Anesth Analg 2006;102:1912-1913
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000215150.02773.96
LETTER TO THE EDITOR
Rocuronium Versus Succinylcholine for Rapid Tracheal Intubation
Mathias Sluga, MD,
Wolfgang Ummenhofer, MD,
Wolfgang Studer, MD,
Martin Siegemund, MD, and
Stephan Marsch, MD, DPhil
Klinik für Intensivmedizin; Universitätsspital Basel; Basel, Switzerland; smarsch{at}uhbs.ch
In Response:
Dr. Kopman (1) questions the use of a rocuronium dose of 0.6 mg/kg in our recent study on rapid sequence intubation (2). Contrary to the belief of Dr. Kopman, we did not "casually" choose this dose.
Our choice was based on the following evidence. In an analysis of more than 1500 patients with different induction sequences, the Cochrane Review of Perry et al. (3) did not find conclusive evidence that increasing doses of rocuronium led to better intubation conditions. Moreover, the analysis of 640 patients with propofol induction revealed no significant difference between rocuronium and succinylcholine. A sensitivity analysis within the propofol induction group for dose of rocuronium used (0.6–0.7 mg/kg versus 0.9–1.0 mg/kg) demonstrated that dose did not alter intubating conditions.
We are well aware that there is a dose-dependent effect of rocuronium on both onset and duration of neuromuscular blockade (3–8). However, most of the studies demonstrating this dose-dependent effect have been performed using an induction drug other than propofol and included no comparison with succinylcholine. Moreover, there are no data in the literature on whether the earlier onset of neuromuscular blockade after larger doses of rocuronium result in acceptable intubating conditions significantly earlier than 60 s after the injection. We did an extensive literature search but failed to find additional comparative studies not already identified by the abovementioned Cochrane Review. Thus, when propofol is used as induction drug, the best available evidence preceding our study indicated that small doses of rocuronium (0.6–0.7 mg/kg) should be used as an alternative to succinylcholine for rapid-sequence induction to avoid a prolonged neuromuscular blockade.
What do our data add to the question of optimal dose of rocuronium for rapid sequence intubation? Scores for intubating conditions were significantly better after succinylcholine 1 mg/kg than after rocuronium 0.6 mg/kg (2). However, this difference resulted almost exclusively from the ratings of the response to intubation, i.e., coughing and bucking, whereas there was no difference in the clinically more important ratings of the conditions of laryngoscopy and vocal cords. Moreover, there was no significant difference in the number of patients with failed first intubation attempt (5 versus 4).
Andrews et al. (9) compared intubating conditions after succinylcholine 1 mg/kg with those after rocuronium 1 mg/kg in 272 predominantly elective cases. They reported a difference in clinically acceptable intubating conditions (rocuronium minus succinylcholine) of –3.9% (95% confidence interval, –9.7% to 1.9%), which is very similar to the difference of –5.6% (95% confidence interval, –14.1% to 2.9%) obtained after rocuronium 0.6 mg/kg in emergent cases in our study. In a recent study Larsen et al. (10) compared intubating conditions 60 s after the injection of either succinylcholine 1 mg/kg or rocuronium 0.6 mg/kg in 209 emergent cases using an induction sequence with propofol and alfentanil. These authors report a nonsignificant difference in acceptable intubating conditions of 2.6% (95% confidence interval, –3.4% to 8.6%) in favor of rocuronium 0.6 mg/kg.
Thus, taking together the results from recent and previous work one can conclude that in terms of intubating conditions, rocuronium in a dose of 0.6 mg/kg is an acceptable alternative to succinylcholine and that little, if any, clinically relevant improvements may be expected with a larger dose. This conclusion is only valid when propofol and an opioid are used for induction of anesthesia.
The data are the data. We do not accept that testing the conclusions of an extensive meta-analysis, mainly based on elective cases, under realistic conditions in a large number of emergent cases represents a "disservice" to the readers of Anesthesia & Analgesia. Rather, we hope that our data will help practitioners make rational choices for their patients.
References
- Kopman A. Rocuronium versus succinylcholine for rapid tracheal intubation. Anesth Analg 2006;102:xxx.
- Sluga M, Ummenhofer W, Studer 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]
- Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2003;CD002788.
- 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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- 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]
- Wright PM, Caldwell JE, Miller RD. Onset and duration of rocuronium and succinylcholine at the adductor pollicis and laryngeal adductor muscles in anesthetized humans. Anesthesiology 1994;81:1110–5.[Web of Science][Medline]
- Andrews JI, Kumar N, Van Den Brom RHG, et al. A large simple randomized trial of rocuronium versus succinylcholine in rapid-sequence induction of anaesthesia along with propofol. Acta Anaesthesiol Scand 1999;43:4–8.[Web of Science][Medline]
- Larsen PB, Hansen EG, Jacobsen LS, et al. Intubation conditions after rocuronium or succinylcholine for rapid sequence induction with alfentanil and propofol in the emergency patient. Eur J Anaesthesiol 2005;22:748–53.[Web of Science][Medline]
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