Study characteristics We included in the review controlled trials from 1966 to February 2015 involving participants of all ages needing rapid intubation using rocuronium and succinylcholine. The minimum dose of rocuronium given was 0.6mg/kg and succinylcholine was 1mg/kg. We have combined the results of 50 trials, with a total of 4151 participants, which compared the e ectiveness of succinylcholine versus rocuronium on intubation conditions. No major side e ects from use of the drugs were reported. Key results We have found that rocuronium is slightly less e ective than succinylcholine for creating excellent and acceptable intubation conditions. Rocuronium should therefore only be used as an alternative to succinylcholine when it is known that succinylcholine should not be used and a more prolonged intubation is expected. Quality of evidence The level of evidence is of moderate GRADE due to imperfect study designs and varying techniques used across trials .

This systemic review was performed to determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during rapid sequence intubation of the trachea. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015) for any randomised controlled trials or controlled clinical trials that reported intubating conditions comparing rocuronium and succinylcholine for rapid or modified rapid sequence intubation. The dose of rocuronium was at least 0.6 mg.kg and succinylcholine was at least 1 mg.kg . Sixty-six studies were identified and 50 included, representing 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions (risk ratio (95%CI) 0.86 (0.81 to 0.92), n = 4151) and clinically acceptable intubation conditions (risk ratio (95%CI) 0.97 (0.95-0.99), n = 3992). A high incidence of detection bias amongst the trials coupled with significant heterogeneity means that the quality of evidence was moderate for these conclusions. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: risk ratio (95%CI) 0.81 (0.73-0.88), n = 2302) with or without the use of opioids (risk ratio (95%CI) 0.85 (0.78-0.93), n = 2292 or 0.85 (0.76-0.95), n = 1428).