NEW YORK (Reuters Health) – In the emergency department, successful intubation on the first try is equally likely using either succinylcholine at a median dose of 1.65 mg/kg or rocuronium at a median dose of 1.19 mg/kg, research suggests.

“These two paralytic agents are most frequently used for rapid sequence intubation in the ED, and succinylcholine is considered to be the gold-standard,” Dr. Asad (Sid) Patanwala, clinical assistant professor in the College of Pharmacy at University of Arizona, Tucson, told Reuters Health.

However, Dr. Patanwala said that many of the physicians at his institution prefer to use rocuronium because of potential adverse effects of succinylcholine in some patients, such as hyperkalemia.

He also noted that most of the studies comparing these paralytics have focused on intubating conditions, in which the intubating physician typically provides their assessment of conditions, such as how well they are able to visualize the airway, during the intubation.

“We went further, beyond just intubating conditions, and looked at success of first intubation attempt in a real-world setting,” Dr. Patanwala said. “This is a more clinically meaningful outcome because failure of first attempt could lead to delays in intubation,” he noted.

In the January issue of Academic Emergency Medicine, Dr. Patanwala and colleagues describe their analysis of 327 patients who underwent successful rapid sequence intubation between July 1, 2007 and October 31, 2008 at a Level I trauma center in Arizona. “This was a retrospective evaluation of information collected prospectively in a quality improvement database,” they explain.

All patients received the sedative etomidate prior to intubation at a median dose of 0.25 mg/kg; 113 (35%) intubations were performed using succinylcholine (median dose, 1.65 mg/kg, interquartile range, 1.26 to 1.95 mg/kg) and 214 intubations were performed with rocuronium (median dose 1.19 mg/kg, interquartile range, 1-1.45 mg/kg).

The two groups were similar with regard to demographics and intubation parameters such as reason for intubation, presence of difficult airway predictors, laryngeal view, intubating device, and physician experience.

The researchers report that the rate of successful intubation on the first attempt was similar between the succinylcholine and rocuronium groups (72.6% vs 72.9%; p = 0.95). There were also no between-group differences in the number of intubation attempts.

The doses of succinylcholine and rocuronium employed are within the recommended dosing range, the investigators note; however, the dose of rocuronium is higher than what is commonly recommended.

“Prior studies showing superiority of succinylcholine have typically used lower doses of rocuronium,” Dr. Patanwala told Reuters Health. “We routinely use higher doses at our institution. Based on previous studies, we had hypothesized similar success when using higher doses, which is what we found in our study,” he noted.

“We recommend using doses similar to that used in this study,” Dr. Patanwala said. “At higher doses used in this study, rocuronium was found to be equivalent to succinylcholine.”

Reference:

Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department

Acad Emerg Med 2011;18:10-14.