Randomized, Double-Blind Study on Sedatives and Hemodynamics During Rapid-Sequence Intubation in the Emergency Department: The SHRED Study,☆☆,,★★

Presented in part at the Fifth Inter national Congress of EmergencyMedicine Meeting, London, England, May 1994, and at the Canadian Association of EmergencyPhysicians Scientific Assembly, Ottawa, Canada, May 1995.
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Abstract

Study objective: To compare thiopental, fentanyl, and midazolam for rapid-sequence induction and intubation (RSI). Methods: Eighty-six patients undergoing RSI in the emergency department were randomly assigned in a double-blind fashion to receive either thiopental (5 mg/kg), fentanyl (5 μg/kg), or midazolam (.1 mg/kg) before paralysis was induced. Outcome measures were mortality, speed and ease of intubation, and hemodynamics. Results: Of the patients who received thiopental, 93% were in tubated within 2 minutes of paralysis (P=.037), but systolic blood pressure fell an average of 38 mm Hg in this group (P=.045). The midazolam group had a greater number of delayed intubations (31%) and an average heart rate increase of 17 beats/minute (P=.008). Mortality (24% inhospital) was unaffected by drug assignment. In all three groups, patients with pulmonary edema had the greatest decrease in blood pressure during RSI, and patients exposed to multiple attempts at intubation manifested pronounced hypertension. Conclusion: Fentanyl provided the most neutral hemodynamic profile during RSI, although factors other than choice of sedative can play a more significant role in determining hemodynamic re sponse. Depth of sedation may influence the speed of RSI. [Sivilotti MLA, Ducharme J: Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED study. Ann Emerg Med March 1998;31;313-324.]

Section snippets

INTRODUCTION

Endotracheal intubation is an essential component of the resuscitation of critically ill patients in the emergency department. In the absence of anticipated upper airway anomaly, use of neuromuscular blockade (NMB) to facilitate and expedite intubation of nonarrested patients has become standard practice among emergency physicians possessing adequate technical skill.1, 2, 3 Based on the experience of anesthetists during urgent “full stomach” intubations, techniques that use short-onset sedating

MATERIALS AND METHODS

All adult patients, including those transferred from other hospitals, who required intubation in the ED were eligible for participation. Exclusion criteria were as follows: cardio pulmonary arrest present or imminent (immediate intubation without medication indicated), status asthmaticus (ketamine sedative of choice), anticipated anatomic difficulties with the airway (paralysis relatively contraindicated), and known hypersensitivity to study medications (eg, porphyria). Every intubation

RESULTS

From May 1992 to June 1993, 120 patients underwent intubation in the ED; of these, 86 patients (72%) were enrolled and completed the study. Of the remainder, 18 patients (15%) met exclusion criteria (8 moribund, 2 status asthmaticus, 1 gunshot wound to larynx, 6 no study kit available, 1 sphygmomanometer malfunction); 11 (9%) were eligible but were excluded because of lack of familiarity with study inclusion criteria; and 5 (4%) were excluded for unknown reasons. In all, 96 (80%) of the 120

DISCUSSION

Based on the range of recommendations and on observed practice, one of the most poorly understood components of RSI is the role of the sedative agent used. As defined historically, RSI refers to rapid and simultaneous production of a sufficiently deep level of unconsciousness (induction) and neuromuscular relaxation to permit endotracheal intubation, ideally without intervening positive-pressure bag-mask–valve ventilation. Many discussions of “RSI” (usually described as rapid sequence

Acknowledgements

The authors wish to thank Richard Bondy, MD, FRCPC, for seminal discussions during the construction of the study, and Charlene Barber, RN, for assistance with data collection.

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    From the Department of Emergency Medicine, Royal Victoria Hospital, McGill University, Montreal, Canada.

    ☆☆

    This project was supported by a grant from l'Association des médecins d'urgence du Québec. Medication costs were partly defrayed by a donation from Hoffmann-La Roche Ltd.

    Address for reprints: Marco Sivilotti, MD, Department of Emergency, Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, Massachusetts 01655, 508-856-4101, Fax 508-856-6902, E-mail [email protected]

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