Friday 30 January 2015

Delayed Sequence Intubation: We did it, we liked it and thought it was cool

Congratulations to Dr Scott Weingart for putting his money where his mouth is and publishing something that is genuinely challenging to study.

How would we ideally design a study to look at the efficacy of DSI? Would we do a large blinded randomized trial comparing DSI to standard rapid sequence intubation with a primary outcome of mortality? Such a study would be near impossible to conduct as it would be totally unfeasible to recruit such large numbers and couldn't be blinded. Therefore we do the best we can.

This study was not an RCT but rather a prospective observational study in a convenience sample of patients in whom DSI was thought to be indicated. They were all given ketamine to facilitate oxygenation before intubation. The primary outcome was improvement in the oxygen saturations during DSI.

In general, it looks like DSI works. Saturations increased from about 90% up to 99% just prior to intubation. There were even two patients with asthma where intubation was avoided.

Critics might argue that this was not a trial, had a convenience sample with small numbers and used a non-patient oriented outcome measure. But good luck finding better evidence! Three large hospitals were only able to recruit a total of 62 patients over a year and a half. It would probably take me two hundred years to recruit enough patients at my hospital to conduct a properly powered RCT looking at small changes in patient oriented outcomes.

I think this is enough evidence to change practice. I doubt we will ever get better data. It seems to work and is probably safer than standard RSI in suitable patients. Yes, this study is far from hard science but I think it is a game changer. Thanks Scott.


Weingart SD, Trueger NS, Wong N, et al. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med 2014 Oct 23. pii: S0196-0644(14)01365-1. doi: 10.1016/j.annemergmed.2014.09.025. [Epub ahead of print]

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