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ROCURONIUM: The "ROC" Block



Rocuronium > Succinylcholine, in my opinion — All day, every day! But with that being said, I have used Succinylcholine (and occasionally still do), and I won't "knock" anyone who chooses to use it... Pending, they have identified that no contraindications likely exist, and their "rationale" seems rational.


Below is my “Quick Look” infographic, which looks at both Succinylcholine and Rocuronium, the benefits, considerations, and adverse effects.

If you read the infographic/image above, you may be scratching your head after noticing a change from the typical 0.6 to 1.2 mg/kg... Well, in my reading of the Wall's Manual of Emergency Airway Management (6th Edition), they make the recommendation of 1.5 mg/kg. Their recommendation, as I can tell, appears to come from two things:

  1. A paper by Levin NM et al. titled "The Association of Rocuronium Dosing and First-Attempt Intubation Success in Adult Emergency Department Patients" revealed that first-attempt intubation success was the highest when more than 1.4 mg/kg of Rocuronium was used [4].

  2. Weight is often estimated, and if guessed low -- which they report is often the case -- inadequate paralysis can result in partial paralysis and poor intubating conditions. Given that circumstance, and in an effort to simplify NMBA in general, the Wall's Manual of Emergency Airway Management recommends 1.5 mg/kg for both Rocuronium and Succinylcholine.

I don't know anyone who is currently utilizing this recommendation, but I DO see it as something we may see in the future. As always, follow your local protocols and guidelines 😎


Before we continue, I do want to mention that I have a slight bias here and that this reading is essentially a "Why I'd choose Rocuronium over Succinylcholine" piece. Yes, I think ROC is better...


I can’t just tell you that I think Rocuronium (Roc) is better than succinylcholine (Sux) without giving you my reasons why... RIGHT? Soooo, here we go with a blog piggybacking off of Jake Good's typical "Pharmacology NOT Taught in Medic School” blogs; this time, the Rocuronium edition.


Be sure to check out “Pharmacology NOT Taught in Medic School — Succinylcholine Edition” HERE.


When I am asked what my “go-to” RSI medications are, I give the typical basic Starbucks answer: Ketamine and Roc. And while I agree, it's "totes basic," I find that having a reason why makes it less cliche and more coming from an educated background. Do I choose them every time? Absolutely not. If I can find a better reason to choose another medication… I will.


Regarding Rocuronium, the typical follow-up questions I get after I give that Ugg Boots response is usually:


  • What about if you fail the attempt, don’t you want them to start breathing again on their own?

  • It takes so much longer to work, aren’t you worried about desaturation during your intubation attempt?

  • Doesn't succinylcholine provide better intubation conditions with higher success rates?

  • You’re worried about contraindications… Why don’t you just perform a more thorough history?


I’m gonna answer these questions and give you the reason for my opinions; then, I’ll give a deep dive into the pharmacology of Rocuronium.

"What about if you fail the attempt, don’t you want them to start breathing again on their own?"


I’m not sure why this is a question I get so often. My rebuttal is usually pretty simple… “If the patient was breathing well enough for that to be an option, then why are you taking that airway in the first place?” More often than not, I’d say that the patient falls under the typical indications for rapid sequence induction if we are choosing to paralyze in the pre-hospital or emergency environment: Airway protection or respiratory failure (ventilation failure or oxygenation failure). They likely still need airway protection or assistance with ventilation or oxygenation 10 minutes later after the Succinylcholine has worn off. Ask yourself, "Will the pre-existing condition remain following recovery from Succinylcholine?"



Take a look at the above picture. This is the oxyhemoglobin desaturation curve or the "Time to Desaturation" chart. If you look at the bottom right of the photo, you’ll notice the “recovery” window. Roughly 7 to 10 minutes in is when the Succinylcholine will wear off. And if you look at the blue lines indicating oxygen saturation, you’ll notice that the patient is INSANELY hypoxic at this point; maybe dead 🤷‍♀️. Doesn’t seem like something we can wait out.



