Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial

Abstract

IntroductionSuccinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI.MethodsThis was a prospective randomized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel. Participants were 401 critically ill patients requiring emergent RSI. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade. The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ≥ 5%, assessed by continuous pulse oxymetry, at any time between the start of the induction sequence and two minutes after the completion of the intubation. A severe oxygen desaturation was defined as a decrease in oxygen saturation ≥ 5% leading to a saturation value of ≤ 80%.ResultsThere was no difference between succinylcholine and rocuronium regarding oxygen desaturations (succinylcholine 73/196; rocuronium 66/195; P = 0.67); severe oxygen desaturations (succinylcholine 20/196; rocuronium 20/195; P = 1.0); and extent of oxygen desaturations (succinylcholine -14 ± 12%; rocuronium -16 ± 13%; P = 0.77). The duration of the intubation sequence was shorter after succinycholine than after rocuronium (81 ± 38 sec versus 95 ± 48 sec; P = 0.002). Intubation conditions (succinylcholine 8.3 ± 0.8; rocuronium 8.2 ± 0.9; P = 0.7) and failed first intubation attempts (succinylcholine 32/200; rocuronium 36/201; P = 1.0) did not differ between the groups.ConclusionsIn critically ill patients undergoing emergent RSI, incidence and severity of oxygen desaturations, the quality of intubation conditions, and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium.Trial RegistrationClinicalTrials.gov, number NCT00355368.

Comparative Study of Succinylcholine with Different Doses of Rocuronium Bromide for Tracheal Intubation during General Anaesthesia

“…Similar findings were observed by Misra M et al [18] and Somani M. [21] There was no significant difference seen in mean saturation of oxygen from baseline to post induction in the groups which is comparable to Marsch A. [22] …”

Sedation and ParalysisDiscussion

“…Atracurium's metabolite, laudanosine, a metabolite of atracurium with neuroexcitatory properties, may rarely cause seizures, especially in patients with hepatic and/or renal failure after prolonged administration. 94 Cisatracurium is the R-cis R'-CIS isomer of atracurium. Unlike atracurium, cisatracurium does not cause histamine release, and its metabolism results in one fifth of plasma concentration of laudanosine, when compared with atracurium.…”

Mandatory mask ventilation before relaxation

“…Ebenfalls müsste das Nichtrelaxieren stets sicherer als das Relaxieren sein, und deshalb dürf te keinesfalls trotz Nichtbeatembarkeit re laxiert werden. [29]. Obwohl mit Sugammadex auch eine tiefe, durch Rocuronium indu zierte Blockade aufgehoben werden kann [41], ist die zeitliche Variabilität der Rever sion zu groß, um sich in der Situation des Cannot ventilate, cannot intubate darauf zu verlassen [7].…”