Neuromuscular Blockade Improves First Attempt Success for Intubation in the Intensive Care Unit: A Propensity Matched Analysis.

<p>Rationale: The use of neuromuscular blocking agents (NMBA) has been shown to be valuable in improving successful tracheal intubation in the operating room and emergency department. However, data on neuromuscular blocking agent use in critically ill intensive care unit (ICU) patients are lacking. Further, there are no data on neuromuscular blocking agent use with video laryngoscopy. Objectives: To evaluate the effect of neuromuscular blocking agent use on first attempt success (FAS) with tracheal intubation in the ICU. Methods: Single-center observational study of 709 consecutive patients intubated in the medical ICU of a university medical center from January 1, 2012-June 30, 2014. Data were collected prospectively through a continuous quality improvement program (CQI) on all patients intubated in the ICU over the study period. Data relating to patient demographics, intubation, and complications were analyzed. We used propensity score (propensity to use a neuromuscular blocking agent) matching to generate 5,000 data sets of cases (failed first intubation attempts) matched to controls (successful first attempts) and conditional logistic regression to analyze the results. Measurements and Main Results: There were no significant differences in patient demographics, except median total difficult airway characteristics (DACs) were higher in the non-neuromuscular blocking agent group (2 vs. 1, p&lt;0.001). There were significant differences in the sedative used between groups and the operator level of training. More patients who were given neuromuscular blocking agents received etomidate (83% vs. 35%) and more patients in the non-neuromuscular blocking agent group received ketamine (39% vs. 9%) (p&lt;0.001). The first attempt success for neuromuscular blocking agent use was 80.9% (401/496) compared to 69.6% (117/168) for non-neuromuscular blocking agent use, p=0.003. The summary odds ratio for first attempt success when a neuromuscular blocking agent was used from the propensity matched analyses was 2.37 (95% CI: 1.36-4.88). In the subgroup of patients intubated with a video laryngoscope, propensity adjusted odds of first attempt success with the use of a neuromuscular blocking agent was 2.50, (1.43-4.37, p&lt;0.001). There were no differences in procedurally related complications between groups. Conclusions: After controlling for potential confounders, this propensity-adjusted analysis demonstrates improved odds of first attempt success at intubation in the ICU with the use of a neuromuscular blocking agent. This improvement in first attempt success is seen even with the use of a video laryngoscope.</p>