I friggin’ hope so! But the goal still remains the same… You need an airway. The medication has worn off and now you may have to resort to administering Rocuronium anyway. Or, hopefully, maybe, you’ve resorted to an extra-glottic device prior to getting to this point.


If you weren’t successful at your first attempt, you’ve lost time. You may need to “bag them back up.” You’re losing more time… You're getting nervous... Haste makes waste... My plan is to obtain the airway as soon as possible. However, that doesn’t always happen. I want the effect of paralysis to maintain through any intervention I perform. If my intubation attempts were unsuccessful, I move to extra-glottic devices. If that is unsuccessful, I move to the knife. I want my patient paralyzed (and sedated) through the entirety of that potential chaos. If I must resort to bagging on my way to my destination, at least the patient is paralyzed (and hopefully sedated), not fighting the intervention.


Am I saying no situation exists where succinylcholine’s short duration isn’t appropriate? NO. But in the pre-hospital and emergency environment, I have found that a majority of my intubations were due to reasons that would still exist 10 minutes after I decided to push my paralytic. The exception has really only been patients whom I have intubated due to clinician safety concerns (inmates, combative, behavioral patients). Clinical judgment and critical thinking are imperative. PLUS, you have likely given an induction agent that may suppress a respiratory drive... Do you really think they're returning to their baseline after you have let Succinylcholine wear off?


"It takes so much longer to work, aren’t you worried about desaturation during your intubation attempt?"


Sure. It absolutely crosses my mind. However, with the appropriate pre-oxygenation technique as discussed in the blog, “Weapon of Choice During Your RSI: Pre-oxygenation,” I find this putting some of those worries at ease.


I also find the following information useful:


Succinylcholine has an onset of approximately 45 seconds, whereas Rocuronium has an approximate onset of 60 to 90 seconds -- Depending on what book you read. That is substantial in some clinical scenarios and not so much in others, in my opinion. BUUUT, this is also "source-dependent" and "dose-dependent." In fact, Herbstritt 2012, identified that there was "no significant difference to time to intubate, intubating conditions, or intubating success rate when using 1 to 1.2 mg/kg Rocuronium versus 1 to 1.5 mg/kg of Succinylcholine during RSI in an ED setting." [1]


The Manual of Emergency Airway Management reports that Rocuronium "produces intubation-level paralysis consistently within 60 seconds, especially when an adequate dose of induction (sedative) agent is used, because the induction agent also causes substantial relaxation." [4]


According to the package insert received with Rocuronium, "Neuromuscular block sufficient for intubation (80% block or greater) is attained in a median (range) time of 1 (0.4 to 6) minute(s) and most patients have intubation completed within 2 minutes. Maximum blockade is achieved in most patients in less than 3 minutes."





In an airway/review article by Dr. Scott Weingart and Dr. Richard Levitan titled, Preoxygenation and Prevention of Desaturation During Emergency Airway Management, it is reported that “Patients with high saturation levels on room air or after oxygen administration are at lower risk (for desaturation) and may maintain adequate oxygen saturations as long as 8 minutes.” [2]


Annals of Emergency Medicine. Airway/Review Article | Volume 59, Issue 3, P165-175.E1, March 01, 2012. https://www.annemergmed.com/article/S0196-0644(11)01667-2/fulltext


In that same article, it is reported that the time to desaturation after administration occurs faster with the use of Succinylcholine versus that of Rocuronium. Desaturation to 95% or lower was seen in 242 seconds (4 minutes) with Succinylcholine and desaturation to 95% or lower was seen in 378 seconds (6.3 minutes) with Rocuronium; both of which were following adequate preoxygenation measures. [2]


To add to the "desat" side of the drugs, Taha 2010, concluded, "When suxamethonium (Succinylcholine) is administered for rapid-sequence induction of anesthesia, a more rapid onset of oxygen desaturation is observed during the subsequent apnea as compared to rocuronium." [11]


Does this make you feel a tad better about choosing Rocuronium yet? My other rebuttal to this question is that if you are that worried about desaturation during the apneic phase, consider using appropriate, but also gentle, bag-mask ventilation technique leading up to laryngoscopy.


