Lauren M. Westafer, DO, MPH, MS reviewing This randomized controlled trial found rocuronium was not noninferior to succinylcholine for rapid sequence intubation. Rocuronium and succinylcholine are the most commonly used paralytics in rapid sequence intubation (RSI) in U.S. emergency departments (EDs). Some clinicians advocate for one medication over the other as they have distinct properties: Succinylcholine has a faster onset and wears off more quickly; rocuronium has fewer contraindications. However, data have largely come from registry studies or operating room experience. In this multicenter noninferiority trial, 1248 adult patients undergoing prehospital RSI in France were randomized to receive either succinylcholine (1.0 mg/kg) or rocuronium (1.2 mg/kg). Patients were intubated using direct laryngoscopy and clinicians used stylets in fewer than 10% of intubations. First-pass success occurred in 74.6% of patients who received rocuronium and 79.4% who received succinylcholine. While the absolute difference in first-pass success was 4.8%, the confidence interval extended to 9%, which exceeds the specified 7% noninferiority margin. Clinicians rated intubating conditions similarly in both groups. Intubation-related complications (most commonly hypoxemia or hypotension) occurred more often in the succinylcholine group. |
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This prehospital trial did not find rocuronium to be noninferior to succinylcholine with regard to first-pass success in RSI. However, this trial will not settle the debate over paralytic agents. First-pass success is assessed in airway trials because it is associated with fewer complications than multiple passes, yet fewer patients in this study who received rocuronium experienced complications. In view of these conflicting findings, as well as issues regarding this study’s generalizability given the low first-pass success rate, patient circumstances should continue to dictate the use of either succinylcholine or rocuronium in RSI.