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Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications*

Wilcox, Susan R. MD; Bittner, Edward A. MD, PhD; Elmer, Jonathan MD; Seigel, Todd A. MD; Nguyen, Nicole Thuy P. BS; Dhillon, Anahat MD; Eikermann, Matthias MD, PhD; Schmidt, Ulrich MD, PhD

doi: 10.1097/CCM.0b013e31824e0e67
Clinical Investigations

Background: Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications.

Methods: Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation.

Results: The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07).

Conclusion: The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

From the Departments of Anesthesia, Critical Care and Pain Medicine (SRW, EAB, JE, ME) and Emergency Medicine (SRW), Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine (JE), Brigham and Women’s Hospital, Boston, MA; Department of Emergency Medicine (TAS), Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, Providence, RI; Boston University School of Medicine (NTPN), Boston, MA; Department of Anesthesia (AD), University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA.

*See also p. 1977.

This work was funded by the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: swilcox1@partners.org

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins