For a patient undergoing closed‑globe vitrectomy with a short neck and Mallampati IV airway (difficult airway and possible ventilation difficulty), which agent is preferred for rapid‑sequence induction—high‑dose rocuronium or succinylcholine?

Difficult Airway RSI in Closed-Globe Vitrectomy: Rocuronium vs Succinylcholine

For a patient with a short neck, Mallampati IV airway, and possible ventilation difficulty undergoing closed-globe vitrectomy, use rocuronium 1.0–1.2 mg/kg as the preferred neuromuscular blocker for rapid-sequence induction, avoiding succinylcholine entirely in this high-risk scenario. 1

Primary Rationale for Rocuronium Preference

The combination of anticipated difficult intubation AND possible difficult ventilation creates a "can't intubate, can't ventilate" (CICV) risk that mandates the ability to reverse paralysis rapidly if airway rescue fails. 2

• Rocuronium 1.0–1.2 mg/kg provides onset within 60 seconds—comparable to succinylcholine's 50 seconds—making it suitable for RSI when dosed appropriately 1, 3
• The critical advantage is reversibility: sugammadex must be immediately available to reverse rocuronium within 2–3 minutes if a CICV situation develops, whereas succinylcholine's 4–6 minute duration cannot be reversed 1
• In your predicted difficult airway scenario, the Difficult Airway Society guidelines explicitly state that Plan B (secondary intubation attempts) is omitted during RSI because repeated attempts increase aspiration risk, making immediate awakening via sugammadex reversal the safest bailout strategy 2

Dosing and Onset Specifications

• Administer rocuronium 1.0–1.2 mg/kg IV based on actual body weight to achieve intubating conditions in 55–75 seconds 1, 3
• Doses below 0.9 mg/kg result in inadequate intubating conditions and longer onset times (89 seconds at 0.6 mg/kg), which are unacceptable in RSI 1, 3
• The 2023 Society of Critical Care Medicine guidelines conditionally recommend either agent when no contraindications exist, but emphasize that rocuronium ≥0.9 mg/kg is the alternative when succinylcholine is unsuitable 2, 1

Why Succinylcholine Is Problematic in This Case

Succinylcholine's irreversible 4–6 minute paralysis creates an unacceptable risk window if you encounter the predicted difficult airway and cannot ventilate. 1

• The Difficult Airway Society explicitly warns that in RSI scenarios with failed intubation, further doses of succinylcholine should NOT be given because the short duration increases laryngospasm risk during recovery of neuromuscular function 2
• Your patient's Mallampati IV and short neck predict Cormack-Lehane grade 3–4 views, where the introducer (bougie) success depends on whether the epiglottis can be lifted—an uncertain prospect 2
• If mask ventilation also fails (your stated concern), you enter Plan D (CICV rescue) with no ability to reverse succinylcholine, forcing immediate surgical airway or accepting hypoxic injury 2

Comparative Efficacy Evidence

• A 2019 multicenter RCT (n=1,248) showed first-pass intubation success of 74.6% with rocuronium 1.2 mg/kg versus 79.4% with succinylcholine, a 4.8% difference that did not meet noninferiority criteria 4
• However, a 2005 emergency surgery study using rocuronium 0.6 mg/kg (suboptimal dose) still achieved 96.1% clinically acceptable intubation conditions versus 93.5% with succinylcholine 5
• The key clinical point: the slightly lower first-pass success with rocuronium is offset by the life-saving ability to reverse paralysis if airway rescue is needed 1

Airway Management Algorithm for This Patient

Pre-Induction Preparation

• Position patient in semi-Fowler (head-up 25–30°) to improve functional residual capacity and reduce aspiration risk if regurgitation occurs 2
• Preoxygenate with high-flow nasal oxygen or non-invasive positive pressure ventilation given the anticipated difficult ventilation 2
• Ensure sugammadex 16 mg/kg (for immediate reversal of rocuronium 1.2 mg/kg) is drawn up and immediately available at bedside 1
• Have videolaryngoscopy as first-line device ready, as it increases success in anticipated difficult intubation 2

Induction Sequence

• Administer sedative-hypnotic induction agent (propofol 1.5–2.5 mg/kg or etomidate 0.3 mg/kg) 2, 1
• Immediately follow with rocuronium 1.0–1.2 mg/kg IV push 1
• Apply cricoid pressure 30N (reduce if it impedes laryngoscopy or causes airway obstruction) 2
• Attempt intubation at 60 seconds using videolaryngoscopy with external laryngeal manipulation 2

Failed Intubation Protocol (Plan C)

• Maximum 3 intubation attempts, then immediately declare failed intubation 2
• Attempt face-mask ventilation with oral/nasal airway; consider reducing cricoid force if ventilation difficult 2
• If oxygenation maintained (SpO₂ ≥90%), insert LMA/ProSeal LMA with reduced cricoid pressure 2

CICV Rescue (Plan D)

• If face-mask AND LMA ventilation both fail (SpO₂ <90% despite FiO₂ 1.0), immediately administer sugammadex 16 mg/kg to reverse rocuronium 1
• Simultaneously prepare for emergency front-of-neck access (scalpel cricothyroidotomy) 2
• Sugammadex reversal within 2–3 minutes allows return of spontaneous ventilation and awakening, avoiding surgical airway in many cases 1

Closed-Globe Vitrectomy-Specific Considerations

• Closed-globe surgery does NOT require the same urgency as open-globe injury, so you can optimize airway management rather than accepting suboptimal conditions 2
• Avoid coughing/straining during intubation to prevent intraocular pressure spikes, which rocuronium's complete paralysis provides better than partially-worn-off succinylcholine 1
• The 30–60 minute duration of rocuronium 1.2 mg/kg is appropriate for vitrectomy duration, eliminating need for redosing 1, 6

Common Pitfalls to Avoid

• Do not use rocuronium 0.6 mg/kg thinking it is adequate for RSI—this dose has 89-second onset and produces inferior intubating conditions 1, 3
• Do not proceed with succinylcholine simply because "it's traditional for RSI"—the irreversibility creates unacceptable risk in your predicted difficult airway 2, 1
• Do not attempt more than 3 laryngoscopy passes—each attempt worsens airway edema and increases CICV risk 2
• Do not forget to reduce or release cricoid pressure if it impedes laryngoscopy or causes airway obstruction—cricoid force can worsen both intubation and ventilation 2
• Never extubate until patient is fully awake with intact airway reflexes—your difficult airway will be equally difficult for re-intubation 1

Monitoring Requirements

• Continuous ECG and pulse oximetry from induction through at least 2 minutes post-intubation 1
• Neuromuscular monitoring (train-of-four) to confirm adequate reversal if sugammadex is administered 1
• Maintain external defibrillation equipment immediately available throughout 2