One of the cornerstones of the argument is the landmark paper by the Benumof Brothers*: patients will invariably desaturate before the sux wears off.
The ubiquitous "time to hemoglobin desaturation curve" that is shown in every airway talk, chapter, paper, etc:
|Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997 Oct;87(4):979-82.|
But wait a minute. This is from 1997. This was before NODESAT -- the use of nasal cannula during laryngoscopy to maintain oxygen saturation.
Does nasal oxygenation during laryngoscopy bring succinylcholine's shorter duration of action back into the question?
My thoughts are below this other mandatory airway management picture:
My answer is no: roc still beats sux.
- Sux risks hyperkalemia, i.e. succinylkalemia
- When the sux wears off, the patient won't be breathing calmly & cleanly. They will be fighting like heck because people are stabbing them in the back of the throat
- The patient who can't get intubated in 8 minutes still needs to be intubated (there is no "cancel case" in the ED) -- and more paralyis is helpful for bagging, placing an LMA, cric, etc
- Intubating conditions are as rapid and as good with roc
- Sux may lead to faster desaturation, because even with NODESAT...
- NODESAT is amazing but not 100% perfect:
This is just an anecdote** of course, but I had a patient who was preoxygenated perfectly with 100% oxygen via NIV with PEEP using DSI, and even with the nasal cannula at 15 L/min during laryngoscopy, desaturated within 15 seconds.
So I still think roc wins. But of course, I was trained by big fans of roc.
*There are 2 Benumof authors on the paper -- Jonathan and Reuben. I don't know for certain but I like to think they are brothers, and I think they should play the Brugada Brothers in a game of basketball.
**Level of Evidence: A for Anecdote