Check out this article on emDocs titled: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI. 😏


Another quick read on the topic from Life in The Fast Lane: Does Roc Rock? Does Sux Suck?


If you're interested in a video regarding the topic, I suggest spending your next 8 minutes watching the lecture linked below regarding this exact topic by Reuben Strayer on the EM Updates website:




"Doesn't Succinylcholine provide better intubation conditions with higher success rates?"


Ehhhh...


According to the Manual of Emergency Airway Management, "Multiple studies have compared succinylcholine with Rocuronium for intubation. All have concluded that the intubation conditions of the two drugs are very similar, provided they are dosed correctly. Recent reviews comparing succinylcholine and Rocuronium for emergency department RSI by emergency physicians demonstrate no significant difference between intubation success with either agent." [4]


Take a peek at the following articles/papers (w/ conclusions/results in the dropdown):

Rocuronium Versus Succinylcholine for Rapid Sequence for Rapid Sequence Induction Intubation [12]

Comparison of Succinylcholine and Rocuronium for First-Attempt Intubation Success in the Emergency Department [13]

BET 3: Is Rocuronium as Effective as Succinylcholine at Facilitating Laryngoscopy During Rapid Sequence Intubation [1]

Rocuronium Versus Succinylcholine for Rapid Sequence Induction Intubation [9]

Rapid Sequence Induction and Intubation With Rocuronium-Sugammadex Compared With Succinylcholine: A Randomized Trial [14]

Succinylcholine Versus Rocuronium for Rapid Sequence Intubation in Intesive Care: A Prospective, Randomized Controlled Trial [15]

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study [16]

Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China [17]

The Association of Rocuronium Dosing and First-Attempt Intubation Success in Adult Emergency Department Patients [18]

Effect of Rocuronium vs. Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial [19]

As we ALL hopefully know, reading only the results or conclusions doesn't give us a full picture of the entire study or article. I made these available for you all to read and make your conclusions as well.

"You’re worried about contraindications… Why don’t you just perform a more thorough history?"


Ok… You got me. I should have probably performed a more thorough history. I should have asked about a family history of malignant hyperthermia, performed a 12 lead ECG, and inquired about the patient's conditions, putting them at risk for hyperkalemia, including:

  • Pre-existing hyperkalemia (got that POC chem7 at the ready?)

  • Renal failure

  • Congenital myopathies

  • Denervating injuries (eg, stroke, spinal cord injury), after 72 hours

  • Denervating diseases (eg, multiple sclerosis, amyotrophic lateral sclerosis)

  • Burns, after 72 hours

  • Crush injuries, after 72 hours

  • Severe infection with exotoxin production (eg, tetanus, botulism)

You know, because we’re not task saturated enough… Especially if we are working with minimal staffing or working a two-clinician crew. I agree that we should perform the most thorough history possible; we really should try. But can you tell me that you have inquired about every one of these things before giving Succinylcholine? Think back to EVERY time you gave it… did you know ALL of this info? Was it even possible to identify them all?! I feel with Rocuronium, I don't have to worry about these issues. You know, sometimes it's all about feeling warm and fuzzy about your decisions, and Roc just does it for me.


Now let me give you this loooooong list of Rocuronium's absolute contraindications.


  • Hypersensitivity [4]


Let this be known. I am NOT anti-succinylcholine, I’m just pro-Rocuronium for a small handful of reasons.


  • The short duration of paralysis isn't a "positive" in my eyes. In the nearing 10 minutes from the administration of Succinylcholine, I doubt the patient's condition has changed. They needed an airway then; why is spontaneous breathing now OK?

  • Desaturation occurs faster with Succinylcholine administration, and higher doses of Rocuronium produce a similar onset time of intubation-level paralysis. PLUS, with top-notch pre-oxygenation prior to the apneic period, the time to critical desaturation can be delayed.

  • Much of the literature comparing Succinylcholine and Rocuronium reports similar intubation conditions when higher doses of Roc are used, with no significant difference in success rates between the two.

  • Contraindications. Contraindications. Contraindications. Life-threatening contraindications.


Hopefully, this is information you all find useful and consider in the future. With some of my opinions out of the way, let us dive into Rocuronium pharma.


BOOM! 💥


ROCURONIUM PHARMA


Rapid sequence intubation with an NMBA is the current standard of care for emergency intubation. Multiple prospective studies and ED registry data confirm the high success rate of RSI with NMBAs when performed by experienced operators in both adult and pediatric emergency patients. [4-7]


Rocuronium is a non-depolarizing neuromuscular blocking agent (paralytic) widely used to produce muscle relaxation. It is one of many non-depolarizing neuromuscular blocking agents that are used, but it has a distinct advantage over the others for having a faster onset and reversibility. [3]


Mechanism of action:


The site of action for our paralytics is the neuromuscular junction (NMJ). The NMJ is a specialized synapse connection between the terminal end of a motor nerve and a muscle, consisting of three main parts: a presynaptic nerve terminal, a postsynaptic motor end-plate, and the space in between — the synaptic cleft. It is the site for transmission of action potential from nerve to muscle [8].


Normally, on arrival of an action potential at the nerve terminal, calcium channels open to cause influx. Increased calcium inside the nerve terminal causes a series of events leading to a release of the neurotransmitter acetylcholine from synaptic vesicles into the synaptic cleft. The released acetylcholine then binds to nicotinic acetylcholine receptors on the postsynaptic neuromuscular endplate. These receptors are acetylcholine-gated ion channels. The binding of acetylcholine to these receptors leads to another cascade of events that generates and transmits action potential to the cell membrane, ultimately resulting in muscle contraction [8].



Rocuronium is a non-depolarizing, competitive NMBA that competes with and blocks the action of acetylcholine at the neuromuscular endplate’s postjunctional, cholinergic nicotinic (acetylcholine) receptors [4]. When Rocuronium is introduced, the medication binds to the receptors on the neuromuscular endplate, inhibiting depolarization.



As I stated, Rocuronium is a non-depolarizing NMBA. Unlike Succinylcholine, which is a depolarizing NMBA, Rocuronium won't cause defasciculations, and issues with hyperkalemia aren't present.


Indications:

Rocuronium is an IV NMBA, serving a multipurpose role in emergency airway management, and is the preferred non-depolarizing NMBA for emergency RSI. [4] Its clinical uses as we see it in the ER, pre-hospital environment, and critical care environment includes:

  • Neuromuscular blockade (paralysis) to facilitate endotracheal intubation

  • Continued paralysis of the mechanically ventilated patient


Contraindications:

  • Hypersensitivity

Dosing:

In appropriately premedicated and adequately anesthetized patients, rocuronium bromide will provide excellent or good intubating conditions in most patients [10]. Dose:

  • 0.6 to 1.2 mg/kg.

Higher doses can be used to provide intubating conditions similar to succinylcholine, with a short onset time of approximately one minute [3]. This dose is:

  • 1.0 to 1.2 mg/kg

With the most recent release of the Wall's Manual of Emergency Airway Management, the suggested dose is:

  • 1.5 mg/kg

    • Reason for dosing as stated at the beginning of the blog

    • I have no knowledge of clinicians who currently use this dose


Advantages/Benefits:

  • Onset time is faster compared to other non-depolarizing NMBAs

    • Higher dosing creates a similar onset time to that of Succinylcholine [1]

  • May be used for postintubation continued paralysis, if desired or indicated

  • Of the non-depolarizing NMBAs, Rocuronium is the recommended choice for emergency RSI [4]

    • Onset time and duration are the shortest in its class (non-depolarizing NMBAs)

  • Reversal agent exists

    • Sugammadex


Adverse Effects & Considerations:

  • Prolonged onset seen in low cardiac output (shock) states

  • Patients with Myasthenia Gravis experience prolonged paralysis [4]


Jared Patterson, CCP-C, FP-C, One Rad Medic

Killin' It Since 1989

Twitter: @OneRadMedic

Instagram: OneRadMedic




Citations:


  1. Herbstritt A, Amarakone K. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation? Emerg Med J. 2012 Mar;29(3):256-8. doi: 10.1136/emermed-2012-201100.4. PMID: 22337834.

  2. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3. PMID: 22050948.

  3. Jain A, Wermuth HR, Dua A, et al. Rocuronium. [Updated 2021 Oct 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539888/

  4. Brown, C. A., Sakles, J. C., & Mick, N. W. (2018). The Walls manual of emergency airway management. Philadelphia: Wolters Kluwer.

  5. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM; NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015 Apr;65(4):363-370.e1. doi: 10.1016/j.annemergmed.2014.10.036. Epub 2014 Dec 20. Erratum in: Ann Emerg Med. 2017 May;69(5):540. PMID: 25533140.

  6. Pallin DJ, Dwyer RC, Walls RM, Brown CA 3rd; NEAR III Investigators. Techniques and Trends, Success Rates, and Adverse Events in Emergency Department Pediatric Intubations: A Report From the National Emergency Airway Registry. Ann Emerg Med. 2016 May;67(5):610-615.e1. doi: 10.1016/j.annemergmed.2015.12.006. Epub 2016 Feb 26. PMID: 26921968.

  7. Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, Eikermann M, Schmidt U. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med. 2012 Jun;40(6):1808-13. doi: 10.1097/CCM.0b013e31824e0e67. PMID: 22610185.

  8. Omar A, Marwaha K, Bollu PC. Physiology, Neuromuscular Junction. [Updated 2021 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470413/

  9. Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015 Oct 29;2015(10):CD002788. doi: 10.1002/14651858.CD002788.pub3. PMID: 26512948; PMCID: PMC7104695.

  10. Rocuronium Bromide Package Insert: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/078717s000lbl.pdf

  11. Taha SK, El-Khatib MF, Baraka AS, Haidar YA, Abdallah FW, Zbeidy RA, Siddik-Sayyid SM. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia. 2010 Apr;65(4):358-61. doi: 10.1111/j.1365-2044.2010.06243.x. Erratum in: Anaesthesia. 2010 Aug;65(8):874. PMID: 20402874.

  12. Perry JJ, Lee JS, Sillberg VAH, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002788. DOI: 10.1002/14651858.CD002788.pub2. Accessed 01 July 2023.

  13. 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.

  14. Sørensen MK, Bretlau C, Gätke MR, Sørensen AM, Rasmussen LS. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth. 2012 Apr;108(4):682-9. doi: 10.1093/bja/aer503. Epub 2012 Feb 6. PMID: 22315329.

  15. Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, Hunziker PR, Siegemund M. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial. Crit Care. 2011 Aug 16;15(4):R199. doi: 10.1186/cc10367. PMID: 21846380; PMCID: PMC3387641.

  16. 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.

  17. Li G, Cheng L, Wang J. Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China. Med Sci Monit. 2021 Jan 14;27:e928462. doi: 10.12659/MSM.928462. PMID: 33441534; PMCID: PMC7814511.

  18. Levin NM, Fix ML, April MD, Arana AA, Brown CA 3rd; NEAR Investigators. The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients. CJEM. 2021 Jul;23(4):518-527. doi: 10.1007/s43678-021-00119-6. Epub 2021 Apr 10. PMID: 33837951.

  19. 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



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