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ยาโรคูโรเนียม (rocuronium) เทียบกับ ยาซัคซินิลโคลีน (succinylcholine) สำหรับการใส่ท่อช่วยหายใจในการนำสลบแบบรวดเร็ว

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Referencias

References to studies included in this review

Abdulatif 1996 {published data only}

Abdulatif M, al‐Ghamdi A, el‐Sanabary M. Rocuronium priming of atracurium‐induced neuromuscular blockade: the use of short priming intervals. Journal of Clinical Anesthesia 1996;8(5):376‐81. [MEDLINE: 8832448]

Abu‐Halaweh 2007 {published data only}

Abu‐Halaweh SA, Massad IM, Abu‐Ali HM, Badran IZ, Barazangi BA, Ramsay MA. Rapid sequence induction and intubation with 1 mg/kg rocuronium bromide in cesarean section, comparison with suxamethonium. Saudi Medical Journal 2007;28(9):1393‐6. [CENTRAL: CN‐00619147]

Alanoglu 2006 {published data only}

Alanoglu Z, Ates Y, Yilmaz AA, Tuzuner F. Is there an ideal approach for rapid‐sequence induction in hypertensive patients?. Journal of Clinical Anesthesia 2006;18(1):34‐40. [MEDLINE: 16517330]

Ali 2008 {published data only}

Ali J, Gurckoo SA, Shora A, Qazi S. Intubating conditions of rocuronium bromide and succinylcholine during rapid sequence induction of anaesthesia in unpremedicated adult patients. Journal of Anaesthesiology Clinical Pharmacology 2008;24(3):337‐42. [CENTRAL: CN‐00708388]

Alvarez Rios1997 {published data only}

Alvarez Rios JJ, Hernandez MV, Baez L, Meza G, Higuera E, Gomez B. Analysis of the effects of rocuronium, mivacurium and succinylcholine for endotracheal intubation. [Analisis del comportamiento de rocuronio, mivacurio y succinilcolina en la intubacion endotraqueal]. Revista Mexicana De Anestesiologia 1997;20:122‐6. [EMBASE: 1997330912]

Andrews 1999 {published data only}

Andrews JI, Kumar N, Van den Brom RH, Olkkola KT, Roest GJ, Wright PM. A large simple randomized trial of rocuronium versus succinylcholine in rapid‐sequence induction of anaesthesia along with propofol. Acta Anaesthesiologica Scandinavica 1999;43(1):4‐8. [PUBMED: 9926179]

Belyamani 2008 {published data only}

Belyamani L, Azendour A, Elhassouni A, Zidouh S, Atmani M, Kamili. Effect of ephedrine on the intubation conditions using rocuronium versus succinylcholine [Effet de l'éphédrine sur les conditions d'intubation après bloc neuromusculaire par le rocuronium versus succinylcholine]. Annales Français d'Anesthésie et de Réanimation 2008;27:292‐6.

Cheng 2002 {published data only}

Cheung CA, Aun CS, Gin T. Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children. Paediatric Anaaesthesia 2002;12(2):140‐5. [MEDLINE: 11882225]

Chiu 1999 {published data only}

Chiu CL, Jaais F, Wang CY. Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anaesthesia. British Journal of Anaesthesia 1999;82(5):757‐60. [MEDLINE: 10536557]

Chung 2001 {published data only}

Chung YT, Yeh LT. Effectiveness and safety of rocuronium‐hypnotic sequence for rapid‐sequence induction. Acta Anaesthesiologica Sinica 2001;39(1):3‐9. [MEDLINE: 11407293]

Cooper 1992 {published data only}

Cooper R, Mirakhur RK, Clarke RS, Boules Z. Comparison of intubating conditions after administration of org 9426 (rocuronium) and suxamethonium. British Journal of Anaesthesia 1992;69(3):269‐73. [MEDLINE: 1389845]
Mirakhur RK, Cooper AR, Clarke RS. Onset and intubating conditions of rocuronium bromide compared to those of suxamethonium. European Journal of Anesthesiology 1994;11(Suppl. 9):41‐3. [EMBASE: 1994232031]

De Almeida 2009 {published data only}

De Almeida MC, Pederneiras SG, Chiaroni S, De Souza L, Locks GF. Evaluation of tracheal intubation conditions in morbidly obese patients: a comparison of succinylcholine and rocuronium [Evaluación de las condiciones de intubación traqueal en pacientes obesos mórbidos: succinilcolina frente a rocuronio]. Revista Española de Anestesiología y Reanimación 2009;56(1):3‐8. [CENTRAL: CN‐00681643]

Dubois 1995 {published data only}

Dubois M, Lea D, Kataria B, Gadde P, Tran D, Shearrow T. Pharmacodynamics of rocuronium with and without prior administration of succinylcholine. Journal of Clinical Anesthesia 1995;7(1):44‐8. [MEDLINE: 7772357]
Dubois MY, Dubois MY, Shearrow T, Tran D, Kataria B, Rever L, Gadde LR. Org 9426 used for endotracheal intubation: a comparison with succinylcholine. Anesthesiology 1991;75(3A):A1066.

Giudice 1998 {published data only}

Giudice G, Tomassini G, Baggianini A, Sagredini R. Speed and ease of endotracheal intubation with the neuromuscular monitoring guide (TOF) after rocuronium doses of various multiples of ED95 and succinylcholine [Tempi e qualita dell'intubazione sulla guida del monitoraggio neuromuscolare (TOF): confronto tra vari multipli della ED95 del rocuronio e succinilcolina]. Acta Anaesthesiologica Italica 1998;49(3):231‐9. [EMBASE: 1999095079]

Iqbal 2013 {published data only}

Iqbal M, Turab SM, Siddiqui MH, Jawad‐Us‐Salam, Majid U, Ali Baloch A, et al. To compare the efficacy of rocuronium bromide and succinylcholine in elective surgery for endotracheal tube. Medical Forum (Monthly) 2013;24(7):38‐41. [EMBASE: 2013630011]

Koroglu 2002 {published data only}

Koroglu N, Iyilikci L, Van Koroglu L, Atay A, Gokel E. Comparison of rocuronium and succinylcholine for rapid sequence intubation cesarean section [Sezaryen Olgularinda Hizli Endotrokeal Entubasyonda Rokuronyum ve Suksiniklolinin Karsilastmlmasi]. Turk Anesteziyoloji Ve Reanimasyon Cemiyeti Mecmuasi 2002;30:173‐80. [EMBASE: 2002280227]

Kulkarni 2010 {published data only}

Kulkarni K, Patil M, Shirke A. Comparison of intubating conditions of succinylcholine with two doses of rocuronium bromide in children. Journal of Anaesthia Clinical Pharmacology 2010;26(3):323‐8. [EMBASE: 2010533834]

Kwon 2013 {published data only}

Kwon MA, Song J, Kim J‐R. Tracheal intubation with rocuronium using a "modified timing principle". Korean Journal of Anesthesiology 2013;64(3):218‐22. [EMBASE: 2013214600]

Lam 2000 {published data only}

Lam AM, Pavlin EG, Visco E, Taraday J. Rocuronium versus succinylcholine‐atracurium for tracheal Intubation and maintenance relaxation during propofol anesthesia. Jounal of Clinical Anesthesia 2000;12(6):449‐53. [MEDLINE: 11090730]

Larsen 2005 {published data only}

Larsen PB, Hansen EG, Jocobsen LS, Wiis J, Holst P, Rottensten H, et al. Intubation conditions after rocuronium or succinylcholine for rapid sequence induction with alfentanil and propofol in the emergency patient. European Journal of Anesthesiology 2005;22(10):748‐53. [MEDLINE: 16211732]

Latorre 1996 {published data only}

Latorre F, Stanek A, Gervais HW, Kleemann PP. Intubation requirements after rocuronium and succinylcholine [Intubations bedingungen nach rocuronium und succinylcholin]. Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie: AINS 1996;31(8):470‐3. [MEDLINE: 9019175]

Le Corre 1999 {published data only}

Le Corre F, Plaud B, Benhamou E, Debaene B. Visual estimation of onset time at the orbicularis oculi after five muscle relaxants: application to clinical monitoring of tracheal intubation. Anesthesia and Analgesia 1999;89(5):1305‐10. [MEDLINE: 10553857]

Magorian 1993 {published data only}

Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid‐sequence induction of anesthesia in adult patients. Anesthesiology 1993;79(5):913‐8. [MEDLINE: 7902034]

Malik 2004 {published data only}

Malik P, Rao S, Malhotra N, Chugh JP, Hooda S. Comparative evaluation of effect of rocuronium and succinylcholine on intraocular pressure. Journal of Anaesthesia and Clinical Pharmacology 2004;20(3):255‐61. [EMBASE: 2005146384]

Marsch 2011 {published data only}

Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, et al. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: A prospective, randomized controlled trial. Critical Care 2011;15(4):R199. [PUBMED: 21846380]

Mazurek 1998 {published data only}

Mazurek AJ, Rae B, Hann S, Kim JI, Castro B, Cote CJ. Rocuronium versus succinylcholine: are they equally effective during rapid‐sequence induction of anesthesia?. Anesthesia and Analgesia 1998;87(6):1259‐62. [MEDLINE: 9842809]

McCourt 1998 {published data only}

McCourt KC, Salmela L, Mirakhur RK, Carroll M, Makinen MT, Kansansho M, et al. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia 1998;53(9):867‐71. [MEDLINE: 9849280]

Mencke 2005 {published data only}

Mencke T, Scherelber J‐U, Knoll H, Werth M, Grundmann U, Rensing H. Influence of gender on the intubation conditions with rocuronium [Ein fluss des Ges chlechts auf die Int ub at io nsb ed ing ung en nach Ro cu ro ni um]. Der Anaesthesist 2005;54:884‐8.

Mencke 2006 {published data only}

Mencke T, Knoll H, Schreiber JU, Echternach M, Klein S, Noeldge‐Schomburg G, et al. Rocuronium is not associated with more vocal cord injuries that succinylcholine after rapid‐sequence induction: a randomized, prospective, controlled trial. Anesthesia and Analgesia 2006;102(3):943‐9. [MEDLINE: 16492856]

Mitra 2001 {published data only}

Mitra S, Gombar KK, Gombar S. The effect of rocuronium on intraocular pressure: a comparison wiht succinylcholine. European Journal of Anaesthesiology 2001;18(12):836‐8. [MEDLINE: 11737185]

Naguib 1994 {published data only}

Naguib M. Different priming techniques, including mivacurium, accelerate the onset of rocuronium. Canadian Journal of Anaesthesia 1994;41(10):902‐7. [MEDLINE: 8001208]

Naguib 1997 {published data only}

Naguib M, Samarkandi AH, Ammar A, Turkistani A. Comparison of suxamethonium and different combinations of rocuronium and mivacurium for rapid tracheal intubation in children. British Journal of Anaesthesia 1997;79(4):450‐5. [PUBMED: 389261 ]

Nelson 1997 {published data only}

Nelson JM, Morell RC, Butterworth JF. Rocuronium versus succinylcholine for rapid‐sequence induction using a variation of the timing principle. Journal of Clinical Anesthesia 1997;9(4):317‐20. [MEDLINE: 9195356]

Patel 1995 {published data only}

Patel N, Smith CE, Pinchak AC. Emergency surgery and rapid sequence intubation: rocuronium vs succinylcholine. Anesthesiology 1995;83(3A):A914.

