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Rocuronium Versus Succinylcholine in Patients With Acute Myocardial Infarction Requiring Mechanical Ventilation

2023; Wiley; Volume: 12; Issue: 10 Linguagem: Inglês

10.1161/jaha.123.029775

2047-9980

Christopher Schenck, Soumya Banna, Cory Heck, Tariq Ali, P. Elliott Miller,

Airway Management and Intubation Techniques

HomeJournal of the American Heart AssociationVol. 12, No. 10Rocuronium Versus Succinylcholine in Patients With Acute Myocardial Infarction Requiring Mechanical Ventilation Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBRocuronium Versus Succinylcholine in Patients With Acute Myocardial Infarction Requiring Mechanical Ventilation Christopher Schenck, Soumya Banna, Cory Heck, Tariq Ali and P. Elliott Miller Christopher SchenckChristopher Schenck https://orcid.org/0000-0002-9659-2033 , Yale School of Medicine, , New Haven, , CT, , USA, , Soumya BannaSoumya Banna , Department of Internal Medicine, , Yale School of Medicine, , New Haven, , CT, , USA, , Cory HeckCory Heck , Yale New Haven Hospital, , New Haven, , CT, , USA, , Tariq AliTariq Ali https://orcid.org/0000-0003-0504-403X , Section of Cardiovascular Medicine, Department of Internal Medicine, , Yale School of Medicine, , New Haven, , CT, , USA, and P. Elliott MillerP. Elliott Miller *Correspondence to: P. Elliott Miller, MD, MHS, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06517. Email: E-mail Address: [email protected] https://orcid.org/0000-0002-0595-1492 , Section of Cardiovascular Medicine, Department of Internal Medicine, , Yale School of Medicine, , New Haven, , CT, , USA, Originally published9 May 2023https://doi.org/10.1161/JAHA.123.029775Journal of the American Heart Association. 2023;12:e8468Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 9, 2023: Ahead of Print Patients with acute myocardial infarction (AMI) who require invasive mechanical ventilation (IMV) are a critically ill patient population with a high risk of mortality.1, 2 Endotracheal intubation often requires rapid sequence induction with a neuromuscular blocking agent (NMBA).3 It remains uncertain which NMBA is superior, with some studies finding improved first‐attempt success with succinylcholine,4 whereas others have found similar outcomes with rocuronium.5 Prior studies evaluating NMBAs for induction enrolled a low proportion of participants with primary cardiovascular disease.4, 5 We therefore evaluated the association between rocuronium and succinylcholine with in‐hospital mortality in a multicenter cohort of patients with AMI requiring IMV.We used the Vizient Clinical Data Base, which at the time of data extraction included >650 US hospitals. Patients aged ≥18 years who were admitted between October 2015 and December 2019 with a primary diagnosis of AMI, required IMV, and received only succinylcholine or only rocuronium on the day of intubation were included. We excluded patients who underwent surgery on the day of intubation. Patient characteristics were described stratified by NMBA. Multilevel logistic regression models were constructed to evaluate the association of NMBA with in‐hospital mortality, adjusting for demographics (age and sex), comorbidities (coronary artery disease, heart failure, end‐stage renal disease, and chronic pulmonary disease), admission characteristics (cardiogenic shock, out‐of‐hospital cardiac arrest, percutaneous coronary intervention, vasoactive medication, mechanical circulatory support, noninvasive ventilation, and renal replacement therapy before or on the same day as intubation), and hospital characteristics (number of beds and Association of American Medical Colleges teaching status), and accounting for center effect by including a random intercept for center. We constructed 2 sensitivity analyses, first excluding patients initiated on extracorporeal membrane oxygenation and second using inverse probability of treatment weighting to address residual confounding. We