1. Harsharon Chopra, BS 1, Josh Malo, MD, John Sakles, MD 2, Cameron Hypes, MD, MPH 2,3, John W Bloom, MD 2, Jarrod Mosier MD 2,3 1 The University of Arizona College of Medicine, 2 Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, The University of Arizona, 3 Department of Emergency Medicine, The University of Arizona Neuromuscular Blockade Improves First Attempt Success for Intubation in the ICU: A Propensity Adjusted Analysis BACKGROUND Tracheal intubation in critically ill patients is a commonly required procedure that is fraught with risk and there is controversy over who should perform intubations in the ICU, what device(s) should be used, and what the optimal method of pharmacologic assistance is. Neuromuscular blocking agent (NMBA) use has been shown to improve first attempt success and decrease procedurally related complications in the OR and ED, yet remains controversial in the ICU. The goal of this study is to compare first attempt success in patients intubated with the use of a NMBA in the medical ICU with patients intubated without a NMBA. Subgroup analyses were identified a priori, which included comparing first attempt success and intubating conditions achieved with succinylcholine versus rocuronium, and the effect of neuromuscular blockade on the patients intubated with video laryngoscopy. RESULTS 711 patients were intubated. Patients were excluded for flexible fiberoptic intubations (42), nasal intubation (1) and medical-student intubation (4) giving a total of 664 patients for the study. 496 (75%) were intubated with NMBA and 168 (25%) were intubated without NMBA. Patients without NMBA-use had higher median DACs (2.4 vs. 1.8 p<0.001) and higher use of ketamine (39.3% vs. 8.9%, p<0.001). First attempt success higher in patients using a NMBA (401/496, 81%, 95% CI 77-84%) compared to those intubated without a NMBA (117/168, 70%, 95% CI 62-76%). The unadjusted odds ration of first attempt success using a NMBA was 1.84 (95% CI 1.24-2.74, p=0.003). Propensity adjusted multivariate regression controlling for confounds demonstrated an odds ration of 2.17 (95% CCI 1.29-3.66, P<0.01) for FAS when a NMBA was used. RESULTS (cont.) ROCURONIUM COMPARED TO SUCCINYLCHOLINE VIDEO LARYNGOSCOPY SUBGROUP MATERIALS AND METHODS Single-center prospective observational analysis of 664 consecutive ICU intubations performed from January 1, 2012 to June 30, 2014 at a major academic referral center with a 20+ bed medical ICU. All intubations are performed under supervision by faculty skilled in airway management. All patients intubated using direct laryngoscopy (DL) or video laryngoscopy (VL) were included in this study. Following each intubation, the operator completed a data collection form, which included information such as patient demographics, operator specialty, indication for intubation, paralytic agent, sedative agent, device(s) used, presence of certain difficult airway characteristics (DACs), pre- oxygenation methods, number of attempts at intubation and the outcome of each attempt, including complications. Propensity adjustment was performed for likelihood of NMBA use. The primary outcome measured was successful first attempt intubation. CONCLUSIONS In this observational study of intubations in the ICU, the use of a neuromuscular blocking agent to facilitate intubation was associated with higher odds of first attempt success after controlling for potential confounding variables. In the video laryngoscopy subgroup, NMBA use was also associated with higher odds of first attempt success and improved laryngoscopic view. These data suggest that a NMBA is an attractive option when faced with intubation in a critically ill ICU patient. First Attempt Success Rate MULTIVARIATE REGRESSION MODEL FOR SUCCESS #729 DIFFICULT AIRWAY PREDICTOR DEMOGRAPHICS Characteristic Paralytic %, (n=496) No Paralytic %, (n=168) p-Value DAPs Total DAPs (median)1.82.4<0.001 None21.7% (108)15.6% (26)0.10 Cervical immobilization2.2%(11)4.2% (7)0.18 Blood in Airway14.9% (74)16.2% (27)0.71 Vomit in Airway5.03% (25)7.2% (12)0.33 Facial/neck Trauma0.6% (3)0.6% (1)1.00 Obesity27.8% (138)33.5% (56)0.17 Short Neck22.5% (112)28.1% (47)0.14 Large Tongue12.1% (60)16.8% (28)0.15 Airway Edema7.0% (35)10.8% (18)0.14 Small Mandible13.9% (69)19.2% (32)0.11 Hypoxia26.2% (130)29.9% (50)0.37 Hemodynamic Instability21.3% (106)28.1% (47)0.07 Limited Mouth Opening10.1% (39)23.9% (32)<.001 Secretions17.9% (69)23.9% (32)0.16 Variable Adjusted Odds Ratio (aOR) 95% CI p-Value Paralytic use2.161.28–3.640.004 Total number of DAPs0.830.74-0.940.004 Sedative None[Reference] Etomidate0.130.01-1.450.10 Ketamine0.190.04-0.980.05 Versed0.260.02-3.410.30 Propofol0.150.02-0.990.05 Device Direct Laryngoscopy[Reference] Glidescope Video Laryngoscopy4.121.92-8.78<0.001 CMAC Video Laryngoscopy3.031.59-5.760.001 Other Video Laryngoscopes2.250.23-22.460.50 Operator PGY 1[Reference] 21.960.90-4.270.09 31.030.46-2.280.95 43.081.42-6.660.004 53.141.44-6.840.004 62.481.02-6.020.05 Attending21.222.30-196.240.007 Propensity Score2.650.23-30.000.43 OutcomeSuccinylcholineRocuroniump-Value First attempt Success 83% (267/323)77% (125/162)0.18 CL I or II85% (273/323)78% (127/162)0.10 POGO Score (mean) 71%73%0.67 OutcomeParalyticNo Paralyticp-Value First attempt Success 85% (334/395)69% (103/149)<0.001 CL I or II87% (343/395)78% (116/149)0.02 POGO Score (mean) 77%71%0.05