Rapid Sequence Intubation (RSI): Rocuronium For RSI

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Mechanism of Action

• Rocuronium is a nondepolarizing NMBA that acts as a competitive inhibitors of acetylcholine (ACh) receptors.
  • Nondepolarizing NMBAs bind to the ACh receptor without causing a conformational change which would tradionally allow passage of sodium ions.
• Rocuronium is monoquaternary steroid analogue of vecuronium designed to provide a rapid onset of action

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Dose

• 1 to 1.2 (commonly 1) mg/ kg total body weight IV
  • In obese patients ideal body weight (IBW) or total body weight (TBW) may be used

Lower doses have been studied (<1 mg/kg), however, the onset of action with lower dosages isn’t ideal for emergent intubations such as RSI.

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Onset

• IV: 45-90 seconds
  • Larger doses lead to quicker onset of action

Duration

• 30-90 minutes
  • Larger doses leads to more prolonged duration of action

Metabolism:

• Minimally hepatically

Elimination

• Renal Excretion: Feces (31%); urine (26%) 

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Adverse effects

• Very few reported, but possible increased peripheral vascular resistance (abdominal aortic surgery)

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Contraindications

• Contraindications
  • Allergy to class/drug

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Pearls

The main problem with high dose nondepolarizing neuromuscular blocking agents is prolonged recovery time

If a patient needs to have frequent neurological assessments soon after intubation, reversal of rocuronium could be considered with a neostigmine + atropine or sugammadex.

Have post-intubation sedation plan set prior to intubation to minimized awake paralysis

Literature Review

Author, year	Design/ sample size	Intervention & Comparison	Outcome
Guihard, 2019	Noninferiority randomized clinical trial n=1248	Succinylcholine ≥ 1.5 mg/kg vs Rocuronium ≥ 1.2 mg/kg	Successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority.
April, 2018	Prospective cohort study n= 4,275	Succinylcholine ≥ 1 mg/kg vs Rocuronium ≥ 1.2 mg/kg	The first-pass intubation success rate was no different between the agents with 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted OR 0.9; 95% CI 0.6- 1.3
Patanwala, 2016	Retrospective cohort study n=233	Succinylcholine (dosing not reported) vs Rocuronium (dosing not reported)	In the high-severity TBI patients, succinylcholine was associated with increased mortality compared with rocuronium (OR 4.10, 95% CI 1.18–14.12).
Watt, 2012	Retrospective cohort study n=200	Succinylcholine 1.7 ± 0.7 mg/kg vs Rocuronium 1.3 ± 0.4 mg/kg	After intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7). Mean time to post-intubation sedation was significantly greater with rocuronium compared to succinylcholine (27 min vs 15; p <0.001)
Marsch, 2011	Prospective, randomized, controlled, singleblind, single-center study n=401	Succinylcholine (dosing not reported) vs Rocuronium (dosing not reported)	No difference in oxygen desaturations between succinylcholine and rocuronium (P = .67)
Magorian, 1993	Prospective, randomized, singlecenter study n=50	Succinylcholine or vecuronium vs rocuronium	Onset time of rocuronium 0.9 mg/kg and 1.2 mg/kg rocuronium and succinylcholine (1 mg/kg) were similar; onset times for rocuronium 0.6 mg/kg and vecuronium (0.1 mg/kg) were much longer

Comments by ED Physician Attendings

Pro’s	Con’s
” Has reversal agent, not associated with malignant hyperthermia, not associated with hyperkalemia (no fasciculation), dosed on ideal body weight (100mg will give 1.2 mg/kg for male that is 6’4)”	” Longer paralytic time, however has reversal agent”

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References

• Guihard B, Chollet-Xémard C, Lakhnati P, et al. Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. JAMA. 2019;322(23):2303-2312. doi:10.1001/jama.2019.18254
• April MD, Arana A, Pallin DJ, Schauer SG, Fantegrossi A, Fernandez J, Maddry JK, Summers SM, Antonacci MA, Brown CA 3rd; NEAR Investigators. Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study. Ann Emerg Med. 2018 Dec;72(6):645-653. doi: 10.1016/j.annemergmed.2018.03.042. Epub 2018 May 7. PMID: 29747958.
• Tran DTT, Newton EK, Mount VAH, Lee JS, Mansour C, Wells GA, Perry JJ. Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia. 2017 Jun;72(6):765-777. doi: 10.1111/anae.13903. PMID: 28654173.
• Patanwala AE, Erstad BL, Roe DJ, Sakles JC. Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy. 2016 Jan;36(1):57-63. doi: 10.1002/phar.1683. PMID: 26799349.
• Patanwala AE, Stahle SA, Sakles JC, Erstad BL. Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med. 2011 Jan;18(1):10-4. doi: 10.1111/j.1553-2712.2010.00954.x. Epub 2010 Dec 23. PMID: 21182564.
• Weiss JH, Gratz I, Goldberg ME, Afshar M, Insinga F, Larijani G. Double-blind comparison of two doses of rocuronium and succinylcholine for rapid-sequence intubation. J Clin Anesth. 1997 Aug;9(5):379-82. doi: 10.1016/s0952-8180(97)00065-2. PMID: 9257203.
• Smith CE, Kovach B, Polk JD, Hagen JF, Fallon WF Jr. Prehospital tracheal intubating conditions during rapid sequence intubation: rocuronium versus vecuronium. Air Med J. 2002 Jan-Feb;21(1):26-32. doi: 10.1067/mmj.2002.121713. PMID: 11805764.
• Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Anesthesiology. 1993 Nov;79(5):913-8. doi: 10.1097/00000542-199311000-00007. PMID: 7902034.
• Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from http://www.micromedexsolutions.com/