EBQ:Comparison of Succinylcholine and Rocuronium for RSI

Under Review Journal Club Article

Laurin EG, et al. "A Comparison of Succinylcholine and Rocuronium for Rapid-sequence Intubation of Emergency Department Patients". Academic Emergency Medicine. 2000. 7(12):1362-9.
PubMed PDF

Clinical Question

How do succinylcholine and rocuronium compare for use is rapid-sequence intubation in the emergency department?

Conclusion

Both succinylcholine and rocuronium produce fast and reliable paralysis for RSI in the ED.

Major Points

Outcome	Succinylcholine	Rocuronium	p value
Measured time of onset (± SD)	39 ± 13 seconds	44 ± 20 seconds	0.04
Frequency of body movements 0-10 (± SD)	9.5 ± 1.1	9.1 ± 1.5	0.01
Vocal cord movements 0-10 (± SD)	9.2 ± 1.6	9.0 ± 1.6	0.15
Satisfaction 0-10 (± SD)	9.4 ± 1.3	8.8 ± 2.0	<0.01
Related complications	1: QRS widening in pt with hyperkalemia	0	--
Mean Dosage	1.7 mg/kg	1.0 mg/kg	--

• No patient desaturated and required assisted ventilations while waiting for paralysis to occur

Study Design

• Prospective cohort study at the UC Davis Medical Center, a level 1 trauma center
• Emergency physicians attended in-service about rocuronium before study, were given information on pharmacologic properties, indications for use, and dose for intubation (1.0 mg/kg used)
• Agreed indications for rocuronium use:
  • Known or suspected hyperkalemia
  • No medical history available
  • Signs of increased intracranial pressure
  • Chronic neuromuscular disease
  • Crush injury
  • Non-acute burns
  • Globe injury
  • To avoid a second dose of succinylcholine
• No paralytic agent was mandated, but succinylcholine continued to be first-choice agent.
• Data form completed by intubator immediately after intubation:
  • Patient's name, age, gender
  • Paralytic used
  • Reason for use
  • Time from administration to paralysis
  • Serum K at time of intubation
  • Need for BVM ventilation
  • Pulse ox readings during intubation
  • Complications

Population

Patient Demographics

• Mean age: 46 years old
  • Range: days old-96 years old
• Male: 63%

Inclusion Criteria

• Every patient intubated in the ED from January 1, 1998 to December 31, 1998 was eligible for enrollment

Interventions

Prospective observational study of paralytic use in ED

Outcomes

N= 521 patients who received RSI in the ED

• 382 (73%) received succinylcholine
• 138 (26%) received rocuronium

Common Indications for Rocuronium Use	Number of Patients (%)
Suspected hyperkalemia	53 (38%)
Chronic renal failure	28
Rhabdomyolysis	6
Lack of medical history	43 (31%)
Known hyperkalemia	11 (8%)
Neuromuscular disease	11 (8%)

• 34 patients had recorded hyperkalemia (>5 mmol/L) before intubation
  • Rocuronium given to 23 of these patients

Common sedative agents used:

• Etomidate: 464 patients (89%), mean dose 0.29 mg/kg
• Midaolam: 12 patients(2%), mean dose 0.09 mg/kg
• Obtunded--no sedative used: 15 patients (3%)
• No sedation recorded: 14 patients (2%)

Criticisms & Further Discussion

• Onset of paralysis was only directly measured in 33% patients, with the rest being estimated by the person intubating
  • Significant difference (p=0.04) was calculated only for the measured values, but no statistical significance was calculated for estimated values
  • Although statistical significance of onset time was established, clinical significance is unclear as there were no incidences of desaturation in either group
• Physicians were allowed to hand-pick patients to include in the study without specific inclusion/exclusion criteria, introducing the possibility for selection bias.
• Patients were not randomized, and physicians were not blinded to medication choice.
  • Satisfaction score, estimated time to paralysis may be biased

External Links

• Rocuronium vs. Succinylcholine Video