Pühringer 1992 {published data only}

Pühringer FK, Khuenl‐Brady KS, Koller J, Mitterschiffthaler G. Evaluation of the endotracheal intubating conditions of rocuronium (org 9426) and succinylcholine in outpatient surgery. Anesthesia and Analgesia 1992;75(1):37‐40. [MEDLINE: 1616158]

Singh 2011 {published data only}

Ratan Singh N, Thangluai T, Laithangbam PKS, Hemjit Singh T, Chaoba Singh L, Shanti Devi RK. Comparison of intubating conditions of succinylcholine, vecuronium and rocuronium in patients undergoing elective surgery ‐ a study. Journal of Medical Society 2011;25(2):54‐8. [EMBASE: 2013558709]

Sluga 2005 {published data only}

Sluga M, Ummenhofer W, Studer W, Siegemund M, Marsch SC. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: A prospective, randomized trial in emergent cases. Anesthesia and Analgesia 2005;101(5):1356‐61. [MEDLINE: 16243994]

Sorensen 2012 {published data only}

Sorensen MK, Bretlau C, Gatke MR, Sorensen AM, Rasmussen LS. Rapid sequence induction and intubation with rocuronium‐sugammadex compared with succinylcholine: a randomized trial. British Journal of Anaesthesia 2012;108(4):682‐9. [PUBMED: 22315329]

Sparr 1996a {published data only}

Sparr HJ, Luger TJ, Heidegger T, Putensen‐Himmer G. Comparison of intubating conditions after rocuronium and suxamethonium following "rapid‐sequence induction" with thiopentone in elective cases. Acta Anaesthesiologica Scandinavica 1996;40(4):425‐30. [MEDLINE: 8738686]

Sparr 1996b {published data only}

Sparr HJ, Giesinger S, Ulmer H, Hollenstein‐Zache M, Luger TJ. Influence of induction technique on intubating conditions after rocuronium in adults: comparison with rapid‐sequence induction using thiopentone and suxamethonium. British Journal of Anaesthesia 1996;77(3):339‐42. [MEDLINE: 8949806]

Stevens 1996 {published data only}

Stevens JB, Shepherd JM, Vories PA, Walker SC, Vescovo MV. A mixture of mivacurinum and rocuronium is comparable in clinical onset to succinylcholine. Journal of Clinical Anesthesia 1996;8(6):486‐90. [MEDLINE: 8872689]

Stoddart 1998 {published data only}

Stoddart PA, Mather SJ. Onset of neuromuscular blockade and intubating conditions one minute after the administration of rocuronium in children. Paediatric Anaesthesia 1998;8(1):37‐40. [MEDLINE: 9483596]

Tang 1996 {published data only}

Tang J, Joshi GP, White PF. Comparison of rocuronium and mivacurium to succinylcholine during outpatient laparoscopic surgery. Anesthesia and Analgesia 1996;82(5):994‐8. [MEDLINE: 8610912]

Tripathi 2010 {published data only}

Tripathi D, Trivedi L, Doshi S, Shah C, Sheth P. Evaluation of onset of action and endotracheal intubating conditions after suxamethonium chloride and rocuronium bromide in adults. Journal of Anaesthesiology Clinical Pharmacology 2010;26(3):350‐4. [EMBASE: 2010533839]

Tryba 1994 {published data only}

Tryba M, Zorn A, Thole H, Zenz, M. Rapid‐sequence orotracheal intubation with rocuronium: a randomized double‐blind comparison with suxamethonium‐preliminary communication. European Journal of Anaesthesiology 1994;11(suppl. 9):44‐8. [MEDLINE: 7925207]

Turan 1999 {published data only}

Turan G, Ozgultekin A, Bafali M, Kasikci M, Senel NA. Is rocuronium an alternative to succinylcholine?. Türk Anesteziyoloji ve Reanimasyon Derne 1999;27(4):193‐7. [EMBASE: 1999190725]

Türkmen 2004 {published data only}

Türkmen A, Altan A, Turgut N, Uluç A, Kutlu F, Üstün H, Kamalı S. Mivacurium in balanced anesthesia, intubation with succinylcholine rocuronium and conditions and clinical effects comparison of time [Dengeli Anestezide Mivakuryumun, Rokuronyum ve Süksinilkolin İle Entübasyon Koşulları ve Klinik Etki Süresi Açısından Karşılaştırılması]. Türk Anesteziyoloji ve Reanimasyon 2004;322:85‐90.

Vinik 1999 {published data only}

Vinik HR. Intraocular pressure changes during rapid sequence induction and intubation: a comparison of rocuronium, atracurium and succinylcholine. Journal of Clinical Anesthesia 1999;11(2):95‐100. [MEDLINE: 10386278]

Weiss 1997 {published data only}

Weiss JH, Gratz I, Goldberg ME, Afshar M, Insinga F, Larijani G. Double‐blind comparison of two doses of rocuronium and succinylcholine for rapid‐sequence intubation. Journal of Clinical Anesthesia 1997;9(5):379‐82. [MEDLINE: 9257203]

Yorukoglu 2003 {published data only}

Yorukoglu D, Asik Y, Okten F. Rocuronium combined with i.v. lidocaine for rapid tracheal intubation. Acta Anaesthesiologica Scandinavica 2003;47(5):583‐7. [MEDLINE: 12699517]

References to studies excluded from this review

Dobson 1999 {published data only}

Dobson AP, McCluskey A, Meakin G, Baker RD. Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia. Anaesthesia 1999;54(2):172‐6. [MEDLINE: 10215713]

Dubois 1992 {published data only}

Dubois MY, Lapeyre G, Lea D, Tran DQ, Kateria BK. Pharmacodynamic effects of three doses of ORG 9426 used for endotracheal intubation in humans. Journal of Clinical Anesthesia 1992;4(6):472‐5. [MEDLINE: 1457115]

Hemmerling 2000 {published data only}

Hemmerling TM, Schmidt J, Wolf T, Klein P, Jacobi K. Comparison of succinylcholine with two doses of rocuronium using a new method of monitoring neuromuscular block at the laryngeal muscles by surface laryngeal electromyography. British Journal of Anaesthesia 2000;85(2):251‐5. [PUBMED: 10992834 ]

Huizinga 1992 {published data only}

Huizinga AC, Vandenbrom RH, Wierda JM, Hommes FD, Hennis PJ. Intubating conditions and onset of neuromuscular block of rocuronium (org 9426); a comparison with suxamethonium. Acta Anaesthesiologica Scandinavica 1992;36(5):463‐8. [MEDLINE: 1321542]

Lam 1997 {published data only}

Lam AM, Pavlin EG. Rocuronium versus succinylcholine‐atracurium for tracheal intubation and maintenance relaxation. European Journal of Anaesthesiology 1997;14(Suppl. 16):13. [CENTRAL: CN‐00330684]

Martin 1998 {published data only}

Martin R, Carrier J, Pirlet M, Claprood Y, Tetrault JP. Rocuronium is the best non‐depolarizing relaxant to prevent succinylcholine fasciculations and myalgia. Canadian Journal of Anaesthesia 1998;45(6):521‐5. [MEDLINE: 9669004]

Misiolek 2009 {published data only}

Misiolek H, Tombarkiewicz M, Zajaczkowska‐Druzba K, Rutkowska K. Rocuronium vs atracurium vs suxamethonium for double‐lumen endobronchial tube intubation. Anestezjologia Intensywna Terapia 2009;41(2):68‐72. [CENTRAL: CN‐00719576]

Naguib 1994b {published data only}

Naguib M. Neuromuscular effects of rocuronium bromide and mivacurium chloride administered alone and in combination. Anesthesiology 1994;81(2):388‐95. [MEDLINE: 8053589]

Ortiz‐Gómez 2005 {published data only}

Ortiz‐Gómez JR, Carrascosa F, Pérez‐Cajaraville JJ, Percaz‐Bados JA, Añez C. Comparative study of intubating conditions at the first minute with suxamethonium, rocuronium and different priming techniques of rocuronium. European Journal of Anesthesiology 2005;22(4):263‐8. [MEDLINE: 15892403]

Robertson 2004 {published data only}

Robertson EN, Driessen JJ, Booij LH. Suxamethonium administration prolongs the duration of action of subsequent rocuronium. European Journal of Anaesthesiology 2004;21(9):734‐7. [MEDLINE: 15595587]

Stourac 2013 {published data only}

Stourac P, Adamus M, Seidlova D, Krikava I, Kosinova M, Hejduk K. Use of rocuronium and active reversal of neuromuscular blockade with sugammedex does not shorten operating time during caesarean section in compare to suxamethonium, rocuronium and negostigmine: prospective randomised interventional multicentre trial. European Journal of Anesthesiology 2013;Supplement 51:179‐80.

Vianna 1997 {published data only}

Vianna PT, Castiglia YM, Ganem EM, Takata IH, Braz JR, Curi PR. Onset time and intubating conditions of rocuronium and succinylcholine. Revista Brasileira de Anestesiologia 1997;47(5):401‐7. [EMBASE: 1997304088]

Vincent 1996 {published data only}

Vincent MO, Schippers HC, De Lange JJ. Rocuronium versus succinylcholine versus vecuronium. Nederland Tijdschrift voor Aneshesiologie 1996;9:132. [CENTRAL: CN‐00251009]

Woolf 1997 {published data only}

Woolf RL, Crawford MW, Choo SM. Dose‐response of rocuronium bromide in children anesthetized with propofol a comparison with succinylcholine. Anesthesiology 1997;87(6):1368‐72. [MEDLINE: 9416722]

Danzl 2000

Danzl DF. Tracheal intubation and mechanical ventilation. In: Tintinalli JE, Kelen GD, Stapczynski JS editor(s). Emergency Medicine ‐ A comprehensive study guide. Toronto: McGraw‐Hill, 2000:85‐96.

Goldberg 1989

Goldberg ME, Larijani GE, Azad SS, Sosis M, Seltzer JL, Ascher J, et al. Comparison of tracheal intubating conditions and neuromuscular blocking profiles after intubating doses of mivacurium chloride or succinylcholine in surgical outpatients. Anesthesia and Analgesia 1989;69(1):93‐9. [MEDLINE: 2525886]

GRADEpro 2015 [Computer program]

McMaster Univeristy. GRADEpro. Hamilton: McMaster Univeristy, 2015.

Haynes 1994

Haynes RB, Wilczynski N, McKibbon KA, Walker CJ, Sinclair JC. Developing optimal search strategies for detecting clinically sound studies in MEDLINE. Journal of the American Medical Informatics Association 1994;1(6):447‐58. [MEDLINE: 7850570]

Herbstritt 2012

Herbstritt A, Amarakone K. Towards evidence‐based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation?. Emergency Medicine Journal 2012;29(3):256‐8. [PUBMED: 22337834]

Higgins 2003

Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses [Measuring inconsistency in meta‐analyses]. British Medical Journal 2003;327:557‐560.

Lebowitz 1989

Lebowitz PW, Ramsey FM. Muscle relaxants. Clinical Anesthesia 1989;1:344‐6.

Martyn 2006

Martyn JA, Richtsfel M. Succinylcholine‐induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006;104(1):158‐69. [PUBMED: 16394702]

Minton 1986

Minton MD, Grosslight K, Stirt JA, Bedford RF. Increases in intracranial pressure from succinylcholine: prevention by prior nondepolarizing blockade. Anesthesiology 1986;65(2):165‐9.

