Succinylcholine or Rocuronium - Which Is Better?

Written by Nicole McCoin

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A large observational series with over 4,000 intubations compared succinylcholine vs. rocuronium in rapid sequence intubation (RSI) and found no association between these two paralytics and first-pass intubation success or peri-intubation adverse effects.

Why does this matter?.... Because I am not a clairvoyant.
As much as I would love to know if my 65 year-old who is not protecting his airway has hyperkalemia, I usually don’t. I want to be able to turn to rocuronium as my beacon in the dark...a drug that will lead to an uneventful RSI. The anesthesia literature notes advantages to succinylcholine: faster onset, offset, and superior intubating conditions. However, this literature draws from RCTs in the OR and uses the Goldberg scale. This study is more applicable to the ED setting. 

Succinycholine vs rocuronium? Not a “polarizing” issue in this article!
Alright, enough with the puns. Here is a quick synopsis of this article while you drink your morning coffee. This was a large observational series in which the authors analyzed prospectively collected data from 4,275 intubations in the National Emergency Airway Registry, which includes 22 emergency departments. First-pass intubation success was 87.0% among succinylcholine encounters and 87.5% among rocuronium encounters (adjusted OR 0.9; 95% confidence interval of 0.6 to 1.3). The incidence of adverse events was also comparable between the two paralytic agents, with a rate of 14.7% for succinylcholine and 14.8% for rocuronium (adjusted OR 1.1; 95% confidence interval of 0.9 to 1.3). Adverse events included issues ranging from mechanical (e.g. esophageal intubation or airway injury) to systemic (e.g. hypotension and cardiac arrest). The analyses performed in this paper show a lack of association between the choice of paralytic and first-pass success and adverse events, which suggests either agent is equally effective and safe.

Source
Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study. Ann Emerg Med. 2018 Dec;72(6):645-653. doi: 10.1016/j.annemergmed.2018.03.042. Epub 2018 May 7.

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