[Evaluation of tracheal intubation conditions in morbidly obese patients: a comparison of succinylcholine and rocuronium]

The optimal dose of succinylcholine for rapid sequence induction: a systematic review and meta-analysis of randomized trials

Background

The evidence base for the widely accepted standard regimen of succinylcholine for rapid sequence induction (1.0 mg kg^− 1) remains unclear.

Methods

We performed a systematic review and meta-analysis of randomized trials comparing any succinylcholine regimen with the standard regimen (1.0 mg kg^− 1) and reporting on intubating conditions and/or apnoea times. Results were expressed as absolute risk differences (ARD) for dichotomous data and mean differences (MD) for continuous data.

Results

We retrieved six trials with relevant data of 864 patients (ASA 1 or 2, aged 18–65 years, body mass index < 30 kg m^− 2). Four regimens (0.3, 0.4, 0.5, 0.6 mg kg^− 1) were compared with 1.0 mg kg^− 1 in at least three trials each, and three (0.8, 1.5, 2 mg kg^− 1) in one each. With 0.3 to 0.5 mg kg^− 1, the likelihood of excellent intubating conditions was significantly decreased (ARD − 22% to − 67%). With 0.3 and 0.4 mg kg^− 1, but not with 0.5, 0.6, 0.8, 1.5 and 2.0 mg kg^− 1, the likelihood of unacceptable intubating conditions was significantly increased (ARD + 22% and + 32%, respectively). With 2.0 mg kg^− 1, but not with 0.8 or 1.5 mg kg^− 1, the likelihood of excellent intubating conditions was significantly increased (ARD + 23%). Apnoea times were significantly shorter with regimens ≤0.8 mg kg^− 1 (MD − 1.0 to − 3.4 min) but were not reported with 1.5 or 2.0 mg kg^− 1.

Conclusions

With succinylcholine regimens ≤0.5 mg kg^− 1, excellent intubating conditions are less likely and apnoea times are shorter, compared with 1 mg kg^− 1. With 0.3 and 0.4 mg kg^− 1, unacceptable intubating conditions are more common. Succinylcholine 1.5 mg kg^− 1 does not produce more often excellent conditions compared with 1 mg kg^− 1, while 2.0 mg kg^− 1 does, but the database with these regimens is weak and apnoea times remain unknown. Limited information size and strong statistical heterogeneity decrease the certainty of the evidence.

Rocuronium versus succinylcholine for rapid sequence induction intubation

BACKGROUND

Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015.

OBJECTIVES

To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation.

SEARCH METHODS

In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.

SELECTION CRITERIA

We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg.

DATA COLLECTION AND ANALYSIS

Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model.

MAIN RESULTS

The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.

AUTHORS' CONCLUSIONS

Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.

A survey of the current use of neuromuscular blocking drugs among the Middle Eastern anesthesiologists

Background:

This survey aimed to assess the extent of practice of the Middle Eastern anesthesiologists in the use of neuromuscular blocking agents (NMB) in 2012.

Methods:

We distributed an electronic survey among 577 members of the Triple-M Middle Eastern Yahoo anesthesia group, enquiring about their practice in the use of neuromuscular blocking agents. Questions concerned the routine first choice use of NMB, choice for tracheal intubation, the use of neuromuscular monitoring (NMT), type of NMB used in difficult airway, frequency of using suxamethonium, cisatracurium, rocuronium and sugammadex, observed side effects of rocuronium, residual curarization, and the reversal of residual curarization of rocuronium.

Results:

A total of 71 responses from 22 Middle Eastern institutions were collected. Most of the Middle Eastern anesthesiologists were using cisatracurium and rocuronium frequently for tracheal intubation (39% and 35%, respectively). From the respondents, 2/3 were using suxamethonium for tracheal intubation in difficult airway, 1/3 were using rocuronium routinely and 17% have observed hypersensitivity reactions to rocuronium, 54% reported residual curarization from rocuronium, 78% were routinely using neostigmine to reverse the rocuronium, 21% used sugammadex occasionally, and 35% were using NMT routinely during the use of NMB.

Conclusions:

We believe that more could be done to increase the awareness of the Middle Eastern anesthesiologists about the high incidence of PROC (>20%) and the need for routine monitoring of neuromuscular function. This could be accomplished with by developing formal training programs and providing official guidelines.