Rocuronium vs Succinylcholine for Anesthesia

Overseen By Ellie Tuchaai

Age: 18+

Sex: Any

Trial Phase: Phase 4

Sponsor: The University of Texas Health Science Center, Houston

Disqualifiers: Respiratory disorders, Ischemic heart disease, Renal failure, Neuromuscular disease, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Prior Safety Data This treatment has passed at least one previous human trial

Compensation: Varies

Number of Visits: 2

152 Participants Needed

Trial Summary

Will I have to stop taking my current medications?

The trial information does not specify if you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

What data supports the effectiveness of the drugs Rocuronium and Succinylcholine for anesthesia?

Research suggests that Rocuronium can be an effective alternative to Succinylcholine for rapid-sequence induction of anesthesia, as it has a quick onset of action and lacks some of the adverse reactions associated with Succinylcholine. Additionally, Rocuronium, when used with Sugammadex, may offer benefits in time to tracheal intubation during cesarean delivery compared to Succinylcholine. ^{1 2 3 4 5}

Is it safe to use Rocuronium or Succinylcholine for anesthesia?

Rocuronium is generally considered safe and has a good safety profile, while Succinylcholine can have several potential side effects, some of which may be serious. Rocuronium is often preferred due to its safety and similar rapid onset of action. ^{2 3 6 7 8}

How do the drugs rocuronium and succinylcholine differ for anesthesia?

Rocuronium and succinylcholine are both used for rapid-sequence intubation during anesthesia, but rocuronium is a nondepolarizing muscle relaxant that avoids the adverse reactions associated with succinylcholine. Additionally, rocuronium can be reversed with sugammadex, offering a unique advantage in certain situations. ^{2 3 4 7 9}

What is the purpose of this trial?

The purpose of this study is to assess and compare conditions for tracheal intubation obtained with modified time principal induction with 0.6 mg/kg rocuronium and 1 mg/kg succinylcholine. Specifically, the investigators will be evaluating ease of laryngoscopy, vocal cord view, vocal cord opening, and movement of limbs and coughing during tracheal intubation in order to assess intubation conditions, to compare efficiency and success rate of tracheal intubation between two induction agents and to determine the rate of patient awareness during induction and post-operative recall of paralysis.

Research Team

Lauren M Nakazawa, MD

Principal Investigator

The University of Texas Health Science Center, Houston

Eligibility Criteria

This trial is for adults needing general anesthesia and intubation, with a BMI over 30 or a Mallampati score of III/IV. It's not for those allergic to certain anesthetics, pregnant women, people with severe health issues (ASA > III), renal failure with high potassium levels, respiratory disorders like COPD/asthma, untreated heart disease, history of malignant hyperthermia or neuromuscular diseases.

Inclusion Criteria

My BMI is over 30, or I have a high Mallampati score.

I will need general anesthesia and a breathing tube for my procedure.

Exclusion Criteria

The American Society of Anesthesiologists (ASA) physical status classification > III

Pregnant women

I have a neuromuscular disease or have suffered from burn injuries.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

1-2 weeks

Induction and Intubation

Participants undergo rapid sequence induction and tracheal intubation using either rocuronium or succinylcholine. Conditions such as ease of laryngoscopy, vocal cord view, and movement during intubation are assessed.

Less than 7 minutes

1 visit (in-person)

Post-operative Monitoring

Participants are monitored for post-operative recall of paralysis, injury associated with intubation, and overall satisfaction within 24 hours after surgery.

24 hours

1 visit (in-person)

Follow-up

Participants are monitored for any delayed adverse effects and overall satisfaction with the procedure.

1-2 weeks

Treatment Details

Interventions

• Rocuronium
• Succinylcholine

Trial Overview The study compares two drugs used during rapid anesthesia induction: rocuronium (0.6 mg/kg) and succinylcholine (1 mg/kg). It looks at how well they work for putting in a breathing tube by checking ease of laryngoscopy, vocal cord view/opening, limb movement and coughing during the procedure.

Participant Groups

Group I: Modified Time Principle Induction (MTPI) with rocuronium Experimental Treatment 1 Intervention

Group II: RSI with succinylcholine Active Control 1 Intervention

Rocuronium is already approved in United States, European Union, Canada, Japan for the following indications:

Approved in United States as Zemuron for:

• Endotracheal intubation
• Mechanical ventilation
• Surgical procedures requiring neuromuscular blockade

Approved in European Union as Esmeron for:

• Endotracheal intubation
• Mechanical ventilation
• Surgical procedures requiring neuromuscular blockade

Approved in Canada as Esmeron for:

• Endotracheal intubation
• Mechanical ventilation
• Surgical procedures requiring neuromuscular blockade

Approved in Japan as Esmeron for:

• Endotracheal intubation
• Mechanical ventilation
• Surgical procedures requiring neuromuscular blockade

Who Is Running the Clinical Trial?

The University of Texas Health Science Center, Houston

Lead Sponsor

Trials

974

Recruited

361,000+

Findings from Research

In a study of 1,045 patients requiring intubation during air medical transport, succinylcholine was found to significantly improve the odds of successful first-attempt intubation compared to rocuronium, with an odds ratio of 1.4.

Patients receiving succinylcholine also required fewer attempts to achieve intubation, with an odds ratio of 1.5, indicating that succinylcholine may be a more effective choice for rapid-sequence intubation in emergency settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Rocuronium versus succinylcholine in air medical rapid-sequence intubation. Hiestand, B., Cudnik, MT., Thomson, D., et al.[2022]

Rocuronium, at doses of 0.9-1.2 mg/kg, has a rapid onset time for tracheal intubation that is comparable to succinylcholine (50-75 seconds), making it a viable alternative for rapid-sequence induction of anesthesia.

Unlike succinylcholine, rocuronium has a longer clinical duration of action, which may provide additional benefits in certain clinical situations, while also avoiding the adverse reactions associated with succinylcholine.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Magorian, T., Flannery, KB., Miller, RD.[2022]

In a study involving 240 women undergoing cesarean delivery, rocuronium with sugammadex was found to be noninferior to succinylcholine in terms of time to tracheal intubation, with only a 2.9-second longer average time.

Rocuronium also resulted in fewer complications, such as postpartum myalgia and subjective complaints, compared to succinylcholine, indicating it may be a safer alternative for rapid-sequence induction in this setting.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation. Stourac, P., Adamus, M., Seidlova, D., et al.[2018]

Succinylcholine provided a faster onset of paralysis (39 seconds) compared to rocuronium (44 seconds) during rapid-sequence intubation in the emergency department, with no patients requiring assisted ventilation while waiting for paralysis.

Physicians reported higher satisfaction with the extent of paralysis achieved with succinylcholine compared to rocuronium, although both agents were effective and safe for use in this context, with only one minor complication noted.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients. Laurin, EG., Sakles, JC., Panacek, EA., et al.[2019]

In a study of 233 patients with traumatic brain injury who underwent rapid sequence intubation, succinylcholine was associated with a significantly higher mortality rate in patients with severe injuries compared to rocuronium, with an odds ratio of 4.10.

For patients with less severe injuries, there was no significant difference in mortality between those treated with succinylcholine and those treated with rocuronium, indicating that the choice of neuromuscular blocker may be critical in high-severity cases.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Patanwala, AE., Erstad, BL., Roe, DJ., et al.[2018]

In a study of 115 surgical patients, atracurium doses of 1 mg/kg and 0.75 mg/kg provided excellent intubating conditions in 86.5% and 84.6% of cases, respectively, indicating its efficacy for rapid sequence induction of anesthesia without a priming dose.

The 1 mg/kg dose of atracurium resulted in significantly better vocal cord and diaphragm paralysis compared to the 0.6 mg/kg dose, suggesting that higher doses can enhance the effectiveness of intubation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Determination of dose and efficacy of atracurium for rapid sequence induction of anesthesia: A randomised prospective study. Chalermkitpanit, P., Rodanant, O., Thaveepunsan, W., et al.[2022]

In a study involving 1248 adult patients needing out-of-hospital tracheal intubation, rocuronium was found to be less effective than succinylcholine, with a first-attempt intubation success rate of 74.6% compared to 79.4% for succinylcholine, failing to meet the noninferiority criteria.

Both rocuronium and succinylcholine were associated with similar rates of adverse events, such as hypoxemia and hypotension, indicating that while rocuronium may not be as effective, it does not present a significantly different safety profile in this emergency setting.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. Guihard, B., Chollet-Xémard, C., Lakhnati, P., et al.[2020]

Succinylcholine is the only neuromuscular blocking agent with a rapid onset and ultra-short duration, but it carries significant risks, including potentially fatal side effects, making it a controversial choice for rapid sequence intubation (RSI) in children.

Rocuronium is preferred by many emergency physicians for RSI in children due to its excellent safety profile and rapid onset, despite having a longer duration of action compared to succinylcholine.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Emergency department use of neuromuscular blocking agents in children. Doobinin, KA., Nakagawa, TA.[2019]

In a study of 200 patients intubated in the emergency department, those who received rocuronium experienced a significantly longer delay in starting post-intubation sedation (27 minutes) compared to those who received succinylcholine (15 minutes).

Both groups had similar demographics and vital signs, but the delay in sedation initiation with rocuronium could impact patient comfort and management after intubation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effect of paralytic type on time to post-intubation sedative use in the emergency department. Watt, JM., Amini, A., Traylor, BR., et al.[2022]

References

1. England pubmed.ncbi.nlm.nih.gov

Rocuronium versus succinylcholine in air medical rapid-sequence intubation. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. [2022]

3. United States pubmed.ncbi.nlm.nih.gov

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation. [2018]

4. United States pubmed.ncbi.nlm.nih.gov

A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients. [2019]

5. United States pubmed.ncbi.nlm.nih.gov

Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. [2018]

6. India pubmed.ncbi.nlm.nih.gov

Determination of dose and efficacy of atracurium for rapid sequence induction of anesthesia: A randomised prospective study. [2022]

7. United States pubmed.ncbi.nlm.nih.gov

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. [2020]

8. United States pubmed.ncbi.nlm.nih.gov

Emergency department use of neuromuscular blocking agents in children. [2019]

9. England pubmed.ncbi.nlm.nih.gov

Effect of paralytic type on time to post-intubation sedative use in the emergency department. [2022]