EBQ:Comparison of Succinylcholine and Rocuronium for RSI: Difference between revisions
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| Related complications || 1: QRS widening in pt with hyperkalemia || 0 || -- | | Related complications || 1: QRS widening in pt with hyperkalemia || 0 || -- | ||
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| Unrelated complications || 7 in 7 patients || 7 in 6 patients || -- | |||
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| Mean Dosage || 1.7 mg/kg || 1.0 mg/kg || -- | | Mean Dosage || 1.7 mg/kg || 1.0 mg/kg || -- | ||
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*No | ===Complications=== | ||
*Succinylcholine given to 5 patients with pre-existing but unknown hyperkalemia | |||
**4 pts with serum K between 5.1-6.0 mmol/L | |||
**1 pt with serum K for 7.1 mmol/L. Found obtunded, with scalp contusions, without known medical history. Developed widened QRS 30 seconds after succinylcholine administration. Pt found to be in DKA, given medical management for hyperkalemia, and had no clinical adverse affects. | |||
*No paralytic-related complications were noted in the rocuronium group | |||
*No patient desaturated and required assisted ventilations while waiting for paralysis to occur | |||
==Study Design== | ==Study Design== | ||
*Prospective cohort study at the UC Davis Medical Center, a level 1 trauma center | *Prospective cohort study at the UC Davis Medical Center, a level 1 trauma center | ||
Revision as of 21:32, 18 September 2015
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
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 | -- |
| Unrelated complications | 7 in 7 patients | 7 in 6 patients | -- |
| Mean Dosage | 1.7 mg/kg | 1.0 mg/kg | -- |
Complications
- Succinylcholine given to 5 patients with pre-existing but unknown hyperkalemia
- 4 pts with serum K between 5.1-6.0 mmol/L
- 1 pt with serum K for 7.1 mmol/L. Found obtunded, with scalp contusions, without known medical history. Developed widened QRS 30 seconds after succinylcholine administration. Pt found to be in DKA, given medical management for hyperkalemia, and had no clinical adverse affects.
- No paralytic-related complications were noted in the rocuronium group
- 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
Exclusion Criteria
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