From the Guidelines
Rocuronium is the primary alternative to succinylcholine for rapid sequence intubation (RSI) when succinylcholine is not available, and it should be used at a dose of 1.0-1.2 mg/kg IV to provide excellent intubating conditions within 60-90 seconds. In cases where succinylcholine is not available, the choice of alternative agent depends on various factors, including the patient's medical history and the potential risks associated with each agent.
- Rocuronium is a suitable alternative to succinylcholine for RSI, with a faster onset of action compared to other non-depolarizing neuromuscular blockers, as noted in the guidelines on muscle relaxants and reversal in anaesthesia 1.
- The use of rocuronium for RSI is supported by the society of critical care medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient, which recommends its use as an alternative to succinylcholine 1.
- Ketamine or a higher dose of versed may be used for sedation before administering the neuromuscular blocker, but the primary focus should be on using rocuronium as the alternative to succinylcholine for RSI.
- The benefits of using rocuronium include its faster onset of action and lower risk of adverse events, such as hyperkalemia and malignant hyperthermia, compared to succinylcholine, as reported in the guidelines on muscle relaxants and reversal in anaesthesia 1.
- However, rocuronium has a longer duration of action compared to succinylcholine, which could be problematic if intubation fails, but sugammadex can rapidly reverse its effects in emergency situations, as noted in the society of critical care medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient 1.
From the FDA Drug Label
Rapid Sequence Intubation Intubating conditions were assessed in 230 patients in six clinical studies where anesthesia was induced with either thiopental (3 to 6 mg/kg) or propofol (1.5 to 2. 5 mg/kg) in combination with either fentanyl (2 to 5 mcg/kg) or alfentanil (1 mg). Most of the patients also received a premedication such as midazolam or temazepam. Most patients had intubation attempted within 60 to 90 seconds of administration of rocuronium bromide 0.6 mg/kg or succinylcholine 1 to 1. 5 mg/kg.
The alternative to succinylcholine for rapid sequence intubation is rocuronium bromide. According to the study, rocuronium bromide 0.6 mg/kg provided excellent or good intubating conditions in 99% of patients, which is comparable to succinylcholine. However, the duration of action of rocuronium bromide is longer than succinylcholine.
- Key points:
- Rocuronium bromide 0.6 mg/kg can be used as an alternative to succinylcholine for rapid sequence intubation.
- Intubating conditions were excellent or good in 99% of patients receiving rocuronium bromide.
- The duration of action of rocuronium bromide is longer than succinylcholine. 2
From the Research
Alternative to Succinylcholine for Rapid Sequence Intubation
In cases where succinylcholine is not used, alternatives such as rocuronium or a higher dose of other agents like ketamine or versed may be considered. The choice of alternative agent depends on various factors, including patient-specific conditions and the desired onset and duration of action.
- Rocuronium as an Alternative: Rocuronium has been shown to be an effective alternative to succinylcholine for rapid sequence intubation, with a rapid onset of action and minimal differences in first-pass success rates 3, 4. However, the duration of action of rocuronium is longer than that of succinylcholine, which may be a consideration in certain clinical scenarios.
- Ketamine and Versed: Ketamine is a commonly used induction agent for rapid sequence intubation, and its use has been studied in various clinical scenarios 3, 5, 6. A higher dose of versed (midazolam) may also be used as an alternative, but its effectiveness and safety profile in this context are less well-studied.
- Considerations for Alternative Agents: The selection of an alternative agent to succinylcholine should be based on patient-specific factors, including the presence of any underlying medical conditions, the desired onset and duration of action, and the potential for adverse effects 3, 5, 4, 6, 7.
Key Points to Consider
- Rocuronium is a viable alternative to succinylcholine for rapid sequence intubation, with a rapid onset of action and minimal differences in first-pass success rates.
- Ketamine is a commonly used induction agent for rapid sequence intubation, and its use has been studied in various clinical scenarios.
- The selection of an alternative agent to succinylcholine should be based on patient-specific factors, including the presence of any underlying medical conditions and the desired onset and duration of action.