[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.206.12.79. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Views 13,457
Citations 0
Original Investigation
December 17, 2019

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Emergency, CHU de la Réunion, Allée des Topazes, Saint Denis, Réunion, France
  • 2Groupe Hospitalo-Universitaire Henri Mondor, SAMU 94, Assistance Publique-Hôpitaux de Paris, Créteil, France
  • 3SMUR 95, Centre Hospitalier de Gonesse, Gonesse, France
  • 4Department of Anesthesia & Critical Care - SAMU, Assistance Publique - Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
  • 5Département d'Anesthésie-Réanimation-SMUR, Hôpital Universitaire Lariboisière, AP-HP, Paris, France
  • 6Emergency Department, General Hospital of Annecy, Annecy, France
  • 7SMUR de l'hôpital Beaujon, Clichy, France
  • 8Department of Emergency, CHU de la Réunion, Réunion, France
  • 9AP-HP, Urgences-SAMU 93, Unité Recherche-Enseignement-Qualité, Hôpital Avicenne, Bobigny, France
  • 10Univ Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
  • 11French National Out-of-Hospital Cardiac Arrest Registry Research Group - Registre électronique des Arrêts Cardiaques, Lille, France
  • 12Emergency Medicine Department and SAMU 59, Lille University Hospital, Lille, France
  • 13Department of Emergency Medicine, Groupe Hospitalier Broca Cochin Hôtel-Dieu, Paris, France
  • 14Department of Emergency Medicine, University Hospital Dijon, Dijon, France
  • 15Raymond Poincaré Hospital (APHP), SAMU 92, Paris, France
  • 16Pôle Médecine d'Urgence, Hôpital Universitaire de Purpan, Toulouse, France
  • 17INSERM UMR 1027, Université Paul Sabatier, Toulouse, France
  • 18Services de Médecine d’Urgence et de Réanimation, Pôle Urgence Réanimation, SAMU 77, Melun, France
  • 19AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
  • 20INSERM CIC 1410 Clinical and Epidemiology/ CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
  • 21Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg
  • 22Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
  • 23Department of Emergency, CHU de la Réunion, Université de la Réunion, Réunion, France
JAMA. 2019;322(23):2303-2312. doi:10.1001/jama.2019.18254
Key Points

Question  Is rocuronium noninferior to succinylcholine with regard to first-attempt endotracheal intubation success among patients undergoing rapid sequence intubation in an out-of-hospital emergency setting?

Findings  In this randomized clinical trial that included 1248 patients, the number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, a difference of −4.8% (1-sided 97.5% CI, −9% to ∞), which did not meet criteria for noninferiority.

Meaning  The study findings failed to demonstrate noninferiority of rocuronium compared with succinylcholine with regard to first-attempt endotracheal intubation success rate.

Abstract

Importance  Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium.

Objective  To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations.

Design, Setting and Participants  Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016.

Interventions  Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624).

Main Outcomes and Measures  The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis.

Results  Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of −4.8% (1-sided 97.5% CI, −9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group.

Conclusions and Relevance  Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.

Trial Registration  ClinicalTrials.gov Identifier: NCT02000674

×