Hellmann, Rafael von

Background and importance Emergency tracheal intubation in critically ill adults is associated with a high risk of peri-intubation adverse events, making first-attempt success a key safety target. Objective This study aimed to evaluate whether the use of neuromuscular blocking agents (NMBAs) improves the proportion of first-attempt success and reduces adverse events during emergent intubations outside the operating room. Methods This was a systematic review and meta-analysis of randomized clinical trials or nonrandomized studies comparing sedative-hypnotic plus NMBA versus sedative-hypnotic alone in critically ill adults undergoing emergency endotracheal intubation in nonoperative settings. Animal, cadaveric, manikin/simulation, and pediatric studies were excluded. Articles were screened on 21 August 2025, in Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection. Main results Of 4736 screened citations, 13 studies (8 cohort; 5 before-after studies) were included in the quantitative analysis, with 14 072 participants. NMBA use was associated with higher first-attempt success, which ranged from 69 to 92% (pooled odds ratio, 2.72; 95% onfidence interval: 1.42–5.21; low-certainty evidence). Secondary outcomes related to adverse events were rated as very low certainty due to sparse data, inconsistent reporting, and serious imprecision. Conclusion NMBA use during emergency intubation was associated with improved first-attempt success, although the certainty of evidence was low.

Background and importance Emergency airway management in the emergency department (ED) is a high-risk procedure associated with patient outcomes. First-attempt success is a widely recognized quality metric, as multiple attempts are associated with an increased risk of peri-intubation complications. In Brazil, where emergency medicine is a recently established specialty, many ED are staffed by physicians without formal emergency medicine training. The association between emergency medicine training and intubation outcomes in this setting has not been well characterized. Objective To assess the association of physician specialty with first-attempt success and immediate peri-intubation complications in Brazilian EDs. Design Secondary analysis of a multicenter, prospective cohort study from the Brazilian Airway Registry Cooperation. Setting and participants This study included adult patients who underwent tracheal intubation in EDs between March 2022 and April 2024. Patients were excluded if the intubation occurred outside the ED, during cardiopulmonary resuscitation, or for elective procedures. Intubations performed by medical students were also excluded. Physicians were categorized by specialty as emergency medicine or nonemergency medicine. Outcome measures and analysis The primary outcome was first-attempt success; secondary outcomes included peri-intubation complications (severe hypoxemia, hemodynamic instability, and cardiac arrest). Multivariable logistic regression was used to assess the association between physician specialty and outcomes. Main results Among 2582 patients, 1087 (42.1%) were intubated by emergency physicians and 1495 (57.9%) by other physicians (mainly internal medicine and surgery). Intubations by emergency physicians were associated with a higher rate of first-attempt success [80.4 vs. 70.9%, adjusted odds ratio [aOR]: 1.63, 95% confidence interval (CI): 1.34–1.97]. There was also a higher odds of intubations without major complications (aOR: 1.20, 95% CI: 1.01–1.42). Conclusion In this study, there was a higher rate of first-attempt success in intubations performed by board-certified emergency physicians compared with other physicians working in Brazilian EDs.

Background and importance Rapid sequence intubation in emergency settings may involve opioid pretreatment to blunt hemodynamic responses during laryngoscopy and intubation; however, opioids may lead to postintubation hypotension, increasing morbidity and mortality. Global clinical practice varies significantly, reflecting uncertainty about opioids’ benefits and risks. Objective Our goal was to evaluate the association between opioid pretreatment and hemodynamic instability, focusing on postintubation hypotension in adult patients undergoing emergency intubation. Design, settings, and participants We performed a systematic review of randomized controlled trials and observational studies comparing opioid administration vs. no opioids before adult emergency intubations. Searches included Cochrane, Embase, Medline, Scopus, and Web of Science databases until November 2024. Elective intubations were excluded. Eight (6708 patients) studies met criteria. Outcomes measure and analysis The primary outcome was postintubation hypotension, variably defined across studies. Secondary outcomes included hypoxemia, first-attempt success, cardiac arrest, and vasopressor use. Independent reviewers conducted data extraction, risk-of-bias assessments, and certainty evaluation. Results were qualitatively synthesized. Main results Among 6708 (2757 opioids and 3951 controls) patients, postintubation hypotension incidence varied widely (risk differences: −12.5% favoring opioids to +13.2% favoring controls). The single low-risk randomized study reported opioids increased hypotension (risk difference: 13%, odds ratio: 2.15, 95% confidence interval: 1.22–3.78). Observational studies yielded inconsistent results. Secondary outcomes showed no consistent differences. Evidence certainty was very low because of risk of bias, inconsistency, and imprecision. Conclusions Current evidence regarding opioid pretreatment effect on postintubation hypotension risk during emergency intubation is limited and conflicting.