improved FPS rate findings seen in emergency department intubations [ 8 ]. It also correlates with a recent paper from the Greater Sydney Area Helicopter Emergency Medical Service, who introduced a higher dose of rocuronium at the end of 2017, and showed there was a trend to fewer inadequately paralysed patients with a higher dose of rocuronium [ 21 ]. Hypoxia can also have an important influence on outcomes, particularly in traumatic brain injury mortality, and we would therefore encourage the use of a higher dose of rocuronium in patients requiring an emergency anaesthetic [ 5 ].…”

The effect of ketamine and fentanyl on haemodynamics during intubation in pre‐hospital and retrieval medicine

“…Despite previous literature showing an association between fentanyl use and higher first‐pass intubation success 21,30 we found no evidence that the addition of fentanyl to the induction regimen affected first‐pass intubation success rates, which were high in both groups. This may be due to the high doses of rocuronium used in our study, which are demonstrated to have low rates of inadequate paralysis, 31 but may also be the result of lower‐range fentanyl doses that are unlikely to improve intubation performance.…”