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LETTER TO THE EDITOR

Rocuronium Versus Succinylcholine for Rapid Tracheal Intubation

Department of Anesthesiology; Saint Vincent's Hospital Manhattan; New York, NY; akopman{at}nyc.rr.com; akopman{at}gmail.com

To the Editor:

In their recent paper Sluga et al. (1) conclude that succinylcholine 1.0 mg/kg provides superior intubation conditions with a faster onset of effect than rocuronium 0.60 mg/kg in the setting of a rapid sequence induction of anesthesia. These results were totally predictable. The authors compared a dose of succinylcholine equal to 3.5–4.0 times the ED₉₅ (2) to a dose of rocuronium that, at best, amounted to half this potency (3).

The authors chose this modest dose of rocuronium because Perry et al. (4) suggested that there "seemed to be no value of larger doses of rocuronium on intubation conditions." Sluga et al. would have been better served by consulting primary sources rather than a single Cochrane Review. There is a convincing body of evidence that the drug is a very acceptable alternative to succinylcholine for rapid-sequence induction of anesthesia when the dose of rocuronium is increased to 0.90 mg/kg or larger (5–9). The authors have done the readers of this journal a disservice by dismissing the use of larger doses of rocuronium so casually and not examining the utility of these doses for themselves.

References

1. Sluga M, Ummenhofer W, Studa W, et al. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases. Anesth Analg 2005;101:1356–61.[Abstract/Free Full Text]
2. Kopman AF, Klewicka MM, Neuman GG. An alternate method for estimating the dose-response relationships of neuromuscular blocking drugs. Anesth Analg 2000;90:1191–7.[Abstract/Free Full Text]
3. Meistelman C, Plaud B, Donati F. Rocuronium (ORG 9426) neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis in humans. Can J Anaesth 1992;39:665–9.[Web of Science][Medline]
4. Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2003;XX:CD002788.
5. Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Anesthesiology 1993;79:913–8.[Web of Science][Medline]
6. Weiss JH, Gratz I, Goldberg ME, et al. Double-blind comparison of two doses of rocuronium and succinylcholine for rapid-sequence intubation. J Clin Anesth 1997;9:379–82.[Medline]
7. Andrews JI, Kumar N, van den Brom RHG, et al. A large simple randomized trial of rocuronium vs succinylcholine in rapid-sequence induction of anaesthesia along with propofol. Acta Anaesthiol Scand 1999;43:4–8.[Web of Science][Medline]
8. Kirkegaard-Nielsen H, Caldwell JE, Berry PD. Rapid tracheal intubation with rocuronium: a probability approach to determining dose. Anesthesiology 1999;91:131–6.[Web of Science][Medline]
9. Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg 2000;90:175–9.[Abstract/Free Full Text]

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