assessed covariate balance using weighted standardized differences with a target difference <0.10. Data analyses were performed using STATA 16.0 (Stata Corp, College Station, TX). Requests for data access may be sent to Vizient, Inc, at [email protected]com. The study included deidentified data and was exempt from institutional review board review.We identified 5604 patients, of whom 3341 (59.6%) received rocuronium (Table). Compared with those receiving succinylcholine, patients given rocuronium were younger (65.5 versus 67.1 years), and more likely to have heart failure (56.5% versus 47.8%) and end‐stage renal disease (10.3% versus 6.2%), but less likely to have chronic pulmonary disease (22.2% versus 26.6%) (all, P<0.001). Patients receiving rocuronium were more likely to present with cardiogenic shock (45.9% versus 41.9%; P=0.003) and undergo extracorporeal membrane oxygenation (9.8% versus 3.4%; P 2‐fold difference across sites after accounting for differences in presentation characteristics (median odds ratio, 2.72).Table . Patient Demographics and Clinical Characteristics for Patients With AMI Requiring Mechanical VentilationPatient characteristicsNeuromuscular blocking agentP valueWeighted standardized differences*Rocuronium (N=3341)Succinylcholine (N=2263)DemographicsAge, y65.5±12.667.1±12.3<0.001−0.011SexMen2275 (68.1)1476 (65.3)0.030.008Women1066 (31.9)785 (34.7)Race or ethnicity<0.001−0.001White2143 (64.1)1508 (66.6)Black568 (17.0)427 (18.9)Hispanic212 (6.4)112 (5.0)Other‡418 (12.5)216 (9.5)Medical comorbiditiesCAD2890 (86.5)1982 (87.6)0.240.001Heart failure1889 (56.5)1082 (47.8)<0.0010.001Valvular heart disease491 (14.7)316 (14.0)0.440.002Stroke212 (6.4)101 (4.5)0.003−0.003PVD491 (14.7)241 (10.7)<0.0010.013Hypertension1833 (54.9)1081 (47.8)<0.0010.009Diabetes1202 (36.0)727 (32.1)0.003<0.001Dyslipidemia1851 (55.4)1280 (56.6)0.390.008ESRD344 (10.3)141 (6.2)<0.001−0.006Chronic pulmonary disease740 (22.2)601 (26.6)<0.001−0.002Cancer89 (2.7)58 (2.6)0.82−0.001Liver disease227 (6.8)120 (5.3)0.02<0.001Admission characteristicsCardiogenic shock1533 (45.9)947 (41.9)0.003<0.001Out‐of‐hospital cardiac arrest585 (17.5)387 (17.1)0.690.002PCI†1637 (49.0)1210 (53.5)0.001<0.001Vasoactive medication†2582 (77.3)1624 (71.8)<0.001<0.001IABP†734 (22.0)510 (22.5)0.62−0.009pLVAD†474 (14.2)287 (12.7)0.11−0.001ECMO†328 (9.8)76 (3.4)<0.0010.017NIV†217 (6.5)160 (7.1)0.40−0.008RRT†206 (6.2)50 (2.2)<0.001−0.010Hospital characteristicsNo. of beds<0.001−0.004 7501296 (38.8)691 (30.5)AAMC teaching hospital2753 (82.4)1651 (73.0)<0.0010.001Values are mean±SD or number (percentage). Data from Vizient Clinical Data Base used with permission of Vizient, Inc. All rights reserved. AAMC indicates Association of American Medical Colleges; AMI, acute myocardial infarction; CAD, coronary artery disease; ECMO, extracorporeal membrane oxygenation; ESRD, end‐stage renal disease; IABP, intra‐aortic balloon pump; NIV, noninvasive ventilation; PCI, percutaneous coronary intervention; pLVAD, percutaneous left ventricular assist device; PVD, peripheral vascular disease; and RRT, renal replacement therapy.*After inverse probability of treatment weighting.†Initiated before or same day as intubation.‡Other refers to patients in the Vizient Clinical Database who did not identify as White, Black or Hispanic.Patients who received rocuronium had higher in‐hospital mortality compared with those who received succinylcholine (42.4% versus 33.6%; P<0.001). After adjusting for demographics, comorbidities, admission characteristics, and hospital characteristics, rocuronium use remained associated with higher in‐hospital mortality (odds ratio [OR], 1.40 [95% CI, 1.23–1.59]). In sensitivity analysis, this association persisted after excluding patients who received extracorporeal membrane oxygenation (OR, 1.46 [95% CI, 1.28–1.66]). After inverse probability of treatment weighting, rocuronium use continued to be associated with a 5.7% (weighted mean; [95% CI, 3.2%–8.2%]) higher