Outcomes Associated With Rapid Sequence Intubation With Rocuronium Versus Succinylcholine

Introduction: Rocuronium (ROC) and succinylcholine (SUC) are common paralytic agents used for rapid sequence intubation (RSI) given their quick onset of action and similar rates of first-pass intubation success. Their durations of action vary significantly at 4-6 minutes with SUC and 30-60 minutes with ROC. Given the long duration of ROC, adequate sedation must be administered after RSI to avoid awareness of paralysis. Previous studies have shown that patients given ROC experience delays in sedation initiation and receive smaller cumulative doses of sedation in the first hour post-RSI. This study aimed to assess sedation practices post-RSI in a cohort of Medical Intensive Care Unit (MICU) patients.


Methods: Adult patients were included in this retrospective cohort study if they received RSI with ROC or SUC between July 5, 2022 and August 1, 2024 and were admitted to a MICU during or immediately after RSI. Key exclusion criteria included ROC or SUCC receipt in the OR, cardiac arrest prior to RSI, Glasgow Coma Score < 8 within 24 hours of intubation, receipt of ROC or SUC for an indication other than RSI, and other compelling indications for deep sedation. Key outcomes included time to initiation of analgosedation after RSI, initial sedation strategy (bolus versus continuous infusion), and cumulative sedation administered within 10-60 minutes post-RSI.


Results: 482 patients were included in the final analysis with 102 patients in the SUC group and 380 patients in the ROC group. Time to initiation of analgosedation did not significantly differ between groups, however, patients in the ROC group received smaller cumulative doses of propofol (74 mg, IQR 38-122 versus 116 mg, IQR 61-194, p < 0.001) and fentanyl (80 mcg, IQR 38-108 versus 100 mcg, IQR 54-166, p < 0.001) within 10-60 minutes post-RSI. Continuous infusions were more common as an initial sedation strategy for patients who received SUC (75% versus 60%, p = 0.006). There were no differences in the cumulative amounts of other sedatives administered.


Conclusions: Although awareness of paralysis could not be directly assessed in this study, MICU patients who received ROC for RSI received significantly smaller doses of propofol and fentanyl and fewer continuous sedative infusions in the immediate post-RSI period compared to patients who received SUC.