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
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
| Result | Succinylcholine | Rocuronium |
|---|---|---|
| Measured time of Onset (± SD) | 39 (± 13) seconds | 44 (± 20) seconds |
| Mean Dosage | 1.7 mg/kg | 1.0 mg/kg |
| Satisfaction 0-10 (± SD) | 9.4 (± 1.3) | 8.8 (± 2.0) |
Study Design
- Data form completed by intubator immediately after intubation with following info
- Patient's name, age, gender, paralytic used, reason for use, time from administration to paralysis, serum K at time of intubation, need for BVM ventilations, pulse ox readings during intubation, any 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
Indications for
| 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%) |
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