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April 26, 2012

Roc vs Sux

Special thanks to Reuben Strayer

As a followup to some recent online discussion about the time of onset of paralysis of rocuronium, I checked with the most devoted rocuronium supporter I know who sent me the references below. Reuben's  excellent and concise (8 minutes) lecture on roc vs sux is much more comprehensive, but I specifically want to review the small amount of data on time of onset of paralysis. Of course there is are certainly more data out there; I just used the 4 references he sent me.

Caveat: these are OR patients, but I just want the time of onset data so it should be close if not equivalent

Study 1:
outcome: measured paralysis (no response in T1 in TOF monitoring)
Roc 1.2 mg/kg
n=10 adults
mean 55 s
SD 14 s
range 36-84 s
Sux 1 mg/kg
n=10 adults
mean 50 s
SD 17 s
range 24-84 s
Study 2:

children (mean age 6.4 and 6.8 years)
outcome: apnea (not clear how they decided exactly on apnea times)
Roc 1.2 mg/kg
n=13 children (1 did not get as the roc precipitated in the IV line)
mean 15.6s
SD 7.4s
range 5-30s
Sux 1.5 mg/kg
n=13 children
mean 22.3 s
SD 12.8 s
range 12-62 s
These are only 46 patients, including 25 children, and by no means definitive. But the time of onset of paralysis is certainly comparable if not equivalent in properly dosed roc (1.2 mg/kg)

These 2 papers, as well as the 2 other citations below, also demonstrate equivalent intubating conditions between roc & sux, which is what really matters.

References:
1: Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Anesthesiology. 1993 Nov;79(5):913-8.
2:Mazurek AJ, Rae B, Hann S, Kim JI, Castro B, Coté CJ. Rocuronium versus succinylcholine: are they equally effective during rapid-sequence induction of anesthesia? Anesth Analg. 1998 Dec;87(6):1259-62.

additional studies on equivalent intubating conditions:

Patanwala AE, Stahle SA, Sakles JC, Erstad BL. Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med. 2011 Jan;18(1):10-4.
Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg. 2000 Jan;90(1):175-9.

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