Rocuronium vs. Succinylcholine for Rapid Sequence Induction: a Cochrane Systematic Review

Tran DTT, Newton EK, Mount VAH et al.

Anaesthesia 2017, 72 (6): 765-777.

Aim of Study

To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during rapid sequence intubation.


Systematic review using the Cochrane Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE and EMBASE to identify all clinical trials directly comparing rocuronium and succinylcholine during rapid sequence intubations.


All randomised clinical trials (RCTs) and controlled clinical trials (CCTs) meeting the following criteria: a score of intubation conditions reported; rocuronium compared with succinylcholine; and the dose of rocuronium given was at least 0.6mg/kg and succinylcholine was at least 1mg/kg.

“Intubating conditions were assessed using the Goldberg scale that allocates a score for each of: ease of intubation, vocal cord movement, and patient response to intubation.”

Primary Outcome

The proportion of excellent intubating conditions created during standard or modified rapid sequence intubation comparing rocuronium with succinylcholine.


Treatment effect was measured using risk ratios with 95% confidence intervals. Analysis was performed on an intention-to-treat basis. Statistical heterogeneity was assessed using the I2 statistic. Reporting bias assessed by visual inspection of a funnel plot of the included trials.


50 trials analysed representing 4151 patients. Suxamethonium was more likely to provide excellent intubating conditions (Goldberg scale 3-5)

  • In all patients; 4151 patients, RR (95% CI), 0.86 (0.81-0.92). Numbers needed to harm (NNTH) was 8 (12-6)
  • Standard RSI; 2535 patients, RR 0.80 (0.72-0.89). NNTH 8 (12-6)
  • Modified RSI RR 0.92, (0.85-0.99), NNTH 8 (11-5).
  • In trials that used thiopental for RSI; 2302 patients, RR 0.81, (0.73-0.88).
  • With or without opioids; 1428 patients, RR 0.85, (0.76-0.95).

Rocuronium was less effective than suxamethonium at doses of 0.6-0.7mg/kg, (2808 patients), RR 0.8 (0.72-0.88), NNTH 6 (7-5). There was no statistically significant difference between either drug at doses of 0.9-1.2mg/kg.


Majority of older trials used low doses of rocuronium (0.6-0.8mg/kg) which we now know to be sub-optimal. There was significant heterogeneity between trials which reduced the quality of the review. Observer bias could not be ruled out as fasciculations caused by suxamethonium on administration invalidates blinding of drugs. There are a lack of published studies that favour rocuronium.


This systematic review does not appear to add anything to current knowledge despite being published and updated several times in literature. It is not made clear in Anaesthesia that this review was first performed in 2002 hence many trials looking at low dose rocuronium for RSI. Comments were also made about the lack of clarity regarding NNTH and which side effects of suxamethonium were regarded as harmful.

Some members of the journal club expressed preference for suxamethonium due to its short duration and that it should remain to have a large role in standard RSI. However others stated that rocuronium is the choice of drug (in specialised airway centres) and that the cost of sugammadex as reversal for neuromuscular blockade should not deter its use.

We agreed that any strong opinion regarding the use of suxamethonium or rocuronium would unlikely be changed due to this review however trainees especially novices should learn how to use both drugs in RSI.

Summary by Dr S Shah. Journal Club 26 October 2017.

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