Patanwala 2011

Patanwala AE, Stahle SA, Erstad BL. Comparison of succinylcholine and rocuronium for first‐attempt intubation success in the emergency department. Academic Emergency Medicine 2011;18(1):10‐4. [PUBMED: 21182564]

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Schreiber 2005

Schreiber JU, Lysakowski C, Fuchs‐Buder T, Tramer MR. Prevention of succinylcholine‐induced fasciculation and myalgia: a meta‐analysis of randomized trials. Anesthesiology 2005;103(4):877‐84. [PUBMED: 16192781]

Soto 2015

Soto R, Jahr JS, Pavlin J, Sabo D, Philip BK, Egan TD, et al. Safety and efficacy of rocuronium with sugammadex reversal versus succinylcholine in outpatient surgery ‐ a multicenter, randomized, saftey assessor‐blnded trial. American Journal of Therapeutics 2015;NA:epub ahead of print.

Stollings 2014

Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid sequence intubation: A review of the process and considerations when choosing medications. Annals of Pharmacotherapy 2014;48(1):62‐76.

Sullivan 1994

Sullivan M, Thompson WK, Hill GS. Succinylcholine induced cardiac arrest in children with undiagnosed myopathy. Canadian Journal of Anaesthesia 1994;41(6):497‐501. [MEDLINE: 8069990]

References to other published versions of this review

Perry 2002

Perry JJ, Lee J, Wells G. Are intubation conditions using rocuronium equivalent to those using succinylcholine?. Academic Emergency Medicine 2002;9(8):813‐32.

Perry 2003

Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews 2003, Issue 1. [DOI: 10.1002/14651858.CD002788]

Perry 2008

Perry JJ, Lee JS, Silberg VAH, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews 2008, Issue 2. [DOI: 10.1002/14651858.CD002788.pub2]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Abdulatif 1996

Methods

RCT
Mixed simulated and modified RSI
N = 144

Participants

ASA I‐II
19 ‐ 57 years
Elective OR
Baseline comparison information not provided

Interventions

1. Rocuronium 0.6 mg/kg (n = 24)
2. Succinylcholine 1 mg/kg (n = 24)
3. Atracurium 0.5 mg/kg (n = 24)*
4. above groups with priming dose of Rocuronium (n = 24 each) *
Premedication: diazepam 10 mg po

Sequence with: fentanyl 2 mcg/kg, propofol 2.5 ‐ 3.0 mg/kg

Outcomes

1. Intubating conditions 60s after muscle relaxant evaluated by blinded observer. Reported as scores (0 ‐ 3) adapted from Fahey et al. Definitions table include vocal cord movement, visualization, participant movement

2. Adductor pollicis response to TOF stimulation

Adverse events

None reported

Time & Place

Study dates not reported. Article accepted November 1995.

King Fahad University Hospital, Al‐Khobar, Saudi Arabia.

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed envelopes

Allocation concealment (selection bias)

Low risk

Participants were randomly allocated via closed envelope

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No mention of blinding

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Data for all participants reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Abu‐Halaweh 2007

Methods

RCT

Elective and emergency caesarean section

N = 120

Participants

ASA I ‐ II

Pregnant women

Mean age 32

Mean weight 78 kg

Interventions

1, Rocuronium 1 mg/kg (n = 60)

2, Succinylcholine 1 mg/kg (n = 60)

Sequence with: thiopental 5 mg/kg

Outcomes

1. Intubating conditions by senior anaesthetist 60s after muscle relaxant. Reported as excellent, good and poor, as modified Viby‐Mogenson Grading system. Features included jaw relaxation, vocal cord position and diaphragmatic activity

Adverse events

Slight increase in heart rate after 5 mins with rocuronium use.

Time & Place

December 2005 to May 2006

Jordan University Hospital, Jordan

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomly shuffled envelopes, probably adequate

Allocation concealment (selection bias)

Low risk

Randomly shuffled sealed envelopes indicating the type of the muscle relaxant to be used for intubation

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

The intubator who was blinded to the type of administered muscle relaxant was called to the theatre 40s after the relaxant administration

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Data for all participants reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Alanoglu 2006

Methods

RCT
Modified RSI
N = 119

Participants

ASA II ‐ III
Adult
Controlled hypertensive

Interventions

1. Succinylcholine 1.0 mg/kg with lidocaine (n = 30)
2. Rocuronium 1 mg/kg with lidocaine (n = 30)
3. Succinylcholine 1.0 mg/kg with remifentanil (n = 29)
4. Rocuronium 1.0 mg/kg with remifentanil (n = 30)
Sequences with opiate (remifentanil) or no opiate and thiopental

Outcomes

1. Intubating conditions 60s after muscle relaxant. Reported as excellent, good, poor based on 6 variables (jaw relaxation, resistance to blade, vocal cord position and movement, movement of limbs and coughing) with table of definitions
2. Haemodynamics before inductio, after induction and at intubation

Adverse events

Mild muscle rigidity in 6 participants with the use of remifentanil.

Time & Place

Study dates not reported. Article accepted June 2005

Ankara University, Ankara, Turkey

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

ITT analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed envelope

Allocation concealment (selection bias)

Low risk

Allocated to 4 groups at random by sealed envelope technique

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

"Authors performing the intubation and scoring intubation conditions were blinded to the study medications." Unclear if blinded allocation or drug administration

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Adequately described in detail

Selective reporting (reporting bias)

Low risk

All outcomes reported

Ali 2008

Methods

RCT

Mixed simulated and modified RSI

N = 100

Participants

ASA I ‐ II

Age 18 ‐ 60

Elective OR

Interventions

1. Rocuronium 0.6 mg/kg at 60s (n = 25)

2. Rocuronium 0.6 mg/kg at 90s (n = 25)

3. Succinylcholine 1.5 mg/kg at 60s (n = 25)

4. Succinylcholine 1.5 mg/kg at 90s (n = 25)

Sequence with thiopental 5 mg/kg

Outcomes

Intubation conditions at 60 or 90s after muscle relaxant. Reported as score (0 ‐ 3) based on 3 variables (jaw relaxation, vocal cords and response to intubation) from Cooper et al with definitions table

Adverse events

None reported

Time & Place

Study dates not reported. Article published 2008.

Sheri Kashmir Institute of Medical Sciences, Soura, Srinagar, India

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Did not provide results of individuals groups. Used aggregate data, classified as modified RSI

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized" but did not elaborate

Allocation concealment (selection bias)

Unclear risk

Used "double‐blind" fashion

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Same fully‐trained anaesthetist (Intubator) performed all the intubations, who was called in the study room 45s after the administration of the neuromuscular blocker in group A participants and after 75s in group B participants (to eliminate possible bias because of fasciculations induced by succinylcholine) and intubation was attempted 15s later

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Data were not presented for all 4 groups, aggregated into 2 groups

Selective reporting (reporting bias)

Unclear risk

Only aggregate data presented

Alvarez Rios1997

Methods

RCT
Modified RSI
N = 60

Participants

ASA I ‐ II
Elective OR
Mean age 28.5
Mean weight 62.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 20)
2. Mivacurium 0.25 mg/kg (n = 20)*
3. Succinylcholine 1 mg/kg (n = 20)
Premedication:
midazolam 2 mg

Sequence with: no opioid
thiopental titrated to response (average 5.3 mg/kg with succinylcholine group and 5.9 mg/kg in rocuronium group)

Outcomes

1. Intubating conditions 90s after muscle relaxant. Reported as excellent, good, poor with definitions described for madibular relaxation, vocal cords and participant movement

Adverse events

None reported.

Time & Place

Study dates were not reported. Article published 1997.

Mexico

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Established groups were formed randomly, but does not state how

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No statement regarding blinding

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Data on all participants reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Andrews 1999

Methods

RCT
Simulated RSI
N = 366

Participants

ASA I ‐ V
18 ‐ 75 years
Elective OR
Mean age 47.5
Mean weight 61.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 48)*
2. Rocuronium 1.0 mg/kg (n = 46)*

3. Rocuronium 1.0 mg/kg (n=133)
4. Succinylcholine 1 mg/kg (n = 139)
Sequence with: no opioid, propofol 2.5 mg/kg

Outcomes

1. Intubating conditions 50s after muscle relaxant. Reported as excellent, good, poor based on 6 variables (jaw relaxation, resistance to laryngoscope, vocal cord position and movement, limb movement and diaphragmatic activity) with definitions described

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted September 1998.

University of Newcastle‐upon‐Tyne, Turnhout, Belgium

Funding and declarations

Funding source: Organon Teknika

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

States randomly without replacement and stratified for centre

Allocation concealment (selection bias)

Low risk

Allocation concealed from investigator performing the randomization

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"blinding was achieved by concealing patient from the investigator until immediately before laryngoscopy."

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All participants accounted for

Selective reporting (reporting bias)

Low risk

All outcomes reported

Belyamani 2008

Methods

RCT

Simulated RSI

N = 80

Participants

ASA I ‐ II

Elective OR

Mean age 34

Mean BMI 23.5

Interventions

1. Succinylcholine 1 mg/kg + ephedrine (n = 20)*

2. Rocuronium 0.6 mg/kg + ephedrine (n = 20)*

3. Succinylcholine 1 mg/kg + saline (n = 20)

4. Rocuronium 0.6 mg/kg + saline (n = 20)

Premedication: Hydroxyzine 1 mg/kg

Sequence with: propofol 2.5 mg/kg, fentanyl 3 mcg/kg

Outcomes

1. Intubation conditions 30s after muscle relaxant. Reported as excellent, good, poor based on criteria from the Copenhagen conference. No definitions provided

2. Heart rate, blood pressure

Adverse events

None reported

Time & Place

Study dates not reported. Article accepted December 2007.

Mohammed‐V Military Hospital, Rabat, Maroc

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

In French.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Used a randomization table

Allocation concealment (selection bias)

Low risk

The participant and the anaesthesiologist were not informed of the contents of the syringes (prepared by a separate individual)

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

30s after injection of the muscle relaxant, another blinded staff anaesthetist performed intubation of the participant

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Cheng 2002

Methods

RCT
Modified RSI
N = 120

Participants

ASA I
1 ‐ 10 years
Elective OR

Interventions

1. Rocuronium 0.6 mg/kg (n = 40)
2. Rocuronium 0.9 mg/kg (n = 40)
3. Succinylcholine 1.5 mg/kg (n = 40)
Sequence with: alfentanil 10 mcg/kg, thiopentone 5 mg/kg

Outcomes

1. Intubating conditions 30s after muscle relaxant. Reported as excellent, good, poor and impossible with table of definitions. Clinical features included: vocal cord movement, participant response to intubation and jaw relaxation

Adverse events

One participant developed bronchospasm during intubation after receiving rocuronium 0.9 mg/kg. This resolved spontaneously.

Time & Place

Study dates not reported. Article published 2002.

Prince of Wales Hospital, New Territories, Hong Kong

Funding and declarations

Funding source: Organon Teknika China Ltd provided rocuronium for study.

Declarations of interest: none declared

Notes

ITT analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomized by sealed envelopes

Allocation concealment (selection bias)

Low risk

"children were randomly assigned by means of opaque, sealed envelopes"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"observer had her back turned to the patient during the 30s before attempting to intubate"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Chiu 1999

Methods

RCT
Simulated RSI
N = 30

Participants

ASA I
18 ‐ 50 years
Elective OR
Mean age 32.4
Mean weight 55.6 kg

Interventions

1. Rocuronium 0.9 mg/kg (n = 15)
2. Succinylcholine 1 mg/kg (n = 15)
Premedication: midazolam 0.15 mg/kg po

Sequence with: fentanyl 2 mcg/kg, propofol 2 mg/kg

Outcomes

1. Intraocular pressure, mean arterial pressure, heart rate measured before induction, immediately after induction and every minute after intubation for 5 mins
2. Intubating conditions 60s after muscle relaxant. Reported as a score (1 ‐ 4) described in Methods section. Clinical variables included jaw relaxation, vocal cord movement, diaphragm movement

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted January 1999.

