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LETTER TO THE EDITOR

Airway Injury with Low-Dose Rocuronium Versus Succinylcholine for Rapid-Sequence Induction: Relevance and Ethics

Mount Sinai School of Medicine, New York, New York, david.wax{at}mssm.edu

To the Editor:

Mencke et al. (1) selected a relatively low dose of rocuronium (0.6 mg/kg) in their prospective study relating airway injury to choice of neuromuscular blocking drug. There is substantial evidence (cited within the study background) that 0.6 mg/kg of rocuronium produces inferior intubating conditions compared to succinylcholine for rapid-sequence induction/intubation, especially when thiopental is used as an induction drug.

I question whether this study design provides clinically relevant information. Because most practitioners use a higher dose of rocuronium for rapid-sequence intubation, the dose used in this study may not represent typical or appropriate dosing. Also, if the authors’ prior study (2) (saline versus atracurium) had already shown increased airway injury with inferior intubating conditions, it might be argued that this follow-up study was really just an indirect comparison of intubating conditions between saline after 3 min and low-dose rocuronium after 50 s. But again, the clinical relevance of an unrealistic rocuronium dose/timing combination is unclear.

Another interesting aspect of this study is an ethical one. Because the authors had already observed increased injury with inferior intubating conditions in their prior study, what was the rationale here for subjecting another group of patients to similar conditions and therefore increased risk of airway injury? Moreover, the subject group they chose was composed of patients at increased risk for pulmonary aspiration. To maximize safety in both clinical practice and research, such patients require preparation with the best intubating conditions possible to achieve rapid and successful intubation. Deliberately creating inferior intubating conditions in such an at-risk patient population appears imprudent.

So I am left wondering how the authors justify a study design that subjects patients to an increased risk of airway injury and aspiration pneumonitis to answer what may be a clinically irrelevant question. Similarly, I wonder why patients, if fully informed, would consent to participate in such a study.

REFERENCES

1. Mencke T, Knoll H, Schreiber JU, et al. Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: a randomized, prospective, controlled trial. Anesth Analg 2006;102:943–9.[Abstract/Free Full Text]
2. Mencke T, Echternach M, Kleinschmidt S, et al. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology 2003;98:1049–56.[Web of Science][Medline]

This article has been cited by other articles:

				T. Mencke, G. Noeldge-Schomburg, and H. Knoll Airway Injury with Low-Dose Rocuronium Versus Succinylcholine for Rapid-Sequence Induction: Relevance and Ethics Anesth. Analg., January 1, 2007; 104(1): 210 - 210. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wax, D. B. Search for Related Content PubMed PubMed Citation Articles by Wax, D. B.