Roc vs. Sux for RSI… a storm in a teacup

Far too much time and effort has been spent debating the winner of the rocuronium vs. succinylcholine contest. But it is a bit too hard to ignore this paper claiming to be the first RCT of these drugs in an emergency setting.

This was a multicenter, non-inferiority RCT of 1248 patients with out-of-hospital cardiac arrest in France. Tout bon!

Rocuronium dosed at 1.2m/kg was compared to succinylcholine at 1mg/kg. The authors note the patients were blinded to the assigned drugs. Yes… really… Patients with no health insurance were excluded. Yes… really…

About 90% of the intubations were conducted by a specialist emergency doctor. They only used direct laryngoscopy (no video) and half the time intubated in some pretty creative places… i.e. on the ground.

The primary outcome was first pass intubation success rate. Hardly a patient oriented outcome, but at least it is reasonably objective and measurable. They also looked at some secondary outcomes.

A non-inferiority margin of 7% was chosen.

Results?

It turns out that rocuronium was not non-inferior to succinylcholine!

Howzat…?

First pass success rate was 79% in the sux group vs. 74% in the roc group. The difference in the 95% confidence interval was up to 9%. This is greater than their non-inferiority margin.

Sux is the winner!

Not really.

There were more adverse events in the succinylcholine group.

Unfortunately, this study will not end the Sux vs. Roc debate. C'est la vie... But either way it doesn’t really matter.

Both drugs are fine. And in your practice, you can always use both.

Don’t forget some contraindications to giving sux (mostly hyperkalemia) and don’t forget to provide post intubation sedation after giving a proper dose of roc.

Covering:

Buihard B, Chollet-Xemard C, Lakhnati P, et al. Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of Hospital Rapid Sequence Intubation. JAMA 2019;322(23):2303-2312 [link to article]