Univeristy of Malaya, Kuala Lumpur, Malaysia

Funding and declarations

Funding source: Organon Teknika (Malaysia) supplied rocuronium. Kemajuan Abadi Optomedic (Malaysia) supplied Keeler Pulsair air pulse tonometer.

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized, double‐blind, controlled study", but does not elaborate

Allocation concealment (selection bias)

Low risk

"drugs were administered ...by one anaesthetist (CYW) who was unaware of the drugs administered"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"the intubating anesthetist were not allowed to observe injection of the neuromuscular blocking drug or the presence of any fasciculations, by standing initially with their back to the patient. They were then asked to turn round to face the patient, 45 s after injection of either succinylcholine or rocuronium; by then the fasciculations had subsided"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Chung 2001

Methods

RCT
Simulated RSI
N = 84

Participants

ASA I ‐ II
Adult
Elective OR
Mean age 45.8

Interventions

1. Rocuronium 0.6 mg/kg and then thiopental 5 mg/kg (n = 28)*
2. Thiopental 5 mg/kg and then succinylcholine 1 mg/kg (n = 29)

3. Thiopental 5 mg/kg and then rocuronium 0.6 mg/kg (n = 27)
Sequence with: fentanyl 2 mcg/kg, lidocaine 20 mg

Outcomes

1. Intubating conditions 60s after muscle relaxant. Reported as excellent, good and poor from a score (0 ‐ 9) (from Cooper et al ) based on 3 variables (ease of laryngoscopy, condition of vocal cords, response to intubation) and defined in a table

2. Apnea time before laryngoscopy

3. Intubation time

4. Total apnoea time

Adverse events

5 participants in Group 1 and 1 in Group 2 had pain in injection. 3 in Group 1 had diminished breathing during induction. 1 in Group 1 had mild desaturation.

Time & Place

Study dates not reported. Article accepted September 2000.

Changhua Christian Hospital, Changhau, Taiwan

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"patients were randomly allocated", but did not elaborate

Allocation concealment (selection bias)

High risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Not mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All participants accounted for, 6/90 participants excluded due to "invisible vocal cords after several attempts"

Selective reporting (reporting bias)

Low risk

All outcomes reported

Cooper 1992

Methods

RCT
Modified RSI
N = 80

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Mean age 34.5
Mean weight 66.3 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 40)
2. Succinylcholine 1 mg/kg (n = 40)
Premedication: temazepam 10 ‐ 20 mg po

Sequence with: fentanyl 1 ‐ 3 mcg/kg, thiopentone 3 ‐ 5 mg/kg

Outcomes

1. Intubating conditions 60 and 90s after muscle relaxant. Reported as excellent, good and poor from a score (0 ‐ 9) based on 3 variables (jaw relaxation, vocal cords, response to intubation), defined in table

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted March 1992.

Queen's University, Belfast, Britain

Funding and declarations

Funding source: rocuronium supplied by Organon Teknika, Belgium

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"patients were allocated randomly"

Allocation concealment (selection bias)

Unclear risk

"patients were allocated randomly"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment on blinding

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

De Almeida 2009

Methods

Controlled Trial

Simulated RSI

N = 80

Participants

ASA I ‐ III

Elective bariatric surgery

Morbidly obese participants BMI ≥ 40

18 ‐ 65 yrs

Mean age 39

Mean weight 128 kg

Interventions

1. Succinylcholine 1 mg/kg ideal body weight (n = 20)*

2. Succinylcholine 1 mg/kg total body weight (n = 20)

3. Rocuronium 0.6 mg/kg ideal body weight (n = 20)*

4. Rocuronium 0.6 mg/kg total body weight (n = 20)

Premedication: midazolam 7.5 mg

Sequence with: propofol 2 mg/kg, fentanyl 2 mcg/kg

Outcomes

Intubation conditions 60s after intubation. Reported as excellent, good, poor based on 5 variables (laryngoscopy, vocal cord position, vocal cord movement, reaction to tube insertion, limb movement with tube insertion) described in a table

Adverse events

None reported.

Time & Place

March 2005 to March 2007.

Federal University of Santa Catarina, Santa Catarina, Brazil

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Paper written in Spanish.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

No mention of randomization

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions.

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No description or comment on blinding

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Dubois 1995

Methods

RCT
Modified RSI
N = 24

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Baseline information not provided (told groups tested and no difference)

Interventions

1. Rocuronium 0.6 mg/kg (n = 12)
2. Succinylcholine 1 mg/kg (n = 12)
Premedication: midazolam 2 ‐ 5 mg iv and/or droperidol 1.25 ‐ 5mg iv

Sequence with: fentanyl 1 ‐ 10 mcg/kg, thiopentone 3 ‐ 5 mg/kg

Outcomes

1. Intubating conditions after 80% first twitch depression of TOF. Reported as excellent good, poor and inadequate based 3 variables (jaw relaxation, vocal cord movement, diaphragm) described in Methods section

2. Heart rate and blood pressure

2. Onset time of muscle relaxant

Adverse events

5 participants had fasciculations. 2 had skin rash and one experienced hypersalivation.

Time & Place

Study dates not reported. Article accepted March 1994.

Georgetown University Medical Center, Washington, DC, USA.

Funding and declarations

Funding source: Support of Clinical Project Director Organon Inc.

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomly assigned via computer generation

Allocation concealment (selection bias)

Low risk

"either R or S in a coded syringe prepared by the pharmacist was given"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"the investigator intubator was blinded to the muscle relaxant randomization scheme and not in the operating room for drug administration"

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

"The other 6 patients were dropped because of incomplete data retrieval". Did not say why data were missing

Selective reporting (reporting bias)

Unclear risk

Outcomes for excluded participants not reported

Giudice 1998

Methods

RCT
Modified RSI
N = 40

Participants

ASA I ‐ II
Age 18 ‐ 56
Mean age uncertain but told groups homogeneous
Mean weight also homogeneous

Interventions

1. Rocuronium 0.3 mg/kg (n = 10)*
2. Rocuronium 0.6 mg/kg (n = 10)
3. Rocuronium 0.9 mg/kg (n = 10)
4. Succinylcholine 1 mg/kg (n = 10)
Premedication: lorazepam 1 mg po 1 hour prior, atropine 0.08 mg/kg few minutes prior

Sequence with: fentanyl prn, propofol 1.5 mg/kg

Outcomes

1. Intubating conditions when T1 of TOF ≤ 5%. Reported as a score (0 ‐ 6). Variables not presented for score assessment

2. Recovery of T1 to 25%
3. Intubating time
4. Recovery time

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted August 1998.

Italy

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Italian

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"patients were randomly allocated into four groups"

Allocation concealment (selection bias)

High risk

Not mentioned

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Iqbal 2013

Methods

RCT

Simulated RSI

N = 60

Participants

ASA I ‐ II

Adult elective surgery

Age 20 ‐ 60 yrs

Interventions

1. Rocuronium 0.9 mg/kg (n = 30)

2. Succinylcholine 1.5 mg/kg (n = 30)

Sequence with: thiopental 5 mg/kg

No premeds

Outcomes

Intubating conditions 60s after induction drugs. Reported as excellent, good, poor and not possible based on 3 variables (jaw relaxation, vocal cords and response to tube) from modification of Goldberg et and Krieg et al.

Adverse events

None reported.

Time & Place

January to August 2009.

Civil Hospital Karachi, Karachi, Pakistan

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized", did not elaborate

Allocation concealment (selection bias)

Low risk

"double‐blind manner"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"endotracheal intubation was done blinded by standing with the back to the patient."

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Koroglu 2002

Methods

RCT
Simulated RSI
N = 80

Participants

ASA I ‐ II
Adult women
Pregnant

Interventions

1. Rocuronium 0.6 mg/kg and propofol 2 mg/kg (n = 20)
2. Succinylcholine 1.5 mg/kg and propofol 2 mg/kg (n = 20)

3. Rocuronium 0.6 mg/kg and thiopentone 5 mg/kg (n = 20)
4. Succinylcholine 1.5 mg/kg and thiopentone 5 mg/kg (n = 20)

Outcomes

1. Intubations conditions. Started intubation 20s after muscle relaxant, intubated according to clinical conditions. Reported as excellent, good, poor based on 3 variables (jaw relaxation, vocal cord movement, reaction to tube) and score (0 ‐ 9) from Cooper et al.

2. Time to intubations
3. Neuromuscular conduction in musculus adductor pollicis by TOF
3. Umbilical arterial and venous blood gas values

Adverse events

None reported.

Time & Place

Study dates not reported. Article published 2002.

Dokuz Eylul University, Turkey

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis
In Turkish

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

"patients were numbered according to their order of arrival to the surgery"

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment made

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

All cases were accounted for

Selective reporting (reporting bias)

Low risk

All outcomes reported

Kulkarni 2010

Methods

RCT

Modified RSI

N = 300

Participants

ASA I ‐ II

Elective cleft palate repair OR

Age 1 ‐ 10

Mean age 4

Mean weight 17 kg

Mallampati I ‐ II

Interventions

1. Succinylcholine 1.5 mg/kg (n = 100)

2. Rocuronium 0.6 mg/kg (n = 100)

3. Rocuronium 0.9 mg/kg (n = 100)

Premedication: glycopyrrolate 0.004 mg/kg IM, midazolam 0.05 mg/kg IM, ketamine 5 mg/kg IM for younger children, tramadol 1 mg/kg iv

Sequence with: thiopental 6 ‐ 8 mg/kg

Outcomes

1. Intubation conditions at 60s after muscle relaxant. Reported as excellent, good, poor, inadequate according to intubation scoring system as per Mangorian et al. Based on 3 clinical variables: jaw relaxation, vocal cord movement and diaphragmatic movements

2. Intubation time

3. Duration of muscle relaxation with TOF monitoring

4. Clinical recovery

Adverse events

Tachycardia in all three groups (58‐66%)

Time & Place

October 2003 to September 2008.

Lotus Hospital & Research Center, Kolhapur, Maharashtra, India

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

used oral RAE tubes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomly divided in three groups"

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment made

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases presented

Selective reporting (reporting bias)

Low risk

All outcomes reported

Kwon 2013

Methods

RCT

Modified RSI

N = 40

Participants

ASA I ‐ II

Elective OR

Mean age 43

Mean weight 61 kg

Interventions

1. Succinylcholine 1.5 mg/kg (n = 20)

2. Rocuronium 0.6 mg/kg (n = 20)

Sequence with: lidocaine 60 mg, fentanyl 1.5 mcg/kg, propofol 1.5 mg/kg

Outcomes

1. Intubating conditions (with loss of consciousness for rocuronium group and 60s after succinylcholine). Reported as excellent, acceptable and poor based on a score. Variables included: mandibular relaxation, resistance to blade insertion, vocal cord position and movement, limb response, coughing

2. Timing of events

3. Complications of intubation: awareness, respiratory difficulty postoperatively

Adverse events

3 participants who received rocuronium complained of injection pain.

Time & Place

Study dates were not reported. Article accepted September 2012

Dankook University, Cheonan, Korea

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"patients were randomly assigned"

Allocation concealment (selection bias)

Low risk

"tracheal intubation were performed...by an experienced anesthesiologist who was blinded to the anesthetic drug"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No blinding mentioned

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases were reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Lam 2000

Methods

RCT
Modified RSI
N = 30

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR

Interventions

1. Rocuronium 0.6 mg/kg (n = 15)
2. Succinylcholine 1 mg/kg (n = 15)
Premedication: midazolam 2 mg

Sequence with: fentanyl 2 mcg/kg, propofol 2.5 mg/kg

Outcomes

1. Intubating conditions 60s after muscle relaxant. Intubation conditions were reported by the same blinded individual as excellent, good, poor and inadequate based on jaw relaxation, vocal cord position and movement, and diaphragm movement
2. Onset muscle relaxation with TOF
3. Offset muscle relaxation with TOF

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted August 2000.

