Rapid Sequence Induction Practices and Outcomes in Abdominal Surgery Patients: A Multicenter Observational Cohort Study

BACKGROUND: Rapid Sequence Induction (RSI) is commonly performed in the operating room to quickly secure the airway and minimize aspiration risk, especially in patients undergoing abdominal surgery. Current practice patterns of medications and RSI techniques used by anesthesiologists are not well-described. METHODS: This observational cohort study utilized the Multicenter Perioperative Outcomes Group database to evaluate RSI practices on adult patients undergoing abdominal surgery from 2015 to 2022. The primary aim was to describe modern RSI practices. We evaluated peri-induction medication use and intubation techniques. We hypothesized that over time, rocuronium would become the most utilized agent. Additionally, we investigated how the choice of neuromuscular blocking agent (NMB) affected outcomes using mixed-effects models and targeted maximum likelihood estimation. The primary endpoint was 30-day mortality. Secondary endpoints included post-induction hypoxia, pulmonary complications, and acute kidney injury (AKI). RESULTS: Across 13 institutions and 82,772 cases, 9,352 (11.3%) had a documented RSI. The most common NMB was succinylcholine (70.5%). However, the use of succinylcholine significantly decreased over the study period (85.4% of RSI cases in 2015; 37.3% in 2022, p < 0.0001), replaced by rocuronium. Patients usually received coadministration of multiple sedatives. Video laryngoscopy was more frequently used (16.2% of RSI vs 8.0% of non-RSI cases, p<0.0001). Rocuronium was not associated with a different risk of mortality (relative risk 0.85; 95% confidence interval 0.67 - 1.09), hypoxia (1.04; 0.61-1.77), pulmonary complications (0.93; 0.81-1.06), or AKI (1.05; 0.84-1.31) as compared to succinylcholine. CONCLUSION: Across institutions in the United States, rocuronium has been increasingly used for RSI, eventually overtaking succinylcholine. Rocuronium use was not associated with a different risk of mortality, hypoxia, pulmonary complications, or AKI.