Practice Changer: I will be using ROC at 1.2mg/kg in my ED patients who do NOT require repeat neurological examination. It has no contraindications, is equally effective to SUX, and will give me LONGER SAFE APNEIC TIME to secure the airway. I will order a sedative medication up front with ROC.
***In this post Rocuronium is ROC and Succinylcholine is SUX
1. SUX ISN’T SAFER
The big advantage cited for SUX is: “With the shorter duration of action, should you encounter a cannot intubate, cannot ventilate situation, most patients will begin breathing spontaneously and you avoid the need for a surgical airway This chart from Anesthesia 2010 shows that this assertion is WRONG.
While this may be true in a healthy OR population, it is NOT the case with ED patients. Looking at the curves above, your patients will have coded WELL before SUX wears off if you can not ventilate them in some manner.
However, if you ARE able to ventilate your patient, and your SUX does wear off, you still have a patient with an unsecured airway who is moving, rather than a paralyzed patient in whom you can attempt other airway maneuvers.
My Conclusion: The shorter duration of action of SUX is not an advantage in the ED.
2. ROC provides a LONGER SAFE APNEIC TIME
Effect of [succinylcholine] vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction
— Anaesthesia 2010
Study: Randomized trial of ROC and SUX in a controlled operating room setting.
Intervention: 3 groups of 20 patients, all preoxygenated on 8L FM x 8 minute
- Patients preoxygenated with mask removed 50 seconds after medications given
- Patients left apneic until oxygen saturations reached 95%
R – Pretreated Lidocaine, Fentanyl, Propofol (2mg/kg), and ROC (1mg/kg)
S – Pretreated as above, then with SUX (1.5mg/kg)
SO – Propofol and SUX (Essentially RSI with Propofol)
Outcome: Time to Desaturation to 95% during apnea
ROC (with pretreatment) time: 378 sec (6 min 18 sec)
RSI with SUX time: 240 sec (4 min)
THAT IS AN EXTRA 2 MINUTES of APNEIC TIME!
Why is this?
Well they also looked at hemodynamic parameters: Patients in the RSI group had stronger fasciculations, Longer fasciculations, elevated HR and BP at 2 minutes after administration… essentially THE FASCICULATIONS ARE USING MORE OXYGEN
Conclusions: In healthy patients, you can expect an extra 2 minutes of apneic time when using Rocuronium vs Succinylcholine
Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients.
Acta Anaesthesiol Scand 2011
Study Design: Prospective evaluation of desaturation time in patients with BMI of 25-30 with use of either Roc or SUX
Intervention: Patients intubated in OR with midazolam, fentanyl, propofol, and either SUCCINYLCHOLINE 1.5 mg/kg or ROCURONIUM 0.9 mg/kg.
- Measured time to desaturation to 92%
Outcome: Time until oxygen saturation reached 92%
ROC: 329 seconds (5 min 29 sec)
SUX: 283 seconds (4 min 43 sec)
My Conclusions: SUX had a more rapid desaturation than ROC in SLIGHTLY overweight patients. (BMI of 30 is relatively fit in my ED population).
3. A good dose of ROC makes it equally effective to SUX
At a dose of 1.2 mg/kg ROC there is essentially no difference to time of onset or intubating conditions, or intubation success compared with SUX.
Rapid tracheal intubation with large-dose rocuronium: a probability-based approach.
Anesth Analg 2000
Design: Prospective randomized study of varying doses of ROC in patients intubated in the OR
Intervention: 0.4 – 2.0 mg/kg ROC pushed and they looked at intubation conditions 40 seconds later. Success was determined by being able to pass an ETT within 30 seconds.
Results: 60 patients
Probability of intubation at 40 seconds (Black = ideal, White = good, Grey = poor)
Conclusions: Higher doses of ROC achieve ideal intubations essentially as fast as SUX. 1.2mg/kg seems like an idea dose.
Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department
Acad Emerg Med. 2011
Study: Retrospective Review of RSI intubations from ED in Arizona in 2007 and 2008
Comparison: All RSI was performed with Etomidate.
Analysis: 327 intubations were included, 113 with sux and 224 with Roc
No difference in intubating conditions or success rates. Average doses of Rocuronium at 1.19mg/kg and Sux at 1.65 mg/kg.
Conclusions: Appropriate (high) dosing of paralytics provide equivalent intubating conditions.
4. SUX has LOTS of contraindications, ROC has NONE
SUX: has a list of uncommon contraindications, primarily having to do with preexisting and inducible hyperkalemia (Anesthesia 2006).
The average person seems to have a rise of 0.5 to 1.0 mEQ of K. (BLUE Bar in Left chart)
With lower limb immobilization you may a greater response (RED Bar in Left Chart)
Even starting with a normal K, you can have significant K release resulting in arrhythmia.
My Conclusions: In an emergent setting where obtaining a history is not always possible, and with the population we serve with one of the highest rates of dialysis in the country, the possibility of encountering a patient with a contraindication is relatively higher than in most places.
5. REMEMBER TO SEDATE YOUR PATIENTS
Patients treated with ROC frequently have their sedation wear off before their paralytic
Effect of paralytic type on time to post-intubation sedative use in the emergency department
— Emerg Med J 2013
Study: Retrospective Cohort of intubated ED patients from tertiary care center in USA
Comparison: All patients sedated with Etomidate and use of either ROC or SUX
Outcome: Time until sedation or analgesia administered
Results: 200 patients (100 per group)
SUX = 15 Min
ROC = 27 MIN
My Conclusions: You lose the cues for sedation you are used to with SUX when you use ROC. Patients are awake but can’t respond. If you are going to use ROC, MAKE SURE SEDATION IS INTEGRATED AS PART OF YOUR PROTOCOL, so you don’t forget to use it.