Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation

Abstract

IMPORTANCE Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium.OBJECTIVE To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations. DESIGN, SETTING AND PARTICIPANTS Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016.INTERVENTIONS Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624). MAIN OUTCOMES AND MEASURESThe primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis.RESULTS Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of −4.8% (1-sided 97.5% CI, −9% to ϱ), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group.CONCLUSIONS AND RELEVANCE Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.

Increased First Pass Success with C-MAC Videolaryngoscopy in Prehospital Endotracheal Intubation—A Randomized Controlled Trial

“…In our study we demonstrated a first-pass success rate of 79% with DL and 95% with VL, which is comparable to the existing literature for DL but better for VL in the prehospital setting [ 10 , 11 ]. The first pass success rate for in-hospital emergency ETI ranges from 75% to 85% with DL [ 15 , 18 , 19 ], and up to 96% with VL [ 16 , 20 , 21 ]. Mackie and colleagues could demonstrate that first pass success could be significantly increased from 59.2 to 85.1% with the C-MAC video-laryngoscope in 163 emergency intubations by emergency registrars [ 22 ].…”

“…In this study there was no difference between well-experienced physicians with more than 100 ETIs and less-experienced physicians. Referring to Mackie and colleagues LEP probably were able to intubate with high success rates with VL [ 22 ] and the success rates with DL are comparable to other physician-based preclinical ETI rates with DL [ 19 ]. Because of the study design with focus on comparison of VL and DL, preplanned patient number in both groups for this particular question would be too small to answer it with high statistical power.…”

Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China

“…Tracheal intubation is a crucial intervention in emergency settings [ 1 ], and sedation in emergency procedures greatly improves its ease and safety [ 2 ]. Therefore, in patients who require emergency tracheal intubation, rapid sequence intubation is the recommended airway management technique [ 3 ].…”

Rocuronium priming for tracheal intubation in COVID‐19 patients

“…Since the introduction of rocuronium into clinical practice the use of the priming principle has almost disappeared [1]. Large doses of rocuronium are usually recommended when tracheal intubation must be achieved rapidly [1]. However, there are several reports that a priming dose of rocuronium administered 2-4 mins before an intubating dose accelerates neuromuscular blockade by 30-60 s. Consequently, tracheal intubation conditions are created within 90 s of an intubating dose of rocuronium [2,3].…”