Neurologic Outcomes Following Intubation with Non-depolarizing vs. Depolarizing Paralytics in Status Epilepticus: A Target Trial Emulation

Abstract

Background: Significant controversy remains, however, regarding the optimal pharmacologic approach for endotracheal intubation in patients suffering from status epilepticus (SE).

Objective: To evaluate post-hospitalization neurologic sequelae and other patient-centered outcomes in SE patients receiving neuromuscular blockers (NMBs). We hypothesized that ability to more rapidly reassess neurologic exam with depolarizing-NMBs (D-NMB) would mediate improved neurologic outcomes compared to non-depolarizing-NMBs (ND-NMB).

Methods: We analyzed a cohort of SE patients in a large academic system from May 2000 to March 2024. Confounders were accounted for via propensity matching and inverse probability of treatment weighting. 480 adults undergoing their first intubation for SE with documented paralytic choice were identified via the search phrase “status epilepticus” in emergency medicine notes. (Exposure: Paralytic selection during rapid sequence intubation – intervention (D-NMB) vs. control (ND-NMB)). Functional neurologic outcomes as assessed by the need for escalation in level of care upon hospital discharge. Secondary outcomes included major hyperkalemia-related events (ventricular or pulseless arrhythmias) and 30-day survival.

Results: Use of ND-NMBs was associated with a higher likelihood of home discharge (69.6% vs. 61.7%, p= 0.02), lower likelihood of requiring escalation in level of care upon hospital discharge (24.4% vs. 30.5%, p=0.04), and a shorter hospital length of stay by approximately 24 hours (101 vs. 124, p=.04). There was no difference in peri-intubation cardiac events such as ventricular or pulseless arrhythmias.

Conclusions: Across 480 SE patients, ND-NMBs were associated with improved neurologic functional outcomes and a higher likelihood of returning home compared to D-NMBs.