in‐hospital mortality (Table).In this large, multicenter study, we found that administration of rocuronium was associated with higher in‐hospital mortality compared with succinylcholine in patients with AMI requiring IMV. Succinylcholine may facilitate improved first‐attempt success compared with rocuronium,4 which may be a mechanism by which choice of NMBA affects clinical outcomes. It is also possible that the 2 drugs may have differential effects on the cardiovascular system, which is possibly heightened in ischemic myocardium.This study has several limitations, including an observational, retrospective design, a lack of clinical variables (eg, vital signs, laboratory data, medication dosage and frequency, and institution of targeted temperature management), and intubation characteristics (eg, Pao2, number of attempts, setting, and operator), which could influence outcomes. There are important differences between groups and likely residual confounding despite multivariable adjustment and inverse probability of treatment weighting analysis. However, this unique database allowed for us to identify diagnoses present on admission, date‐stamped procedures, and detailed pharmacy data.In conclusion, rocuronium use may be associated with higher in‐hospital mortality compared with succinylcholine in patients with AMI requiring IMV. Although our results should be interpreted as hypothesis generating only, given the lack of patients with AMI in clinical trials and their unique physiological features, we believe a randomized controlled trial with appropriate rocuronium dosing is necessary to assess outcomes in disease‐specific populations, such as AMI, before changing practice.Sources of FundingNone.DisclosuresNone.Footnotes*Correspondence to: P. Elliott Miller, MD, MHS, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06517. Email: elliott.[email protected]eduThis article was sent to Julie K. Freed, MD, PhD, Associate Editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 3.References1 Metkus TS, Miller PE, Alviar CL, Baird‐Zars VM, Bohula EA, Cremer PC, Gerber DA, Jentzer JC, Keeley EC, Kontos MC, et al. Advanced respiratory support in the contemporary cardiac ICU. Crit Care Explor. 2020; 2:e0182. doi: 10.1097/CCE.0000000000000182CrossrefMedlineGoogle Scholar2 Rubini Giménez M, Miller PE, Alviar CL, van Diepen S, Granger CB, Montalescot G, Windecker S, Maier L, Serpytis P, Serpytis R, et al. Outcomes associated with respiratory failure for patients with cardiogenic shock and acute myocardial infarction: a substudy of the CULPRIT‐SHOCK trial. J Clin Med. 2020; 9:860. doi: 10.3390/jcm9030860CrossrefMedlineGoogle Scholar3 Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM, Society DA, Society IC. Medicine FoIC, et al. guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018; 120:323–352. doi: 10.1016/j.bja.2017.10.021CrossrefMedlineGoogle Scholar4 Guihard B, Chollet‐Xémard C, Lakhnati P, Vivien B, Broche C, Savary D, Ricard‐Hibon A, Marianne Dit Cassou PJ, Adnet F, Wiel E, et al. Effect of rocuronium vs succinylcholine on endotracheal intubation success rate among patients undergoing out‐of‐hospital rapid sequence intubation: a randomized clinical trial. JAMA. 2019; 322:2303–2312. doi: 10.1001/jama.2019.18254CrossrefMedlineGoogle Scholar5 Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, Hunziker PR, Siegemund M. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial. Crit Care. 2011; 15:R199. doi: 10.1186/cc10367CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails May 16, 2023Vol 12, Issue 10 Article InformationMetrics Copyright © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.123.029775PMID: 37158165 Manuscript receivedFebruary 8, 2023Manuscript acceptedApril 25, 2023Originally publishedMay 9, 2023 Keywordsrapid sequence inductionacute myocardial infarctionrespiratory failureneuromuscular blocking agentmechanical ventilationPDF download SubjectsCardiopulmonary Resuscitation and Emergency Cardiac Care