University of Washington, Seattle, USA

Funding and declarations

Funding source: Organon West Orange, New Jersey

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer generated

Allocation concealment (selection bias)

Low risk

Intubator unaware of drug

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

"there were no attempts made to blind the individual"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Complete data set

Selective reporting (reporting bias)

Low risk

All outcomes reported

Larsen 2005

Methods

RCT
Simulated RSI
N = 209

Participants

ASA I ‐ III
> 17 years
Emergency OR

Interventions

1. Rocuronium 0.6 mg/kg (n = 102)
2. Succinylcholine 1 mg/kg (n = 107)
Premedication: i.m morphine 30 mins prior

Sequence with: alfentanil 10 ‐ 20 ug/kg, propofol 2 ‐ 3 mg/kg

Outcomes

1. Intubating conditions 60s after muscle relaxant by senior anaesthesiologist. Intubations not achieved in 30s were recorded as failed. Reported as excellent, good, poor and first attempt failed. Based on 5 variables: ease of laryngoscopy, position of vocal cords, movement of vocal cords, movement of limbs and coughing during tracheal intubation
2. Heart rate and blood pressure

Adverse events

1 participant in Group 2 had atrial fibrillation requiring treatment verapamil and sotalol. Hypotension requiring treatment with ephedrine occurred in 18 Group2 and 17 Group 1. Five participants in Grp 2 and 2 in Group1 reported postoperative muscle pain.

Time & Place

Study dates not reported. Article accepted June 2005.

University of Copenhagen, Glostrup, Denmark

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed envelopes

Allocation concealment (selection bias)

Low risk

The participant was allocated by the concealed envelope method

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"anaesthesiologist (a senior member of the study group) blinded to the muscle relaxant and concealed in a room next to the operation theatre until 40 secs after its administration, hereby preventing him from seeing fasciculations after succinylcholine"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases accounted for

Selective reporting (reporting bias)

Low risk

All outcomes reported

Latorre 1996

Methods

RCT
Modified RSI
N = 40

Participants

ASA I ‐ III
Age 18‐62, mean 44.5
Mean weight 73.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 20)
2. Succinylcholine 1 mg/kg (n = 20)
Sequence with: fentanyl 2 ‐ 3 mcg/kg, propofol 1.5 ‐ 2.0 mg/kg

Outcomes

1. Intubating conditions 60s after muscle relaxant. Reported as score based on clinical variables: laryngoscopy, vocal cord movement and coughing
2. Onset time
3. Clinical duration of muscle block with EMG recordings on adductor pollicis
4. % blocked at time of intubation

5. Heart rate, blood pressure and arterial oxygen saturation

Adverse events

None reported.

Time & Place

Study dates not reported.

University of Johannes‐Gutenberg, Mainz, Germany

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

In German

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"patients were allocated randomly"

Allocation concealment (selection bias)

Low risk

Examiner did not know which drug was injected

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases accounted for

Selective reporting (reporting bias)

Low risk

All outcomes reported

Le Corre 1999

Methods

RCT
Modified RSI
N = 150

Participants

ASA I ‐ II
18 ‐ 75 years
Elective OR
Mean age 47.5
Mean weight 61.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 30)
2. Succinylcholine 1 mg/kg (n = 30)
3. Atracurium 0.5 mg/kg (n = 30)*
4. Mivacurium 0.2 mg/kg (n = 30)*

5. Vecuronium 0.08 mg/kg (n = 30)*
Premedication: alprazolam 0.5 mg/kg po

Sequence with: fentanyl 3 mcg/kg, propofol 2.5 mg/kg

Outcomes

1. Time to complete disappearance of response to orbicularis oculi after TOF stimulation
2. Intubation conditions reported as excellent, good, poor and impossible. Scale variables were vocal cord movement and ease of laryngoscopy.

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted June 1999.

Jean Bernard Hospital, Poitiers, France

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"random allocation"

Allocation concealment (selection bias)

Low risk

"intubation was performed by another physician unaware of muscle relaxant injected"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"onset time of neuromuscular blockade ...was estimated by a blinded physician who was not involved in the intubating procedure. When the orbicularis oculi was completely blocked, intubation was performed by another physician "

Incomplete outcome data (attrition bias)
All outcomes

High risk

Participants were excluded from the final analysis in 2 cases: 1) when the vocal cords were not completely visualized during the laryngoscopy and 2) when onset time was longer than 300s.

In participants not fully paralysed after 300s after the administration of the muscle relaxant, intubation was performed after giving a supplemental dose of muscle relaxant

Selective reporting (reporting bias)

Unclear risk

due to incomplete outcome data, difficult to assess.

Magorian 1993

Methods

RCT
Modified RSI
N = 50

Participants

ASA I III
18 ‐ 70 years
uncertain location
Mean age 36
Mean weight 68 kg

Mallampati 1 or 2 airway and no contraindication to RSI

Interventions

1. Rocuronium 0.6 mg/kg (n = 10)
2. Rocuronium 0.9 mg/kg (n = 10)
3. Rocuronium 1.2 mg/kg (n = 10)
4. Vecuronium 0.1 mg/kg (n = 10)*
5. Succinylcholine 1 mg/kg (n = 10)
Premedication: midazolam 0.02‐0.05 mg/kg

Sequence with: fentanyl (?dose), thiopental 2 ‐ 7 mg/kg

Outcomes

1. Ablation of T1 (onset)
2. Return of T1 to 25% of duration
3. Intubation conditions 60s after muscle relaxant. Reported as excellent, good, poor, inadequate based on jaw relaxation, vocal cord movement and diaphragm movement
4. Presence of fasciculations

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted June 1993

University of California, San Franscisco, USA.

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomly designated"

Allocation concealment (selection bias)

Low risk

"intubation of trachea was attempted by a clinician who was blinded to the muscle relaxant administered"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

"Intubating conditions were judged by each clinician, and the presence or absence of fasciculations was noted"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Malik 2004

Methods

RCT
Simulated RSI
N = 60

Participants

ASA I ‐ II
20 ‐ 50 years
Elective non‐ophthalmic surgery

Interventions

1. Rocuronium 0.9 mg/kg (n = 30)
2. Succinylcholine 1.5mg/kg (n = 30)
Sequence with an opiate and thiopental

Outcomes

1. Intubation conditions 60s after muscle relaxants. Reported as excellent, adequate and poor as per Abbott and Samuel. Variables included jaw relaxation, vocal cord position and cough reflex
2. Heart rate and blood pressure before, just after and 1,3, 5 mins after intubation
3. Intraocular pressure

Adverse events

None reported.

Time & Place

Study dates not reported. Article published 2004.

Rohtak, India

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomly allocated"

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment made

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Marsch 2011

Methods

RCT

Simulated RSI

N = 401

Participants

Emergency ICU

Age ≥ 18 yrs

Mean age 62

Mean weight 73 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 201)

2. Succinylcholine 1 mg/kg (n = 200)

Sequence with: fentanyl 1 mcg/kg, propofol 1 mg/kg or etomidate 0.2 mg/kg

Outcomes

1. Incidence of desaturation ≥ 5% by pulse oximetry

2. Duration of intubation sequence

3. Incidence of failed first intubation

4. Intubation conditions after fasciculations stopped or 60s from muscle relaxant injection. Reported as excellent, good and poor based on a score from 6 clinical variables (laryngoscopy, vocal cords position, vocal cord movement and intubation response with regard to coughing and limb movement).

5. Haemodynamic consequences

Adverse events

None reported

Time & Place

August 2006 to June 2010

University Hospital of Basel, Basel, Switzerland.

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stratified randomization by gender was used to ensure a similar distribution of gender in both groups

Allocation concealment (selection bias)

Low risk

Using sealed envelopes, participants were randomly allocated by the study physician

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Outcome assessor was unblinded

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases accounted for

Selective reporting (reporting bias)

Low risk

All outcomes reported

Mazurek 1998

Methods

RCT
Simulated RSI
N = 26

Participants

ASA I ‐ III
2 ‐ 15 years
Emergency OR
Mean age 6.6
Mean weight 28 kg

Interventions

1. Rocuronium 1.2 mg/kg (n = 13)
2. Succinylcholine 1.5 mg/kg (n = 13)
Sequence with: atropine 0.01 mg/kg, thiopental 5 mg/kg

Outcomes

1. Onset and quality of muscle paralysis with TOF
2. Intubation conditions 30s after muscle relaxant. Reported excellent, good, fair and poor from a score based on jaw relaxation, vocal cords and response to tube.

3. Onset of apnoea

Adverse events

Precipitation of thiopental and rocuronium during induction in one case.

Time & Place

Study dates not reported. Article accepted for publication September 1998

Chicago, USA.

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomized using a random numbers table

Allocation concealment (selection bias)

Low risk

"all investigators except the one designated to dispense the study drug were blinded to choice of muscle relaxant"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"The investigators performed the laryngoscopies but were blinded to the relaxant by standing with their back to the patient during the induction so that they could not detect fasciculations."

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data

Selective reporting (reporting bias)

Low risk

All outcomes reported

McCourt 1998

Methods

RCT
Simulated RSI
N = 318

Participants

ASA I ‐ IV
18 ‐ 75 years
Emergency and elective participants in OR
Mean age 41.5
Mean weight 71 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 61)
2. Rocuronium 1.0 mg/kg (n = 130)
3. Succinylcholine 1 mg/kg (n = 127)
Sequence with: fentanyl 1 ‐ 2 mcg/kg, thiopentone 5 mg/kg

Outcomes

1. Intubation conditions 60s after muscle relaxant. Reported as excellent, good and poor after Viby‐Mogensen et al. Based on conditions for laryngoscopy, vocal cords and reaction to intubation presented in a table

Adverse events

Erythema occurred in 6 participants who received succinlycholine and 17 who received rocuronium. Bronchospasm occurred once in Group 2.

Time & Place

The Queen's University of Belfast, the Helsinki University Central Hospital UK

Funding and declarations

Funding source: Organon Teknika

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated randomizations

Allocation concealment (selection bias)

Low risk

Intubator unaware of drug given

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"intubation were carried out by an assessor, blinded to the treatment administered, 50s after the end of injection of the neuro‐muscular blocking drug This assessor was not present in the room until about 45s after the neuromuscular blocking drug had been given."

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Incomplete data were accounted for and well explained

Selective reporting (reporting bias)

Low risk

All outcomes reported

Mencke 2005

Methods

RCT

Simulated RSI

N = 120

Participants

ASA I ‐ II

Adults

Mean age 49.8

Mean weight 75 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 30 men)

2. Rocuronium 0.6 mg/kg (n = 30 women)

3. Succinylcholine 1.0 mg/kg (n = 30 men)

4. Succinylcholine 1.0 mg/kg (n = 30 women)

Premed: midazolam 7.5 mg

Sequence with: thiopental 5 mg/kg, fentanyl 3 mcg/kg

Outcomes

1. Intubation conditions 60s after muscle relaxant. Reported as excellent, good and poor based on laryngoscopy, vocal cord position and reaction to tube

2. Intubation times

Adverse events

None reported.

Time & Place

Study dates not reported.

