Is paralysis necessary during intubation?

From the Guidelines

Paralysis is not always necessary during intubation, but it is commonly used to optimize conditions for successful tube placement. The decision to use paralysis should be individualized based on the clinical situation, the provider's skill level, and the risk-benefit assessment for each patient. Neuromuscular blocking agents (paralytics) like succinylcholine (1-1.5 mg/kg IV) or rocuronium (0.6-1.2 mg/kg IV) are frequently administered as part of rapid sequence intubation (RSI) to provide optimal intubating conditions by relaxing the vocal cords and eliminating patient movement 1. However, certain clinical scenarios may warrant intubation without paralysis, such as when dealing with patients who have anticipated difficult airways where maintaining spontaneous breathing is preferred, patients with severe neuromuscular disorders, or situations where paralytics are contraindicated. When intubation is performed without paralysis, adequate sedation is essential, often using medications like etomidate (0.2-0.3 mg/kg), ketamine (1-2 mg/kg), or propofol (1-2 mg/kg) 1. Paralysis offers the advantage of improved first-pass success and reduced risk of trauma to airway structures, but it removes the patient's ability to maintain their own airway and ventilation if intubation proves difficult. According to the most recent guidelines, the use of rocuronium or succinylcholine for RSI is suggested when there are no known contraindications to succinylcholine 1. It is also recommended to ensure full neuromuscular blockade before tracheal intubation is attempted, and a peripheral nerve stimulator may be used or wait 1 minute 1. The choice of paralytic agent and the decision to use paralysis should be based on the individual patient's needs and the clinical scenario, with consideration of the potential benefits and risks. In general, the use of paralysis during intubation should be guided by the principles of minimizing morbidity, mortality, and improving quality of life, and the most recent and highest quality evidence should be consulted to inform clinical decision-making 1.

Some key points to consider when deciding whether to use paralysis during intubation include:

• The patient's underlying medical conditions and potential contraindications to paralytics
• The anticipated difficulty of the intubation
• The provider's skill level and experience with intubation
• The availability of appropriate monitoring and equipment
• The potential benefits and risks of paralysis in the individual patient.

Ultimately, the decision to use paralysis during intubation should be made on a case-by-case basis, taking into account the individual patient's needs and the clinical scenario.

From the FDA Drug Label

Rocuronium bromide has no known effect on consciousness, pain threshold, or cerebration. Therefore, its administration must be accompanied by adequate anesthesia or sedation. Administration of rocuronium bromide results in paralysis, which may lead to respiratory arrest and death;

Paralysis is a necessary effect of the medication Rocuronium for intubation, as it helps to facilitate the procedure by relaxing the muscles. However, this does not necessarily mean that paralysis is always required for intubation in general. The medication is used to induce paralysis, and its administration must be accompanied by adequate anesthesia or sedation. The decision to use paralysis during intubation depends on the specific clinical situation and the judgment of the healthcare provider. 2

From the Research

Paralysis During Intubation

• Paralysis is often necessary during intubation to facilitate endotracheal intubation and minimize complications such as aspiration, airway trauma, and other difficulties of airway management 3.
• The use of neuromuscular blocking agents (NMBAs) like succinylcholine and rocuronium can increase first pass success rates and protect patients from gastric aspiration, tracheal injury, and death 4.
• A study comparing complications of intubation with and without paralysis found that complications were greater in number and severity in the nonparalyzed group, including aspiration, airway trauma, and death 3.

Alternatives to Paralysis

• Intubation without paralysis, also known as intubation minus paralysis, is an alternative method that can be used in some cases 3.
• However, this method has been associated with a higher risk of complications, including aspiration, airway trauma, and death 3.
• The use of NMBAs like succinylcholine and rocuronium is still widely used and recommended for rapid sequence intubation (RSI) due to their ability to provide rapid paralysis and minimize complications 5, 6.

Considerations for Paralysis

• The choice of NMBA and dosage should be individualized to fit the patient's needs, taking into account factors such as weight, medical history, and potential risks 4.
• Nurses should provide specific care when managing patients who receive NMBAs, including close assessments to prevent complications and individualized interventions based on the patient's needs 4.
• The development of new NMBAs and reversal agents is ongoing, with the goal of finding an ideal agent with a rapid onset and offset without side effects 7.