Dilemma In Rapid Sequence Intubation: Succinylcholine Vs. Rocuronium

摘要

Succinylcholine is the single ultra-short acting depolarizing neuromuscular blocking agent (NMBA) used in the rapid sequence intubation protocol with its rapid onset of effect, complete reliability, short duration of action. Rocuronium is diverse from other non-depolarizing NMBA being the first one with a short onset time and devoid of untoward effects. Despite its widespread use, succinylcholine has several potential hazards including an increase in potassium levels, bradycardia for children and prolonged apnea for those with pseudocholinesterase deficiency. Rocuronium is indicated in subjects with disease states such as known or suspected hyperkalemia, crush injury, non-acute burns, increased intracranial or intraocular pressure and neuromuscular disease.Although succinylcholine has many side effects, it remains to be the first-choice NMBA for the majority of attempts for rapid sequence intubation. Rocuronium may be a suitable alternative to succinylcholine with its short onset time.The objective of this article is to update data from studies comparing the use of succinylcholine and rocuronium in rapid sequence intubation protocol in adults. Introduction Rapid sequence intubation (RSI) is developed to secure the airway of a critically ill or injured patient rapidly and safely. RSI applies to virtually all attempts for endotracheal intubation (ETI) in the emergency departments (ED) except for arrest situations. RSI is particularly preferred for ED use because of the simultaneous onset of sedation, paralysis and minimizing the risk of aspiration (1). After being launched in the late seventies, the procedure has been dynamically changing in time with introduction of many newer and advantageous agents (2,3,4).RSI protocol is still in development in order to minimize the risk of aspiration of gastric contents in case of “full stomach” while preventing secondary brain injury via rendering unconsciousness and paralysis and to achieve higher rates of successful ETI.Laryngoscopy and ETI are performed after administering rapid and short-acting sedative, hypnotic and amnestic agents in conjunction with neuromuscular blocking agents (NMBA) (5). Short-acting agents like succinylcholine (SCh) are generally preferred for fear of protracted intubation failure (5,6). For decades, SCh used to be the sole agent demonstrated to consistently provide paralysis in less than one minute (7,8,9). It is still the sole depolarizing NMBA used in the procedure. It is particularly useful in the critically ill or injured with a full stomach for whom a RSI technique is needed (10). Patients intubated in emergent conditions generally have full stomach and rapid intubation is critical to prevent aspiration of gastric contents. SCh provides a means for rapid intubation in these high-risk patients. Rocuronium (RCR) is diverse from other non-depolarizing NMBA being the first one with a short onset time devoid of adverse effects. The objective of this article is to review all prospective studies comparing the use of SCh and RCR in RSI protocol in adults. Clinical And Pharmacological Properties Of Each Agent Introduced in 1952, SCh depolarizes the neuromuscular membrane and is structurally consisted of two acetylcholine molecules. It acts as a false transmitter of acetylcholine by avidly binding to postsynaptic cholinergic receptors, resulting in persistent depolarization and paralysis (10). This action is associated with muscle fasciculation which can lead to increased intracranial and intragastric pressures. The molecule is rapidly hydrolyzed by serine pseudocholinesterase. SCh is rapidly active within 60 seconds of administration by IV bolus. The clinical duration of action is 3 to 10 minutes and normal neuromuscular function returns within 15 minutes. The first report on the administration of SCh for performing ETI in multiple cases in the ED was published by Thompson et al in 1982 (11).Prolonged or repeated use may augment its effects at vagal or sympathetic