University of Rostock, Rostock, Germany

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

In German. Data aggregated for groups 1 & 2 and groups 3 & 4

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computerized randomization

Allocation concealment (selection bias)

Low risk

Intubation performed by blind operator

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Mencke 2006

Methods

RCT
Simulated RSI
N = 150

Participants

ASA I ‐ II
18 ‐ 77 years
Uncertain location

Interventions

1. Rocuronium 0.6 mg/kg (n = 76)
2. Succinylcholine 1.0 mg/kg (n = 74)
Sequence with: fentanyl 3 mcg/kg, thiopental 5.0 mg/kg

Outcomes

1. Intubation conditions 50s after muscle relaxant by experienced anaesthesiologist. Reported as excellent, good and poor based on laryngoscopy, vocal cord movement and position and reaction to tube insertion or cuff inflation
2. Intubation time

3. Adverse outcomes: Postoperative hoarseness, sore throat, vocal cord injuries

Adverse events

Thoroughly reported as one of the primary outcomes.

Time & Place

Study dates not reported. Article accepted September 2005.

University of Rostock, Rostock, Germany

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Random number draws

Allocation concealment (selection bias)

Low risk

"syringes were prepared by an independent investigator"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"To prevent the anesthesiologist who performed the tracheal intubation from noting succinylcholine‐induced muscle fasciculations, he was called to enter the study room after 40s"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Mitra 2001

Methods

RCT
Modified RSI
N = 40

Participants

ASA I ‐ II
Adult, mean age 40

Mean weight 59.6 kg
Elective OR

Mallampati 1 or 2 airways

Interventions

1. Rocuronium 0.6 mg/kg (n = 20)
2. Succinylcholine 1.5 mg/kg (n = 20)
Premedication: diazepam 5 mg

Sequence with: morphine 1 mg/kg, propofol 2.0 mg/kg

Outcomes

1. Intraocular pressure
2. Intubating conditions 60s after muscle relaxant. Reported as excellent, good, poor and inadequate

Adverse events

None reported.

Time & Place

Study dates not reported.

Government Medical College and Hospital, Chandigarh, India

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized"

Allocation concealment (selection bias)

Low risk

"all drugs administered into ...infusion by one anaesthetist who was unaware of drug administered"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"he intubating anaesthetist were not allowed to observe the injection of the neuromuscular blocking drug or the presence of fasciculation by making them stand with their back to the patient for 45 s after injection of the drug"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Naguib 1994

Methods

RCT
Modified RSI
N = 70

Participants

ASA I ‐ II
Elective OR
Mean age 33.5
Mean weight 68.4 kg

Interventions

1. Mivacurium 0.15 mg/kg (n = 10)*
2. Mivacurium 0.015mg/kg then 0.135mg/kg 3 mins later (n = 10)*
3. Rocuronium 0.6 mg/kg (n = 10)
4. Rocuronium 0.06 mg/kg then 0.54mg/kg 3 mins later (n = 10)
5. Mivacurium 0.015 mg/kg then Rocuronium 0.54 mg/kg (n = 10)*

6. Rocuronium 0.06 mg/kg then mivacurium 0.135 mg/kg (n = 10)
7. Succinylcholine 1.0 mg/kg (n = 10)
Sequence with: incremental doses of fentanyl, midazolam 0.03 mg/kg, thiopentone 5 ‐ 7 mg/kg

Outcomes

1. Onset time after priming of muscle blockade with TOF

2. Intubation conditions with different priming sequences 30s after thiopentone dose. Reported as excellent, good or poor based on jaw relaxation, vocal cord movement and diaphragm movement.

3. Recovery of twitch height to 10% of control

Adverse events

None reported

Time & Place

Study dates not reported. Article accepted April 1994.

King Khalid University Hospital, Riyadh, Sadui Arabia

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"patients were randomly assigned to seven groups"

Allocation concealment (selection bias)

Low risk

Tracheal intubation was performed after complete neuromuscular block by an experienced anaesthetist who was not involved in the study and was not aware of the muscle relaxant used

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No comment on blinding

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Naguib 1997

Methods

RCT
Simulated RSI
N = 60

Participants

ASA I
3 ‐ 10 years
weight 12 ‐ 40 kg
Elective OR
Mean Age 5.0
Mean weight 20.1 kg

Interventions

1. Succinylcholine 1 mg/kg (n = 10)
2. Mivacurium 0.2 mg/kg (n = 10)*
3. Rocuronium 0.6 mg/kg (n = 10)
4. Rocuronium 0.9 mg/kg (n = 10)
5. Mivacurium 0.2 mg/kg + rocuronium 0.3 mg/kg (n = 10)*
6. Mivacurium 0.1 mg/kg + rocuronium 0.45 mg/kg (n = 10)*
Premedication: trimeprazine 2 mg/kg po

Sequence with: fentanyl 2 mcg/kg, propofol 2 mg/kg

Outcomes

1. Intubation conditions 60s after muscle relaxant. Reported as excellent, good and poor based on jaw relaxation, vocal cord movement and diaphragm movement.
2. TOF at 60s
3. Pharmacodynamic study (not used)

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted May 1997.

King Khalid University Hospital, Riyadh, Sadui Arabia

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"allocated randomly"

Allocation concealment (selection bias)

Low risk

To maintain blinding, participants who received a single neuromuscular blocking drug had a simultaneous injection of placebo. 60s after the end of injection the trachea was intubated in all participants by the same anaesthetist who was unaware of the participant’s grouping

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No mention of blinding muscle relaxant used

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Nelson 1997

Methods

RCT
Modified RSI
N = 42

Participants

ASA I ‐ II
25 ‐ 77 years
Elective OR
Mean age 50
Mean weight 73.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 20)
2. Succinylcholine 1 mg/kg (n = 22)
Premedication: midazolam 0.02 ‐ 0.03 mg/kg

Sequence with: fentanyl 2 ‐ 3 mcg/kg, thiopental 4 ‐ 5 mg/kg

Outcomes

1. Onset time of neuromuscular blocker
2. Intubation conditions 60s after injection of blinded syringe. Reported as excellent, good, fair or poor based on jaw relaxation, vocal cord movement and cough response

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted January 1997.

The Bowman Gray School of Medicine, Winston‐Salem, USA

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Patients were randomly assigned, via computer‐generated random numbers table"

Allocation concealment (selection bias)

Low risk

Used blinded syringes

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Laryngoscopy and intubation began 60s after the injection of the contents of the final blinded syringe by an anaesthetist unaware of the treatment group. This individual was not allowed to look at or touch the participant during the period of time in which fasciculations would occur, nor was he or she allowed to look at the polygraph tracing

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Did not explain why 2 participants were excluded from rocuronium group

Patel 1995

Methods

RCT
Modified RSI
N = 22

Participants

Uncertain ASA
Adult participants
Emergency OR
Mean age 44.2
Mean weight 74.7 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 7)
2. Rocuronium 0.9 mg/kg (n = 8)
3. Succinylcholine 1 mg/kg (n = 7)
Sequence with: fentanyl (?dose), thiopental (?dose)

Outcomes

1. Intubation conditions after visual loss of orbicularis oculi TOF or after 90s. Reported as excellent, good, fair based on jaw relaxation, vocal cord position and coughing

Adverse events

None reported.

Time & Place

Study dates not reported.

MetroHealth Medical Center, Cleveland, USA

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis
Abstract only

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized"

Allocation concealment (selection bias)

Low risk

Anaesthesiologist was blinded to relaxant

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment on blinding effects of drugs

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Pühringer 1992

Methods

RCT
Modified RSI
N = 30

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Mean age 28.9
Mean weight 66.1 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 20)
2. Succinylcholine 1 mg/kg (n = 10)
Premedication: meperidine 1 mg/kg, atropine 0.01 mg/kg

Sequence with: afentanyl 25 mcg/kg, propofol up to 2.5 mg/kg

Outcomes

1. Intubation conditions 60s after muscle relaxant. Reported as excellent, good, poor and inadequate based on jaw relaxation, vocal cord position and reaction to intubation

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted February 1992.

Univeristy of Innsbruck, Innsbruck, Austria

Funding and declarations

Funding source: grant from Organon Teknika

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomization table

Allocation concealment (selection bias)

Low risk

"Unaware of the muscle relaxant used"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"This person was unaware of the twitch response at the time of laryngoscopy, unaware of the muscle relaxant used"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Singh 2011

Methods

RCT

Modified RSI

N = 90

Participants

ASA I ‐ II

Major elective surgery in OR

20 ‐ 60 years

Mean age 38

Mean weight 53 kg

Interventions

1. Succinylcholine 1.5 mg/kg (n = 30)

2. Rocuronium 0.6 mg/kg (n = 30)

3. Vecuronium 0.08 mg/kg (n = 30)*

Sequence with propofol 2 ‐ 2.5 mg/kg

Outcomes

1. Intubation conditions were assessed as per Cooper et al. Reported as excellent, good, fair and poor from a score of 0 ‐ 9

2. Intubation time

Adverse events

None reported

Time & Place

Study dates not reported.

Regional Institute of Medical Sciences, Imphal, India

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Using computer generated randomization"

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Once the control response had been noted, the neuromuscular blocking agent was injected and the endotracheal intubation was carried out by the same person (unblinded)

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Sluga 2005

Methods

RCT
Simulated RSI
N = 180

Participants

ASA I ‐ IV
18 years or older
Emergency OR

Interventions

1. Rocuronium 0.6 mg/kg (n = 90)
2. Succinylcholine 1 mg/kg (n = 90)

Outcomes

1. Intubation conditions. Reported as excellent, good and poor based on a score that was evaluated from laryngoscopy, vocal cords and response to intubation
2. Intubation time

Adverse events

5 failure to intubate on first attempt. Desaturations in 5 of 90 in Group 2 and 9 of 90 in Group 1.

Time & Place

Study dates not reported. Article accepted April 2005.

Krankenhaus Thusis, Switzerland

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

ITT analysis
Exact numbers for intubating conditions provided by authors

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed envelopes

Allocation concealment (selection bias)

Low risk

"Patients were randomly allocated (sealed envelopes)"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

The staff anaesthesiologist was not blinded to the neuromuscular blocking drug used, and the management of difficulties and complications, if any, was left to his discretion

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Adequately described

Selective reporting (reporting bias)

Low risk

All outcomes reported

Sorensen 2012

Methods

RCT

Modified RSI

N = 55

Participants

Elective surgery

18 ‐ 60 years

Mean age 51

Mean weight 78 kg

Interventions

1. Succinylcholine 1 mg/kg (n = 26)

2. Rocuronium 1 mg/kg (n = 29)

Sequence with alfentanil 0.01 mg/kg, propofol 2 mg/kg

Outcomes

1. Time from correct placement of endotracheal tube to spontaneous ventilation

2. Duration of action of neuromuscular blocking agent measured on TOF‐WatchSx

3. Intubation difficulty scale

4. Intubation conditions 55s after muscle relaxant administration. Reported as excellent, good and fair

Adverse events

Tachycardia above 100 beats per minute

Time & Place

Study dates not reported.

