Paralytic or Sedative First for RSI?

Written by Clay Smith

Spoon Feed
There was no statistically or clinically important difference in time from drug push to tube placement for neuromuscular (NM) blocker first followed by the sedative or vice versa.

Why does this matter?
Some push a sedative first then NM blocker; some do the opposite. Does it matter?

How bad could conscious paralysis be anyway?
This was a secondary analysis of a prior RCT comparing first pass success with bougie or stylet. In that study, drug order was not specified. They compared the total apnea time (first drug push to tube placement) for all patients intubated on the first attempt in a total of 562 patients: 153 sedative first; 409 NM blocker first. Pushing the NM blocker first resulted in 6 seconds shorter apnea time, with a 95%CI 0 to 11 seconds. They concluded that either drug first is acceptable.

The authors state, “apart from the theoretical, albeit unlikely, concern of awareness of neuromuscular blockade, it is difficult to think of a compelling reason to administer the sedative agent before the neuromuscular blocking agent.” Now we are into the realm of opinion, but I could not disagree more. Maybe it’s just me, but potentially being conscious while paralyzed seems pretty “compelling.” In view of this study’s finding, with no statistically or clinically important difference in time to tube placement, I can’t justify pushing a paralytic first.

Source
Drug Order in Rapid Sequence Intubation. Acad Emerg Med. 2019 Mar 4. doi: 10.1111/acem.13723. [Epub ahead of print]

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Reviewed by Thomas Davis

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