Lit Matters #1: Does Roc rock, and does Sux suck?

Rapid sequence intubation success depends more on airway technique and team performance than on whether you choose rocuronium or succinylcholine. In a large secondary analysis of DEVICE and PREOXI, the two paralytics showed similar first-pass success and no clear difference in severe peri-intubation complications.

Rocuronium Versus Succinylcholine in RSI

• Comparable first-pass success: First-pass success was essentially the same with succinylcholine and rocuronium, reinforcing that paralytic choice alone is unlikely to rescue a weak intubation setup.
• No clear complication gap: Severe complications within 2 minutes of induction were not significantly different between agents, despite numerically higher events in the rocuronium group.
• Traditional tradeoff framing: Succinylcholine still offers a slightly faster onset, while rocuronium avoids the classic hyperkalemia and malignant hyperthermia concerns that shape bedside choice.
• System over drug dogma: The bigger signal is consistency: a familiar RSI workflow usually matters more than paralytic tribalism, and we get into that practice angle in the episode.
• Patient-specific exceptions: Certain patients still push the choice one way or the other, especially when potassium risk or prolonged paralysis changes the calculus, but the broad winner never really emerged.