Rocuronium Dose and First-Attempt Intubation Success in the Critically Ill: Secondary Analysis of Two Multicenter Trials

Abstract

RATIONALE Neuromuscular blockade dose may affect intubation success on the first attempt, thereby impacting outcomes for patients undergoing emergency tracheal intubation. OBJECTIVE To evaluate the association between rocuronium dose and tracheal intubation outcomes among adults undergoing emergency tracheal intubation in the emergency department (ED) and intensive care unit (ICU). METHODS We conducted a secondary analysis of data from 2 multicenter randomized controlled trials studying airway management in the ED and ICU. We compared patient characteristics and intubation outcomes between patients receiving high-dose (>1.2 mg/kg) versus standard-dose (≤1.2 mg/kg) rocuronium. The primary outcome was successful intubation on the first attempt. We used propensity matching to account for measured potential confounders, stratified by setting. MEASUREMENTS AND MAIN RESULTS Participating sites included 9 EDs and 24 ICUs in the United States. Among 2,440 patients in the trial datasets, we included the 1,822 (74.7%) patients who received rocuronium in the current analysis. Of these, 720 (39.5%) received high-dose rocuronium and 1,102 (60.5%) received standard-dose rocuronium. Participants receiving high-dose rocuronium had higher probability of successful intubation on the first attempt (adjusted relative risk [RR] 1.06, 95% confidence interval [CI] 1.01-1.11). This difference in the primary outcome was not present for ED intubations (adjusted RR 0.97, 95%CI 0.90-1.04) but was present for ICU intubations (adjusted RR 1.12, 95% CI 1.05-1.19). CONCLUSION In this secondary analysis, high-dose rocuronium (>1.2 mg/kg) was associated with higher first-attempt success. Given the potential for unmeasured confounding, these findings warrant evaluation in a randomized controlled trial.