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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

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