Paralytics for Intubation of the Critically Ill

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 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)


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:


CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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