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Rocuronium vs Succinylcholine – Prehospital RSI

January 29, 2020

Written by Aaron Lacy

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In this randomized control trial studying out-of-hospital RSI, rocuronium was a little worse than succinylcholine in first-pass success rate. In journal club speak…rocuronium failed to show it was non-inferior to succinylcholine.

Why does this matter?
Succinylcholine and rocuronium are the two most commonly used paralytics in the United States, and everyone seems to have their favorite. If either were associated with higher success in RSI, it would have massive implications in clinical practice.

Rocuronium sux?
This was a multicenter noninferiority trial in which 1,248 adults undergoing prehospital RSI in France were randomized to either succinylcholine or rocuronium. The primary outcome, first-pass success rate, was 74.6% for rocuronium versus 79.4% for succinylcholine (1-sided 97.5% CI, -9% to ∞), with the confidence interval exceeding the noninferiority margin of 7%. So what do we do with this information? A higher first-pass success rate is associated with fewer complications than multiple attempts. In this study, however, even though succinylcholine was associated with higher first-pass success rate, that group had more intubation-related complications than those intubated with rocuronium. This was a pre-hospital study in France, with medical doctors attempting intubation, and may not be generalizable to the United States, where non-physicians normally perform out-of-hospital RSI. In the U.S., RSI first-pass success rates in the emergency department seem to be no different based on paralytic choice. Also, physicians were not blinded to the drug. Perhaps they timed the attempt better after they watched fasciculations from succinylcholine come and go.

Given that this study is not particularly generalizable to my patient circumstances, along with the conflicting findings, I will continue to let the clinical scenario dictate my use of rocuronium versus succinylcholine for RSI in the emergency department.

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. JAMA. 2019 Dec 17;322(23):2303-2312. doi: 10.1001/jama.2019.18254.

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What are your thoughts?