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Airway Series: Paralyzing Agents


  1. Rapid sequence intubation (RSI) is a process whereby an induction agent and a neuromuscular blocking agent are given in rapid succession to facilitate endotracheal intubation
  2. The selection of a specific sedative depends on multiple factors: the clinical scenario, which includes patient factors (includes cardiorespiratory and neurologic status, allergies, comorbidity) and the clinician’s experience/training and institutional factors, as well as the characteristics of the  paralytic
  3. Succinylcholine remains the most commonly used paralyzing agent, however, it does have pharmacologic considerations
  4. The use of rocuronium continues to increase due to its unique pharmacologic profile and its niche is becoming prevalent in situations where the risk of hyperkalemia and bradycardia are high
DoseIV: 1.5 mg/kg; IM: 3-4 mg/kg (ABW)1-1.2 mg/kg  (IBW)
AdministrationIV pushIV Push
Formulation200 mg/ 10 ml vial (must be refrigerated) 100 mg/10 ml vial (non-refrigerated)
PK/PDOnset: 40-60 seconds   Duration: 4-10 minutes   Metabolism: Rapidly hydrolyzed by plasma pseudocholinesterase to inactive metabolites    Renal Excretion:10%Onset: ~ IV 45-90 seconds   Duration: 30-90 minutes   Metabolism: N- demethylation       Renal Excretion: 
Adverse EffectsBradycardia, Hyperkalemia, fasciculations,  ↑ intraocular pressure, transient ↑ ICP ~5-10 mmHg, malignant hyperthermia (rare)Very few reported Increased peripheral vascular resistance (abdominal aortic surgery)
Drug Interactions No major reactionsNo major reactions
CompatibilityIncompatible with sodium bicarbonate, nafcillin, oxacillin, phenytoin, phenobarbitalIncompatible with furosemide, regular insulin, lorazepam, phenytoin, pantoprazole, and Zosyn
ContraindicationsHypersensitivity to succinylcholine or any component of the formulation; personal or familial history of malignant hyperthermia; skeletal muscle myopathies; >3-5 days  following major burns, intra-abdominal sepsis, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury.Hypersensitivity to rocuronium 

Jlpruitt@gmh.edu                                                                                                                                   For educational purposes only

 Advantages per EM PhysiciansConsiderations per EM Physicians
SuccinylcholineShorter duration of paralysisCan see hyper-K with CNS/spinal cord injury (>3 days), myopathies, burns (few days late), IA sepsis, critical illness, and occasionally with severe traumatic injury acutely due to succinic acid mechanism. Avoid sux when possible in pediatric populations (<8)
RocuroniumHas reversal agent, not associated with malignant hyperthermia, not associated with hyperkalemia (no fasciculation), dosed on ideal body weight (100mg will give 1.2 mg/kg for male that is 6’4)   Certain centers (not GHS) may have access to sugammadex (Bridion) instead of neostigmine + atropine for reversal. Longer paralytic time, however has reversal agent  
 Overview of Evidence
Author, year Design/ sample sizeIntervention & ComparisonOutcome
April, 2018Prospective cohort study/ n= 4,275Succinylcholine ≥ 1.5 mg/kg     vs Rocuronium ≥ 1.2  mg/kgFirst-pass intubation success rate was no difference between the agents with  87.0% with succinylcholine versus 87.5% with rocuronium (adjusted OR 0.9; 95% CI 0.6- 1.3   Incidence of any adverse events were no difference   There was a difference in first pass intubation success with rocuronium ≥ 1.2  mg/kg compared to (<1.2 mg/kg)
Tran,  2017Cochrane Meta- Analysis/ n= 4151Succinylcholine ≥ 1 mg/kg     vs Rocuronium ≥ 0.6 mg/kgOverall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions (risk ratio (95%CI) 0.86 (0.81 to 0.92), n = 4151) and clinically acceptable intubation conditions (risk ratio (95%CI) 0.97 (0.95–0.99), n = 3992).   A high incidence of detection bias amongst the trials 
Patanwala, 2016Retrospective cohort study/ n=233Succinylcholine (dosing not reported)      vs Rocuronium (dosing not reported)In the high-severity TBI patients, succinylcholine was associated with increased mortality compared with rocuronium (OR 4.10, 95% CI 1.18– 14.12).
Patanwala, 2011Retrospective analysis/ n=327Succinylcholine  1.65 mg/kg     vs Rocuronium  1.19 mg/kgThe rate of first-attempt intubation success was similar between the succinylcholine and rocuronium groups (72.6% vs. 72.9%, p = 0.95).    
Watt, 2012retrospective cohort study/ n=200Succinylcholine  1.7 ± 0.7 mg/kg     vs Rocuronium 1.3 ± 0.4 mg/kg After intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7).   Mean time to post intubation sedation was significantly greater with rocuronium compared to succinylcholine  (27 min vs 15; p <0.001)
Smith 2002Prospective, blinded Study/ n=100Rocuronium 1 mg/kg        vs Vecuronium 0.15 mg/kgIntubation was successful in 95% of patients in the vecuronium group and 100% in the rocuronium group
Weiss,1997RCT/  n=45Succinylcholine 1.5 mg/kg     vs Rocuronium 0.7 and 0.9mg/kgRocuronium bromide at a dose of 0.9 mg/kg provides intubating conditions similar to succinylcholine 1.5 mg/kg at 1 minute.   Intubating conditions at 1 minute following rocuronium 0.7 mg/kg inferior to higher dose of rocuronium or succinylcholine.
Magorian 1993RCT/ n= 50Succinylcholine 1 mg/kg     vs Rocuronium 0.6, 0.9, and 1.2 mg/kg     vs Vecuronium 0.1 mg/kg  Onset time of rocuronium 0.9 mg/kg and 1.2 mg/kg rocuronium and succinylcholine 1 mg/kg) were similar; onset times fo rocuronium 0.6 mg/kg and vecuronium mg/kg) were much longer.     Rocuronium (1.2 mg/kg) had a mean onset time of 55 seconds, which was similar to the mean onset time of succinylcholine (50 seconds)


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  6. Patanwala S. Pharmacotherapy. 2016 Jan;36(1):57-63.
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