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

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial compares two drugs, rocuronium and succinylcholine, to determine which works better for patients requiring general anesthesia and a breathing tube during surgery. Researchers aim to assess the ease of performing the procedure with each drug and whether patients recall any part of it afterward. Suitable candidates for this trial include those needing surgery, with a BMI over 30, or a challenging airway classification (Mallampati class III or IV). As a Phase 4 trial, this study involves FDA-approved treatments and seeks to understand how they can benefit more patients.

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 is the safety track record for these treatments?

Research shows that both rocuronium and succinylcholine are generally safe for people, but they have some differences. Rocuronium, a muscle relaxant often used during surgeries, helps relax muscles and facilitates the insertion of a breathing tube. Studies suggest rocuronium can increase heart rate, though this isn't always noticeable. Some reports also indicate it can help reduce stress during surgery.

Succinylcholine, another muscle relaxant, is used for quick procedures. Known for its rapid action, it is often employed in emergencies. However, some individuals might experience muscle pain or rare issues like changes in heart rhythm.

Overall, both treatments are widely used and usually well-tolerated when used correctly. For those considering joining a trial, these findings suggest the treatments are generally safe, but discussing any concerns with the study team is important. ^{1 2 3 4 5}

Why are researchers enthusiastic about this study treatment?

Researchers are excited about these treatments because they explore different approaches to rapid sequence induction (RSI) for anesthesia. Rocuronium, used in the Modified Time Principle Induction (MTPI) method, offers a potentially smoother and longer-lasting muscle relaxation compared to succinylcholine, which is typically used for its fast-acting properties. Unlike succinylcholine, which can cause certain side effects like increased potassium levels, rocuronium provides an alternative for patients where these risks are a concern. This study aims to determine if MTPI with rocuronium can be as effective or superior to the traditional use of succinylcholine, potentially offering a safer or more efficient option for anesthesia induction.

What evidence suggests that this trial's treatments could be effective for anesthesia?

This trial will compare the effectiveness of rocuronium and succinylcholine for tracheal intubation. Research has shown that both drugs effectively aid in breathing tube placement. Participants may receive rocuronium, which studies have found to work well, especially in children, by providing good conditions for tube insertion and high success rates on the first attempt. Rocuronium relaxes muscles by blocking nerve signals. Alternatively, participants may receive succinylcholine, which acts quickly and has been the standard choice for rapid intubation. Evidence indicates that while recovery from rocuronium may take slightly longer, it remains a reliable alternative to succinylcholine. Both drugs have proven effective for intubation procedures. ^{2 6 7 8 9}

Who Is on the Research Team?

Lauren M Nakazawa, MD

Principal Investigator

The University of Texas Health Science Center, Houston

Are You a Good Fit for This Trial?

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 for a Trial Participant

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

What Are the Treatments Tested in This Trial?

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.

How Is the Trial Designed?

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+

Published Research Related to This Trial

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 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 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]

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 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]

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]

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 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]

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Rocuronium is a non-depolarizing neuromuscular blocker widely used to produce muscle relaxation to help facilitate surgery and ventilation of the lungs.

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New Practice Guidelines for Neuromuscular Blockade

The practice guidelines present eight recommendations regarding the type of monitoring of neuromuscular blockade, location of monitoring, and medications used.

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While general anesthesia is necessary for some emergency deliveries, it carries risks such as failed intubation and neonatal complications.