Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study

April, MD, Arana A, Pallin DJ et al. On behalf of the NEAR Investigators

Annals of Emergency Medicine 2018: 72 (6) 645-53.

Aim of Study

Compare first-pass intubation success and peri-intubation adverse effects between emergency department (ED) rapid sequence intubation facilitated by succinylcholine versus rocuronium

Design and Location

Observational Study.

Prospectively collected data from the National Emergency Airway Registry (NEAR), a multicentre registry collecting data on all intubations performed in 22 EDs throughout the US


Intubating providers at each participating site used a standard data collection instrument to provide information about each patient encounter involving intubation. Sites uploaded data into a centralised Web-based data management database.

Included patients older than 14 years whose data had been entered into the NEAR database from January 1 through December 31, 2016.

Primary Outcome

First-pass intubation success, succinylcholine vs rocuronium.

Secondary Outcomes

Incidence of any adverse event, succinylcholine vs rocuronium.


Calculating risk difference with 2-sided 95% confidence interval (CI)

Using a Cochran-Mantel-Haenszel chi2 test

Logistic regression model to compare the odds


First-pass intubation success was 87.0% with succinylcholine and 87.5% with rocuronium (risk difference 0.5%; 95% CI –1.6% to 2.6%).

Higher first-pass intubation success among patients without any difficult airway characteristics who were treated with high-dose rocuronium (>1.2 mg/kg) versus low-dose rocuronium (<1.2 mg/kg) (odds ratio 2.2; 95% CI 1.2 to 3.4)

There was no association between the incidence of any peri-intubation adverse event and paralytic agent (odds ratio 1.1; 95% CI 0.9 to 1.3)


No significant difference in first-pass intubation success or peri-intubation adverse effects between succinylcholine and rocuronium. Study compared to previous Cochrane Study in 2015 (which showed superior intubating conditions with succinylcholine vs rocuronium 0.6mg/kg, but no statistical difference between succinylcholine and rocuronium >1.2mg/kg)

Higher dose rocuronium (>1.2mg/kg) had a satistically superior first-pass intubation rate than lower dose rocuronium (<1.2mg/kg)

As study showed non inferiority of rocuronium vs succinylcholine but fewer contraindications, suggestion of default first line paralytic agent should be rocuronium, perhaps at a higher dose (>1.2mg/kg)

Stated Limitations from the Study

Confounding – does not establish the presence or absence of a causal relationship between the variables

Factors such as provider preference or patient contraindications (eg, hyperkalaemia, neurologic conditions) may have biased the analysis

Lacks other variables of clinical relevance

Self-reported data are susceptible to recall bias

Discussion from Journal Club Meeting (?Change of Practice)

Limitations of study due to variables of clinical relevance, ie condition of patient.

Availability in ED – have both succinylcholine and rocuronium.

However no sugammadex in ED. Would people feel safe giving high dose rocuronium without reversal agent?

Newer trainees using rocuronium more than succinylcholine.

Potential QIP and further work to get ED to store sugammadex.

Summary by Dr S Chapman. Journal Club Meeting 19 September 2019.

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