Reviewed and revised 5 March 2015
Two major controversies exist:
- should suxamethonium or rocuronium be used for rapid sequence intubation?
- is a neuromuscular blocker even necessary for intubation of the critically ill? (facilitated or sedation only intubation)
USE A PARALYTIC AGENT
Use of a fast-acting neuromuscular blocker is best practice:
- improves intubating conditions
- makes ventilation easier
- prevents the patient from interfering with peri-intubation procedures should sedation wear off
- allowing the patient to wake is virtually never an option in the critically ill patient requiring intubation (proceed to surgical airway in the CICV situation)
USE ROCURONIUM IN MOST CASES
Rocuronium has the following advantages over suxamethonium:
- 1.2mg/kg dose achieves optimal intubating conditions as fast as suxamethonium
- absence of fasciculations decreases oxygen consumption
- less contra-indications and adverse effects
- prolonged paralysis prevents the patient from interfering with peri-intubation procedures should sedation wear off
- even the shorter duration of suxamethonium cannot be relied upon in the CICV situation to allow the patient awaken safely (need to proceed to surgical airway)
Suxamethonium has an advantage if early neurological assessment is required (e.g. status epilepticus)
Here is Roc advocate Reuben Strayer’s great presentation on roc versus sux:
- EMCrit Podcast 061 – Debate: Paralytics for ICU Intubations?
- LITFL Ruling the Resus Room 004 — Does Roc rock? Does Sux suck?