Copenhagen University Hospital, Copenhagen, Denmark

Funding and declarations

Funding source: funding supported by Tryg Foundation, Lyngy Denmark

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐ generated list

Allocation concealment (selection bias)

Low risk

Opaque envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

The investigator (in all cases, an anaesthesiology consultant) was blinded by only being allowed to enter the operating theatre after correct placement of the tracheal tube had been verified. The personnel doing the statistical evaluations were blinded to the allocation by being presented the allocation list without the key. After statistical evaluation, an abstract and a conclusion were written in 2 copies, 1 for each allocation possibility

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Adequate description of excluded participants

Selective reporting (reporting bias)

Low risk

All outcomes reported

Sparr 1996a

Methods

RCT
Simulated RSI
N = 50

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Mean age 31
Mean weight 75.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 25)
2. Succinylcholine 1 mg/kg (n = 25)

Sequence with: thiopentone 6 mg/kg

Outcomes

1. Intubating conditions 45s after administration of muscle relaxant. Reported as excellent, good, fair and poor according to a scoring condition as per Cooper et al. Clinical variables include ease of laryngoscopy, aspect of vocal cords and response of diaphragm
2. Presences of fasciculations
3. Intubation time

Adverse events

One case of bronchospasm and 2 cases of ventricular ectopic beast in Group 2. One case of desaturation in Group 1.

Time & Place

Study dates not reported. Article accepted September 1995

University of Innsbruck, Innsbruck, Austria

Funding and declarations

Funding source: supported by Organon Teknika NV, Belgium.

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Randomly allocated

Allocation concealment (selection bias)

Low risk

"The intubator was blinded to the muscle relaxant administered"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

" Forty seconds after the administration of the muscle relaxant, the intubator was called to enter the study room...The occurrence of muscle fasciculations or body movements was noted by both the intubator and the anaesthetist"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Accounted for excluded participants

Selective reporting (reporting bias)

Low risk

All outcomes reported

Sparr 1996b

Methods

RCT
Simulated RSI
N = 150

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Mean age 34
Mean weight 69 kg

Interventions

1. Rocuronium 0.6 + thiopentone 5 mg/kg (n = 25)
2. Rocuronium 0.6 mg/kg + propofol 2.5 mg/kg (n = 25)*
3. Rocuronium 0.6 mg/kg + thiopentone 5 mg/kg + alfentanyl 20mcg/kg (n = 25)*
4. Rocuronium 0.6 mg/kg + propofol 2.5 mg/kg + alfentanyl 20mcg/kg (n = 25)*
5. Succinylcholine 1 mg/kg + thiopentone 5 mg/kg (n = 50)
Sequence with: as above

Outcomes

1. Intubating conditions 45s after muscle relaxant administration. Reported as per Cooper et al as excellent, good, fair and poor based on scores evaluating jaw relaxation, vocal cords and response to intubation
2. Intubating time
3. Fasciculations

Adverse events

Nonre reported

Time & Place

Study dates not reported. Article accepted April 1996

University of Innsbruck, Innsbruck, Austria

Funding and declarations

Funding source: supported by Oganon GmbH, Division of Organon Teknika, Vienna, Austria

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"allocated randomly"

Allocation concealment (selection bias)

Low risk

"Intubator was blinded to the treatment each patient received"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"In order to prevent the intubator from noting …. muscle fasciculations…. called to enter the study room 40s after the administration of the blocker"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases accounted for

Selective reporting (reporting bias)

Low risk

All outcomes reported

Stevens 1996

Methods

Modified RCT
N RSI
N = 70

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Mean age 37.6
Mean weight 73.9 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 30)
2. Succinylcholine 1 mg/kg (n = 10)

3. Mivacurium 0.15mg/kg and rocuronium 0.6mg/kg (n = 30)*

Premedication: midazolam 0.02 ‐ 0.05 mg/kg iv

Sequence with: fentanyl 3 mcg/kg, thiopental up to 7 mg/kg

Outcomes

1. Onset time of neuromuscular blocker
2. Duration of neuromuscular blocker
3. Intubation conditions

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted November 1995.

University of Texas Health Science Center, Texas, USA

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Envelopes

Allocation concealment (selection bias)

Low risk

"previously prepared envelopes containing cards assigning patients to one of the three groups".

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

"Presence or absence of fasciculations was noted. Laryngoscopy was begun with a Miller 2 blade 45 seconds later, and intubation was completed within 15 seconds. The same experienced anesthesiologist, who was unaware of the status of T₁, performed and graded all the intubations in the investigation"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Stoddart 1998

Methods

RCT
Modified RSI
N = 60

Participants

Uncertain ASA
3 ‐ 15 years
Elective OR for tonsillectomy
Mean Age 7.5
Mean weight 26.9 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 30)
2. Succinylcholine 1 mg/kg (n = 30)
Premedication: paracetamol 20 mg/kg po

Sequence with: propofol 3 ‐ 4 mg/kg

Outcomes

1. Intubation conditions 1 min after muscle relaxant. Reported as excellent, good, fair or poor based on scores evaluating jaw relaxation, vocal cords and response to intubation
2. Duration of neuromuscular blocker
3. Onset time of neuromuscular blocker

Adverse events

None reported.

Time & Place

Study dates not reported.

Bristol Hospital for Sick Children, Bristol, UK

Funding and declarations

Funding source: rocuronium and TOF guard device was provided by Organon Teknika Ltd, Cambridge UK.

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed envelopes

Allocation concealment (selection bias)

Low risk

Sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Blinded to identity of relaxant but not fasciculations

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All cases reported

Selective reporting (reporting bias)

Low risk

All outcomes reported

Tang 1996

Methods

RCT
Modified RSI
N = 100

Participants

Uncertain ASA
All women getting elective laparoscopic surgery
Mean Age 29.4
Mean weight 70.0 kg

Interventions

1. Succinylcholine 1 mg/kg + rocuronium boluses (n = 23)

2. Succinylcholine 1mg/kg + mivacurium boluses(n = 25)
3. Mivacurium 0.2 mg/kg (n = 25)*
4. Rocuronium 0.6 mg/kg (n = 27)
Sequence with: fentanyl 1.5 mcg/kg, thiopental 4 mg/kg

Premedication: midazolam 2 mg iv

Outcomes

1. Intubating conditions 90s after dose of muscle relaxant. Reported using a 3‐point scale: excellent, good and poor based on jaw relaxation and movement of vocal cords
2. Neuromuscular effects

Adverse events

1 in Group 1 and 6 in Group 4 had upper body erythema not requiring treatment. 16% in Group 1+ 2 developed postoperative myalgias.

Time & Place

Study dates not reported. Article accepted January 1996.

University of Texas Southwestern Medical Center, Dallas, USA

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomly assigned"

Allocation concealment (selection bias)

High risk

No comment made

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"laryngoscopy was performed by an anesthesiologist who was unaware of the twitch response"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Complete data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Tripathi 2010

Methods

RCT

Modified RSI

N = 100

Participants

ASA I ‐ II

Elective OR

20 ‐ 60 yrs

Mean age 37

Mean weight 51 kg

Interventions

1. Rocuronium 0.9 mg/kg (n = 50)

2. Succinylcholine 1.5 mg/kg (n = 50)

Premedication: glycopyrrolate 0.004 mg/kg iv, ranitidine 50 mg iv, tramadol 1mg/kg iv, midazolam 0.015 mg/kg iv

Sequence with thiopental

Outcomes

1. Onset time of neuromuscular blockade

2. Intubation conditions reported as excellent, good, fair and poor. Scores were based on jaw relaxation, vocal cord motion and response to intubation

3. Haemodynamics

4. Complications at time of intubation

Adverse events

Both groups demonstrated an increase in blood pressure, heart rate, arrhythmias and laryngospasm. No significant difference between the two groups.

Time & Place

Study dates not reported.

Government Medical College, Bhavnagar, Gujarat, India

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"sealed envelope"

Allocation concealment (selection bias)

Low risk

"opening sealed envelope"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No mention of blinding to fasciculations

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Complete data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Tryba 1994

Methods

RCT
Simulated RSI
N = 80

Participants

ASA I ‐ III
Adult participants
Elective OR
Mean age 31.7
Mean weight 74.5 kg

Interventions

1. Rocuronium 0.6 mg/kg prior to induction agent (n = 20)
2. Rocuronium 0.6 mg/kg following induction agent (true RSI) (n = 20)
3. Rocuronium 0.56 mg/kg prior to induction agent after rocuronium primer 0.04 mg/kg (n = 20)
4. Succinylcholine 1.5 mg/kg (with rocuronium primer 0.04 mg/kg) (n = 20)
Premedication: lormethazepam 2 ‐ 3 mg po and clorazepate 0.4 mg/kg po

Sequence with: fentanyl 2 mcg/kg, thiopental 6 mg/kg

Outcomes

1. Intubating conditions 30s after 3rd dose of muscle relaxant. Reported as scores according to scoring system of Damaoal et al and modified by Krieg et al. Factors evaluated include laryngoscopy, severity of coughing and movement of vocal cords

Adverse events

1 case of severe coughing in Group 1 and 5 in Group 2.

Time & Place

Study dates not reported.

University Hospital Bergmannsheil, Bochum, Germany

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

ITT analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"Prospective randomized double blind"

Allocation concealment (selection bias)

Low risk

"The investigator preparing the syringes was not involved with the induction"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No blinding of fasciculations

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Complete data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Turan 1999

Methods

RCT
Modified RSI
N = 40

Participants

Uncertain ASA
Adult participants
Uncertain type of OR
Mean age 36.3 years
Mean weight 74.5 kg

Interventions

1. Rocuronium 1.2 mg/kg (n = 20)
2. Succinylcholine 1.0 mg/kg (n = 20)
Sequence with: thiopentone 6 mg/kg

Outcomes

1. Intubation conditions 45s after muscle relaxant reported as excellent, good, poor and inadequate. Evaluated based on Magorian et all and Dubois et all based on jaw relaxation, vocal cords and diaphragm movement
2. SBP

Adverse events

None reported

Time & Place

Study dates not reported.

Turkey

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

ITT analysis

In Turkish

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"divided into two groups randomly"

Allocation concealment (selection bias)

High risk

No comment

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No comment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Türkmen 2004

Methods

RCT

Modified RSI

Adult elective surgery

N = 60

Participants

ASA I ‐ II

Age 19 ‐ 73 years

(Baseline demographics table unavailable)

Interventions

1. Mivacurium 0.25 mg/kg (n = 20)*

2. Rocuronium 0.6 mg/kg (n = 20)

3. Succinylcholine 1 mg/kg (n = 20)

Premedication: Midazolam 10 mg im

Sequence with: fentanyl 2 mg/kg, propofol 2 mg/kg

Outcomes

1. Intubation conditions after full relaxation as measured by TOF monitoring. Reported as excellent, good and bad

2. Haemodaynamics

Adverse events

None reported.

Time & Place

Study dates not reported.

Istanbul Hospital, Istanbul, Turkey

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

In Turksih

Only data for excellent intubation conditions were available (paper missing tables)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"randomized'"

Allocation concealment (selection bias)

Low risk

"intubation was performed by an anesthesiologist who do not know muscle relaxant used"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No comment made

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Tables unavailable

Vinik 1999

Methods

RCT
Modified RSI
N = 45

Participants

ASA I ‐ III
18 ‐ 65 years
Elective OR for eye surgery
Mean age 41.4
Mean weight 74.5 kg

Interventions

1. Rocuronium 0.6 mg/kg (n = 15)
2. Succinylcholine 1 ‐ 1.5 mg/kg (n = 15)
3. Atracurium 0.5 mg/kg (n = 15)*
Sequence with: alfentanyl 0.025 mg/kg, propofol 1.5 mg/kg, midazolam 0.025 mg/kg

Outcomes

1. Intraocular pressure
2. Intubating conditions 60s after muscle relaxant administration. Reported as excellent, good, poor and inadequate based on jaw relaxation, vocal cord movement and diaphragm movement

Adverse events

None reported.

Time & Place

Study dates not reported. Article accepted December 1998

Eye Foundation Hospital, Birmingham, USA

Funding and declarations

Funding source: supported by a grant from Organon, Inc. West Orange NJ.

