Paralytics for Intubation of the Critically Ill
Reviewed and revised 5 March 2015
OVERVIEW
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:
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
- EMCrit Podcast 061 – Debate: Paralytics for ICU Intubations?
- LITFL Ruling the Resus Room 004 — Does Roc rock? Does Sux suck?
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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