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Meta-Analysis
. 2015 Oct 29;2015(10):CD002788.
doi: 10.1002/14651858.CD002788.pub3.

Rocuronium versus succinylcholine for rapid sequence induction intubation

Diem T T Tran  1 , Ethan K Newton, Victoria A H Mount, Jacques S Lee, George A Wells, Jeffrey J Perry
Affiliations
Meta-Analysis

Rocuronium versus succinylcholine for rapid sequence induction intubation

Diem T T Tran et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

Diem TT Tran: none known Ethan K Newton: none known Victoria AH Mount: none known Jacques S Lee: none known George A Wells: none known Jeffrey J Perry: none known

Figures

1
1
Search flow diagram for this update from July 2007 to February 2015
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included trial
4
4
Funnel plot of comparison: Rocuronium any dose versus succinylcholine, outcome: Excellent versus other intubation conditions.
5
5
Forest plot of comparison: 1 Rocuronium any dose versus succinylcholine, outcome: 1.1 Excellent versus other intubation conditions
6
6
Forest plot of comparison: 3 Rocuronium versus succinylcholine for induction agent, outcome: 3.1 Excellent versus other intubation conditions
1.1
1.1. Analysis
Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.
1.2
1.2. Analysis
Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.
2.1
2.1. Analysis
Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.
2.2
2.2. Analysis
Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.
3.1
3.1. Analysis
Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 1 Excellent versus other intubation conditions.
3.2
3.2. Analysis
Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 2 Acceptable versus suboptimal intubation conditions.
4.1
4.1. Analysis
Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 1 Excellent versus other intubation outcomes.
4.2
4.2. Analysis
Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.
5.1
5.1. Analysis
Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 1 Excellent versus other intubation conditions.
5.2
5.2. Analysis
Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.
6.1
6.1. Analysis
Comparison 6 Comparison of children and adults, Outcome 1 Excellent versus other intubation conditions.
6.2
6.2. Analysis
Comparison 6 Comparison of children and adults, Outcome 2 Acceptable versus suboptimal intubation conditions.
7.1
7.1. Analysis
Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 1 Excellent versus other intubation conditions.
7.2
7.2. Analysis
Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 2 Acceptable versus suboptimal intubation conditions.
8.1
8.1. Analysis
Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 1 Excellent versus other intubation conditions.
8.2
8.2. Analysis
Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 2 Acceptable versus suboptimal intubation conditions.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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Dobson 1999 {published data only}
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