Skip to content

Rocuronium leads to delays in post RSI sedation initiation compared with Suxamethonium

Hi folks. Reading time again.

Rocuronium  I used in a recent RSI a week ago. Then I read this paper. See what you think. Gentle reminder not to forget preparing your maintenance sedation and analgesia and how rocuronium may somehow lead to a delay in initiation.

Emerg Med J doi:10.1136/emermed-2012-201812

Effect of paralytic type on time to post-intubation sedative use in the emergency department

  1. John M Watt1,
  2. Albert Amini1,
  3. Brittany R Traylor2,
  4. Richard Amini3,
  5. John C Sakles3,
  6. Asad E Patanwala2

+Author Affiliations

  1. 1Department of Surgery College of Medicine, University of Arizona Tucson, Arizona, USA

  2. 2Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA

  3. 3Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
  1. Correspondence to Dr Asad E Patanwala,  1295 N. Martin, PO Box 210202, Tucson, AZ 85721, USA;
  • Accepted 30 September 2012
  • Published Online First 8 November 2012


Objective To determine the difference between rocuronium and succinylcholine with regard to post-intubation sedative initiation in the emergency department.

Methds This was a retrospective cohort study conducted in a tertiary care emergency department (ED) in the USA. Consecutive adult patients intubated in the ED using succinylcholine or rocuronium for paralysis were included. Data collected included patient demographics, vital signs, medications used post-intubation and times of drug administration. Patients were divided into two groups based on the type of paralytic used for rapid sequence intubation: (1) rocuronium or (2) succinylcholine. All patients received etomidate for induction of sedation. Time between intubation and post-intubation sedative use was compared between the two groups using an unpaired Student’s t test.

Main results A total of 200 patients were included in the final analyses (100 patients in each group). There were no significant differences between the groups with regard to patient demographics, vital signs or other baseline characteristics. After intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7). The remaining patients received sedation as bolus doses only. Mean time between intubation and post-intubation sedative use was significantly greater in the rocuronium group compared with the succinylcholine group (27 min vs 15 min, respectively; p<0.001).

Conclusions Patients intubated with rocuronium had greater delays in post-intubation sedative initiation compared with succinylcholine.

4 Comments Post a comment
  1. unfortunately it is the patient moving that is often our reminder to initiate post-intubation sedation and analgesia, which is why the sux group got their drips faster. use a checklist.

    November 13, 2012
    • thanks mate!
      Use a checklist like EDICT

      Also consider auditing your RSI via audio recording, with permission/consent from all parties/institutions involved as part of a rigourous QA/QI process. Consider use of your iPhone or similar device to record the audio of your RSIs so you can measure the time of delivery of RSI drugs, till time of request for initiation of post intubation sedation/analgesia.

      I call it the Airway intubation recorder, analagous to the flight black box recorder on all aircraft.

      Something to consider and plan for as part of airway QI process. Check with colleagues and employer first!

      Dr Paul Mayo of Long Beach first described the routine use of this audio recording process in ICU intubations.

      November 13, 2012
  2. Ben Hoffman #

    I agree Minh, we’ve talked a bit about using recording of your RSI +/- smartphone +/- video for quality improvement and I think it is a great idea, certainly something done routinely for decades in the aviation industry.

    A checklist and standard operating procedures would also go a ways to being of great assistance in this instance. There are many checklists floating around and London HEMS has developed a comprehensive set of standardised procedures for RSI.

    I believe the Metropolitan Ambulance Service in Victoria, Australia draw up all drugs before they begin – to include post intubation sedation (they are using a fentanyl and midazolam infusion).

    November 15, 2012

Trackbacks & Pingbacks

  1. The LITFL Review 084

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Rural GP Education

Thought and experiences on the journey to enlightenment



EM in Focus

time to get focused on your patients.


In memory of Dr John Hinds

Dr. Smith's ECG Blog

In memory of Dr John Hinds


"Live as if you will die tomorrow; Learn as if you will live forever"

Songs or Stories

Sharing the Science and Art of Paediatric Anaesthesia


In memory of Dr John Hinds

"Sweat the small stuff...."

"If someone is willing to teach you something for free, take them up on it. Do it. Every single time. All it does is make you more likely to succeed. And its kind of a nice way to go through life...."

Liz Crowe

Wellbeing Counsellor and Educator


In memory of Dr John Hinds

EM Basic

Your Boot Camp Guide to Emergency Medicine

Ash Witt

In memory of Dr John Hinds


Ramblings from a gasdoc with interests in #anaesthesia, #intensivecare, #echo, #PHEM and #FOAM

PulmCrit: Pulmonary Intensivist's Blog

In memory of Dr John Hinds

Miss Chardy

Laughter in the Outback

The Collective

A Hive Mind for Prehospital and Retrieval Med

Bits & Bumps

Obstetrics and Gynaecology FOAM


Why FOAM it alone?

In memory of Dr John Hinds


Or "How I'm Learning to Stop Worrying and Love Emergency Medicine"


A great site

Genevieve's anthology

Writings to amuse, teach, inspire and entertain.

JR Paramedic

In memory of Dr John Hinds

Monash Anaesthesia

In memory of Dr John Hinds


A topnotch site


Bringing the boring to emergency medicine


Navigating resuscitation

Doctor's bag

by Dr Edwin Kruys

EM nerd

In memory of Dr John Hinds

The Chart Review

In memory of Dr John Hinds

ETM Course

Emergency Trauma Management Course

The Doctor's Dilemma

Modern Medical Musings from Dr Marlene Pearce

Sim and Choppers

A blog combining medical education, simulation and helicopter retrieval medicine


Reflections of a Rural GP

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

Rural Doctors Net

useful resources for rural clinicians


Searching for the big picture in intensive care

Nomadic GP

Adventures of a Rural Locum


Free Open Access Medical Education for Paramedics

Not just a GP

Why GP is the greatest job in the world

the short coat

In memory of Dr John Hinds


Bringing the Boring to EM

When your shift turns to shit? Keep moving, keep caring!

KI Doc

Kangaroo Island doctor blogging about Rural Medicine in Australia


pulling apart cases from the ED...

Little Medic

Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.


Get every new post delivered to your Inbox.

Join 11,330 other followers

%d bloggers like this: