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Chapter 7

Lit Matters: Roc vs Sux. Clash of the Titans?

Matt Delaney, MD and Salim Rezaie, MD
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A prehospital study comparing Roc and Sux for first pass intubation success.

  • Lit Matters #3: Guihard B, et al. 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. PMID: 31846014.

    • Bottom line:  For patients being intubated in the field, compared with succinylcholine, rocuronium failed to demonstrate noninferiority in terms of first-pass success rate.

    • Methods: This RCT compared rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for RSI in 1248 adults requiring out-of-hospital intubation. 

    • Results:  Succinylcholine performed better than rocuronium (1st pass success rate of succinylcholine = 79.4% vs rocuronium = 74.6%). Noninferiority criteria were not met.

    • Editors’ comments: 

      • Know the onset and duration of action of your drugs.

        • Rocuronium has an onset of action of 60 seconds but lasts up to 40-50 min.

        • Succinylcholine has an onset of action of 45 seconds but lasts 6-8 min.

      • Things to consider:

        • This is an out-of-hospital, not ED, trial. 

        • The 1st pass success rate was lower in this study compared to traditional ED studies (ie. 85 to 95%).

        • Intubation protocols used in this study are much different than standard practices in North America (i.e. no stylet, use of Sellick’s maneuver, reversal of rocuronium in cannot intubate/cannot oxygenate situations).

      • Biggest issue with this study is that the choice of paralytic shouldn’t influence first pass success rate of intubation unless the dose is incorrect (ie. to low) or the intubation attempt occurred too early (ie. patient not fully paralyzed).

Lucas M. -

Roc on.

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