Rocuronium versus succinylcholine for rapid sequence induction intubation.
BACKGROUND
Patients requiring emergency endotracheal intubation often require a rapid sequence induction (RSI) intubation technique to protect against aspiration or increased intracranial pressure, or to facilitate intubation. Succinylcholine is the most commonly used muscle relaxant 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 meta-analysis is an update since our initial Cochrane systematic review in 2003.


OBJECTIVE
To determine if rocuronium creates comparable intubating conditions to succinylcholine during RSI intubation. Comparisons were made based on dose of rocuronium, narcotic use, emergency versus elective intubation, age and induction agent. The primary outcome was excellent intubation conditions. The secondary outcome was acceptable conditions.


METHODS
In our initial systematic review we searched all databases until March 2000. We have updated that search and searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2007 issue 3), MEDLINE (1966 to June Week 3 2007), EMBASE (1988 to 2007 Week 26) for randomized controlled trials or controlled clinical trials relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.


METHODS
We included all trials meeting the inclusion criteria (comparison of rocuronium and succinylcholine, main outcomes of intubation conditions).


METHODS
Two authors (JP, JL or VS) independently extracted data and assessed methodological quality for allocation concealment. We combined the outcomes in RevMan using relative risk (RR) with a random-effects model.


RESULTS
In our initial systematic review we identified 40 studies and included 26. In this update we identified a further 18 studies and included 11. In total, we identified 58 potential studies; 37 were combined for meta-analysis. Overall, succinylcholine was superior to rocuronium, RR 0.86 (95% confidence interval (95% CI) 0.80 to 0.92) (n = 2690). In the group that used propofol for induction, the intubation conditions were superior with succinylcholine (RR 0.88, 95% CI 0.80 to 0.97) (n = 1183). This is contrary to our previous meta-analysis results where we reported that intubation conditions were superior in the rocuronium group when propofol was used. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.


CONCLUSIONS
Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent and clinically acceptable intubating conditions.
Perry
Jeffrey J
JJ
Clinical Epidemiology Programme, Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9.
Lee
Jacques S
JS
Sillberg
Victoria A H
VA
Wells
George A
GA
D000732:Androstanols / Q000008:administration & dosage*; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D009467:Neuromuscular Depolarizing Agents / Q000008:administration & dosage* / Q000009:adverse effects; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage* / Q000009:adverse effects; D015742:Propofol / Q000008:administration & dosage; D016032:Randomized Controlled Trials as Topic; D000077123:Rocuronium; D013390:Succinylcholine / Q000008:administration & dosage* / Q000009:adverse effects
D000732:Androstanols; D009467:Neuromuscular Depolarizing Agents; D003473:Neuromuscular Nondepolarizing Agents; D013390:Succinylcholine; D000077123:Rocuronium; D015742:Propofol