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HWN Suggests

Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI

The RSI agent preference has swung away from succinylcholine... There are likely numerous reasons for this swing including drug shortages but a better understanding of the limitations of succinylcholine are also likely at play.

Point #1 – Short paralysis time is not an advantage... The ED is not the OR. Once you decide the patient needs to have their airway secured, you MUST secure the airway. Allowing the patient to wake up and breathe spontaneously isn’t an option for the vast majority of intubations. Thus, we can see why rocuronium is the preferred agent. With rocuronium, the patient will be paralyzed for 30-45 minutes. If your first airway attempt fails, you will proceed down…

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 Rocuronium

I have to start off by saying I do have a small bias here and that this reading is largely a "Why I'd choose Rocuronium or Succinylcholine" piece. Rocuronium > Succinylcholine in my opinion — All day, every day. But with that being said, I have used Succinylcholine (and occasionally still do). I won’t “knock” anyone who chooses to use it… pending they have identified that no contraindications exist.

Articles of Interest

Does Roc rock? Does Sux suck?

What are the side effects of roc and sux? Let’s start with roc as it’s easy — none! (OK, I’m exaggerating… Allergy is always a risk, but there’s nothing else significant I can think of) Suxamethonium, on the other hand, can cause....

Ketamine and Rocuronium: The New Etomidate and Succinylcholine?

Arguably, the modern combination of ketamine and rocuronium has less significant complications, and provides a superior alternative to etomidate and succinylcholine.

Mega-Dose Roc?

So while we don’t have the studies we want to take higher doses of rocuronium standard of care, we also don’t have data to refute utilizing higher doses. There appears to be no negative effects other than a longer duration of action at higher doses, which needs to be considered. At a minimum, we should be dosing all RSI at 1.2mg/kg with, ideally an accurate weight.

Rocuronium Reversal in the Emergency Department: Retrospective Evaluation of Hemodynamic Instability Following Administration of Sugammadex Versus Neostigmine With Glycopyrrolate

Rocuronium is an intermediate-acting non-depolarizing neuromuscular blocking agent frequently used in the emergency department for rapid sequence intubation. The prolonged effects of rocuronium may prevent the ability to conduct a meaningful neurological examination, thereby delaying appropriate diagnosis and treatment. Sugammadex and neostigmine are pharmacologic agents commonly used to reverse rocuronium.

Succinylcholine or Rocuronium for 1st Pass Success Rate

There was no significant difference in first-pass success rate, overall success rate or adverse event rate between succinylcholine and rocuronium. Clinicians should continue to use the NMB agent they are most comfortable with for ED intubation.

Succinylcholine vs Rocuronium

Various links...

Succinylcholine vs. Rocuronium: Battle of the RSI Paralytics

Succinylcholine has been traditionally used as a first-line paralytic due to its quick onset of action and short half-life. Succinylcholine’s duration of action is 10—15 minutes, whereas the half-life of rocuronium is anywhere from 30—90 minutes, depending on the dose. However, succinylcholine has major side effects, including hyperkalemia, malignant hyperthermia, fasciculations and bradycardia. These effects are seen most significantly in patients with prior stroke, baseline neuromuscular disease and recent burn victims. Rocuronium has a much more limited side effect profile, and is limited to hepatotoxicity.

Resources

StatPearls

Rocuronium is a non-depolarizing neuromuscular blocker widely used to produce muscle relaxation to help facilitate surgery and ventilation of the lungs in elective and emergent situations. It is one of the many non-depolarizing neuromuscular blockers that is used but has the distinct advantage of being fast-acting and reversible.