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Tue Aug 24 09:12:31 BST 2010

Roc (in the 1.2 mg/kg dose) is about the only reasonable alternative to sux. Trauma patients are rarely going to be good candidates for an awake intubation due to the time required for patient preparation and need for patient cooperation so not being able to wake the patient up in the event of trouble is less of an issue than in other settings.  But since there's no turning back if you don't have sugammadex, it behooves the person performing airway management to consider their skill not only with intubating using a conventional laryngoscope but also with managing the difficult airway. The people who say they can always get the tube in are the ones who scare me the most because such hubris is a sign they haven't done this enough.  What tools are available  and how much experience does one have with using them in real patients? If you get into trouble, you need to be prepared to rapidly modify your approach until you have the airway secured even if it means a surgical airway. Repeated attempts at the same technique rarely achieves success and tends to cause additional complications.

 Curt Bergstrom, MD

-----Original Message-----
From: Ian Seppelt <seppelt at med.usyd.edu.au>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Tue, Aug 24, 2010 3:36 pm
Subject: Re: Alternatives to succinylcholine?

Rocuronium 1 mg/kg may not make any difference to patient outcome but it is a slower onset than 1 mg/kg suxamethonium which is the 'gold standard'. All clinical research has been compared that dose. Probably of no concern whatsoever IN YOUR SKILLED HANDS but in less skilled hands, a clumsy or "too early" attempt at intubation (not waiting for max effect) can lead to laryngospasm, intracranial hypertension or other nasty effects. 

Others have suggested that offset time 'does not matter' in the real world, as 5 to 10 min for sux is still too slow. This may be true in patients with other chronic comorbidities but trauma patients are more likely to be healthy with nice functional plasmacholinesterase. 

Two real life examples of the offset of sux: (1) my wife spent some years as a nurse with a neonatal retrieval service. Their standard (IMHO illogical, but let's not debate it here) induction sequence was morphine, atropine and suxamethonium when intubating babies. A paediatrician with the retrieval service gave those drugs to a baby in a rural hospital, failed to intubate, the baby turned blue then black then started breathing and saved its own life. The paediatrician did it again and the same thing happened again. My wife physically prevented him from a third attempt and insisted the local anaesthetist be called in (who intubated the baby easily). For her efforts this led to a formal complaint against her for obstructing the paediatirician's medical management!!! (2) I have also seen this in the operating theatre when a junior anaesthetic trainee had trouble with RSI and difficultly mask ventilating before emergency abdominal surgery but with good preoxygenation the patient started to breathe without ever desaturating below 85% and again may have saved his own life. 

So I maintain that the offset time of a neuromuscular blocker used for emergency intubation is crucial, particularly in the hands of less experienced personnel (or even more experienced with less recent time in difficult airway management). And for our protocols to be safe we need to cater for the lowest common denominator, not the expert. 

Best wishes, 

Ian 

On 24/08/2010 7:35 AM, Ante Ćorić wrote: 
> Basics of Anesthesia by Miller and Complications in Anesthesia by Atlee and 
> experience thought me that 1 mg/kg is all you need. Don't need to expect any 
> significant hypertension due to DL if you induce properly with anaesthetic. 
> Usually those that can't receive any analgesia benefit of little of increase 
> in BP due to DL anyway. But even if you use 1.5 mg/kg what makes it 
> different on patient outcome as opposed to 1mg/kg? 
> 
> Ante 
> 
> 2010/8/23 Ian Seppelt<seppelt at med.usyd.edu.au> 
> 
>    >> I completely miss your point. 
>> 
>> Ian 
>> 
>> 
>> On 24/08/2010, at 6:48 AM, Ante Ćorić<ante.coric85 at gmail.com>  wrote: 
>> 
>>   Exactly, that's why in common RSI l would always prefer Roc over Sux, 
>>      >>> leaving sux for some specific situations. 
>>> 
>>> Ante 
>>> 
>>> 2010/8/23 Ian Seppelt<seppelt at med.usyd.edu.au> 
>>> 
>>>   RSI stands for Rapid Sequence INDUCTION (of anaesthesia), as originally 
>>>        >>>> developed for obstetrics. Those who have subverted it into 'Rapid 
>>>> Sequence 
>>>> Intubation' have missed the point - shoving a bit of plastic into a hole 
>>>> is 
>>>> not the primary purpose of the exercise - management of the patient, 
>>>> including appropriate induction and airway management is the object. 
>>>> 
>>>> Ian 
>>>> 
>>>> 
>>>> On 24/08/2010, at 1:54 AM, "Bjorn, Pret"<pbjorn at emh.org>  wrote: 
>>>> 
>>>> A teachable moment for me: I was not aware that RSI was ever specific to 
>>>> 
>>>>          >>>>> thiopental and suxamethonium, or exclusive of anything else. 
>>>>> 
>>>>> Is there a reference? 
>>>>> 
>>>>> Pret 
>>>>> 
>>>>> -----Original Message----- 
>>>>> From: trauma-list-bounces at trauma.org [mailto: 
>>>>> trauma-list-bounces at trauma.org] On Behalf Of Ross Hofmeyr 
>>>>> Sent: Monday, August 23, 2010 11:33 AM 
>>>>> To: Trauma-List [TRAUMA.ORG] 
>>>>> Subject: Re: Alternatives to succinylcholine? 
>>>>> 
>>>>> Pendantic, but forgive me: 
>>>>> 
>>>>> RSI (Rapid Sequence Induction) is a term which, when used in it's pure 
>>>>> form, 
>>>>> _specifically_ refers to the use of a predetermined dose of sodium 
>>>>> thiopental followed immediately by a predetermined dose of 
>>>>> suxamethonium. 
>>>>> Anything else is a 'Modified' RSI, although most people have come to 
>>>>> refer 
>>>>> to "RSI" as any rapid induction agent (thio, propofol, ketamine or 
>>>>> etomidate) with sux, and MRSI as any of those with rocuronium. 
>>>>> 
>>>>> The accepted MRSI dose of rocuronium is 1.2mg/kg, although once again 
>>>>> many 
>>>>> just use 1mg/kg for simplicity. 
>>>>> 
>>>>> Sux has significant and well-known problems, and while onset is slightly 
>>>>> faster than roc it wears of much more rapidly (still, it's a fool's 
>>>>> paradise 
>>>>> to presume that if you fail intubation the patient will be breathing 
>>>>> before 
>>>>> they desaturate from sux).  An MRSI dose of roc will leave your patient 
>>>>> paralysed for the better part of an hour... 
>>>>> 
>>>>> R. 
>>>>> 
>>>>> On 23 August 2010 17:20, Ante Ćorić<ante.coric85 at gmail.com>  wrote: 
>>>>> 
>>>>> There is: Roc 1mg/kg iv. has same speed of action as sux. But maybe sux 
>>>>> 
>>>>>            >>>>>> shouldn't be so widely spread in usage, as routine drug to be pushed in 
>>>>>> RSI, 
>>>>>> especially by non anaesthetists (MDs not mid levels that is). Most of 
>>>>>> RSI 
>>>>>> can be done w/o relaxans at all. Sux is should always be present if you 
>>>>>> admit kids. 
>>>>>> 
>>>>>> just my 2 cents 
>>>>>> 
>>>>>> Ante 
>>>>>> 
>>>>>> 2010/8/23 T. Al West<talwest at mac.com> 
>>>>>> 
>>>>>> Hello fellow trauma-listers: 
>>>>>> 
>>>>>>              >>>>>>> As you may know, there is a national shortage of succinylcholine. I 
>>>>>>> don't 
>>>>>>> know how many hospitals have gotten caught with their pants down by 
>>>>>>> not 
>>>>>>> stockpiling, but I know mine certainly has--less than 20 doses remain 
>>>>>>> in 
>>>>>>> 
>>>>>>>   the 
>>>>>>>                >>>>>>   hospital. I agree with our anesthesiologists that we really can't 
>>>>>>              >>>>>>>   function 
>>>>>>>                >>>>>>   effectively as a trauma center without this medication. 
>>>>>>              >>>>>>> Is this position valid? Is there any reasonable alternative to "sux" 
>>>>>>> for 
>>>>>>> rapid sequence intubation, from a safety/efficacy standpoint in a 
>>>>>>> trauma 
>>>>>>> situation? 
>>>>>>> 
>>>>>>> Thanks in advance for your comments. 
>>>>>>> 
>>>>>>> T. Al West, MD, FACS 
>>>>>>> Medical Director, Trauma Services 
>>>>>>> The Medical Center of Plano 
>>>>>>> -- 
>>>>>>> trauma-list : TRAUMA.ORG 
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>>>>>> 
>>>>>> 
>>>>>> 
>>>>>>              >>>>> -- 
>>>>> Dr Ross Hofmeyr 
>>>>> wildmedic at gmail.com 
>>>>> ross at wildmedix.com 
>>>>> www.wildmedix.com 
>>>>> Tel: +2784 54 99259 
>>>>> Skype:  wildmedic 
>>>>> “Semper Paratus” 
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Alternatives to succinylcholine?