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

"Randomized"

Allocation concealment (selection bias)

High risk

"Open‐label"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No attempt at blinding made

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Weiss 1997

Methods

RCT
Simulated RSI
N = 45

Participants

ASA I ‐ II
18 ‐ 65 years
Elective OR
Mean age 36.7
Mean weight 73.2 kg

Interventions

1. Rocuronium 0.7 mg/kg (n = 15)
2. Rocuronium 0.9 mg/kg (n = 16)
3. Succinylcholine 1.5 mg/kg (n = 14)
Sequence with: fentanyl 2 mcg/kg, thiopental 4 ‐ 5 mg/kg

Outcomes

1. Intubating conditions 60s after muscle relaxation. Reported as excellent, good, poor or impossible based on ease of laryngoscopy, vocal cords and response to intubation

Adverse events

None reported.

Time & Place

Study dates not reported. Accepted March 1997.

Robert Wood Johnson Medical School at Camden, Camden, USA

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"patients were randomly assigned, via computer‐generated random numbers table"

Allocation concealment (selection bias)

Low risk

"Both the patient and the anesthesiologist intubating the patient were blinded to the muscle relaxant used"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"anesthesiologist performing the intubation was out of the OR during the induction to avoid witnessing the fasciculations from succinylcholine."

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data

Selective reporting (reporting bias)

Low risk

All outcomes reported

Yorukoglu 2003

Methods

RCT
Modified RSI
N = 125

Participants

ASA I ‐ II
Adult
elective OR

Excluded expected difficult intubations

Interventions

1. Succinylcholine 1 mg/kg intubated 60s(n = 25)

2. Rocuronium 0.6 mg/kg intubated 60s (n = 25)

3. Rocuronium 0.6 mg/kg intubated 60s with lidocaine 1.5mg/kg (n = 25)*

4. Rocuronium 0.6 mg/kg intubated 90s (n = 25)*

5. Rocuronium 0.6 mg/kg intubated 90s with lidocaine 1.5mg/kg (n = 25)*

Premedication: atropine 0.5 mg/kg, pethidine 50 mg im

Sequence with: alfentanyl 10 mcg/kg, propofol 2 mg/kg

Outcomes

1. Intubating conditions 60 or 90s after end of muscle relaxant injection. Reported as excellent, good, poor and inadequate as per Goldberg et al, based on vocal cords and coughing
2. Haemodynamic changes

Adverse events

None reported

Time & Place

Study dates not reported. Article accepted November 2002

University of Ankara, Ankara, Turkey

Funding and declarations

Funding source: none declared

Declarations of interest: none declared

Notes

Efficacy analysis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Patients were randomly allocated into five groups using a computer‐generated table of random numbers"

Allocation concealment (selection bias)

Low risk

"patients and the intubating anesthetist were blinded to the study solutions administered"

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participant asleep and personnel performance does not affect intubating conditions

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

60 or 90secs after the end of the muscle relaxant injection, the intubating anaesthesist was called to enter the study room and the intubating anaesthesist was instructed by an assistant to start laryngoscopy

Incomplete outcome data (attrition bias)
All outcomes

Low risk

125 participants were enrolled and all completed the study

Selective reporting (reporting bias)

Low risk

All outcomes reported

* Not used in analysis
ASA status: American Society of Anesthesia score I ‐ IV, determined by health (decreased health as score increases)
BMI: Body mass index, kg/m²
EMG: electromyogram
i.m: intramuscular
IOP: Intraocular pressure
ITT: Intention‐to‐treat
iv: intravenous
N: number
OR: operating room
po: per os
R: rocuronium
RAE: name of endotracheal tube
RCT: randomized controlled trial
RSI: rapid sequence induction
S: succinylcholine
s: seconds
SBP: systolic blood pressure
T₁: first twitch of train of four
TOF: train‐of‐four

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Dobson 1999

Only looked at rocuronium with propofol versus rocuronium with thiopental without comparing to succinylcholine

Dubois 1992

No comparison with succinylcholine

Hemmerling 2000

No outcome of intubation conditions

Huizinga 1992

The control group used not only succinylcholine but also gallamine in the sequence which cannot be controlled for when combining studies

Lam 1997

Abstract data only. Unclear what intubation scores were based on results given

Martin 1998

No comparison of single intubating dose of rocuronium versus succinylcholine. Study looks at priming dose of non‐depolarizing muscle relaxants with succinylcholine only

Misiolek 2009

Used double lumen tubes

Naguib 1994b

No comparison with succinylcholine

Ortiz‐Gómez 2005

RCT but intubation condition data is presented in graphic form only and cannot be reliably extracted

Robertson 2004

No outcome of intubation conditions

Stourac 2013

Conference abstract only, no data could be abstracted

Vianna 1997

Does not document intubation scores in paper

Vincent 1996

Abstract only. Unable to obtain document from North American source. Will reconsider if able to obtain in future

Woolf 1997

Did not record intubating conditions, measures other parameters only

RCT = randomized controlled trial
RSI: rapid sequence intubation

Data and analyses

Open in table viewer
Comparison 1. Rocuronium any dose versus succinylcholine

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4151

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.81, 0.92]

Analysis 1.1

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.

1.1 Simulated RSI

23

2535

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.72, 0.89]

1.2 Modified RSI

25

1468

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.85, 0.99]

1.3 Mixed simulated and modified RSI

2

148

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.33, 1.08]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

3992

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

Analysis 1.2

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Simulated RSI

22

2416

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.90, 0.98]

2.2 Modified RSI

24

1428

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.99, 1.01]

2.3 Mixed simulated and modified RSI

2

148

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.66, 1.01]

Open in table viewer
Comparison 2. Rocuronium specific dose versus succinylcholine

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4352

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.81, 0.92]

Analysis 2.1

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.

1.1 Rocuronium 0.6 ‐ 0.7mg/kg

39

2808

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.72, 0.88]

1.2 Rocuronium 0.9 ‐ 1.0mg/kg

16

1458

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.89, 1.00]

1.3 Rocuronium 1.2 mg/kg

3

86

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.75, 1.15]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

4193

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.96, 0.99]

Analysis 2.2

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Rocuronium 0.6 ‐ 0.7mg/kg

38

2768

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.93, 0.99]

2.2 Rocuronium 0.9 ‐ 1.0mg/kg

15

1339

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.98, 1.01]

2.3 Rocuronium 1.2 mg/kg

3

86

Risk Ratio (M‐H, Random, 95% CI)

1.0 [0.92, 1.08]

Open in table viewer
Comparison 3. Rocuronium versus succinylcholine for induction agent

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

49

3750

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.80, 0.91]

Analysis 3.1

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 1 Excellent versus other intubation conditions.

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 1 Excellent versus other intubation conditions.

1.1 Propofol

22

1448

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.84, 1.01]

1.2 Thiopental

28

2302

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.73, 0.88]

2 Acceptable versus suboptimal intubation conditions Show forest plot

47

3591

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 1.00]

Analysis 3.2

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Propofol

21

1408

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.97, 1.01]

2.2 Thiopental

27

2183

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.92, 0.99]

Open in table viewer
Comparison 4. Rocuronium versus succinylcholine with narcotic

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation outcomes Show forest plot

34

2292

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.78, 0.93]

Analysis 4.1

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 1 Excellent versus other intubation outcomes.

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 1 Excellent versus other intubation outcomes.

1.1 Propofol Induction

17

992

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.78, 1.01]

1.2 Thiopental Induction

17

1300

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.73, 0.92]

2 Acceptable versus suboptimal intubation conditions Show forest plot

32

2193

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.94, 1.00]

Analysis 4.2

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Propofol Induction

16

952

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.96, 1.02]

2.2 Thiopental Induction

16

1241

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.90, 1.00]

Open in table viewer
Comparison 5. Rocuronium versus succinylcholine without narcotic

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

15

1428

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.76, 0.95]

Analysis 5.1

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 1 Excellent versus other intubation conditions.

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 1 Excellent versus other intubation conditions.

1.1 Propofol Induction

4

426

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.85, 1.06]

1.2 Thiopental Induction

12

1002

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.69, 0.94]

2 Acceptable versus suboptimal intubation conditions Show forest plot

14

1368

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.95, 1.01]

Analysis 5.2

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Propofol Induction

4

426

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.94, 1.02]

2.2 Thiopental Induction

11

942

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.94, 1.02]

Open in table viewer
Comparison 6. Comparison of children and adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4151

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.80, 0.91]

Analysis 6.1

Comparison 6 Comparison of children and adults, Outcome 1 Excellent versus other intubation conditions.

Comparison 6 Comparison of children and adults, Outcome 1 Excellent versus other intubation conditions.

1.1 Adults

45

3615

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.80, 0.92]

1.2 Children

5

536

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.70, 1.06]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

3992

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

Analysis 6.2

Comparison 6 Comparison of children and adults, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 6 Comparison of children and adults, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Adults

43

3456

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

2.2 Children

5

536

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.97, 1.02]

Open in table viewer
Comparison 7. Rocuronium versus succinylcholine in emergency intubation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

5

1073

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.73, 0.98]

Analysis 7.1

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 1 Excellent versus other intubation conditions.

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 1 Excellent versus other intubation conditions.

2 Acceptable versus suboptimal intubation conditions Show forest plot

5

1073

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.96, 1.01]

Analysis 7.2

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 2 Acceptable versus suboptimal intubation conditions.

Open in table viewer
Comparison 8. Rocuronium versus succinylcholine by blinding of outcome assessment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4151

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.81, 0.92]

Analysis 8.1

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 1 Excellent versus other intubation conditions.

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 1 Excellent versus other intubation conditions.

1.1 Low Risk

21

1880

Risk Ratio (M‐H, Random, 95% CI)

0.83 [0.75, 0.92]

1.2 Unclear Risk

4

229

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.72, 1.18]

1.3 High Risk

25

2042

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.80, 0.96]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

3992

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

Analysis 8.2

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 2 Acceptable versus suboptimal intubation conditions.

2.1 Low Risk

23

1970

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.94, 1.00]

2.2 Unclear Risk

3

110

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.92, 1.07]

2.3 High Risk

22

1912

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.94, 1.00]

Search flow diagram for this update from July 2007 to February 2015
Figuras y tablas -
Figure 1

Search flow diagram for this update from July 2007 to February 2015

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

Risk of bias summary: review authors' judgements about each risk of bias item for each included trial
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included trial

Funnel plot of comparison: Rocuronium any dose versus succinylcholine, outcome: Excellent versus other intubation conditions.
Figuras y tablas -
Figure 4

Funnel plot of comparison: Rocuronium any dose versus succinylcholine, outcome: Excellent versus other intubation conditions.

Forest plot of comparison: 1 Rocuronium any dose versus succinylcholine, outcome: 1.1 Excellent versus other intubation conditions
Figuras y tablas -
Figure 5

Forest plot of comparison: 1 Rocuronium any dose versus succinylcholine, outcome: 1.1 Excellent versus other intubation conditions

Forest plot of comparison: 3 Rocuronium versus succinylcholine for induction agent, outcome: 3.1 Excellent versus other intubation conditions
Figuras y tablas -
Figure 6

Forest plot of comparison: 3 Rocuronium versus succinylcholine for induction agent, outcome: 3.1 Excellent versus other intubation conditions

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 1.1

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 1.2

Comparison 1 Rocuronium any dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 2.1

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 1 Excellent versus other intubation conditions.

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 2.2

Comparison 2 Rocuronium specific dose versus succinylcholine, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 3.1

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 1 Excellent versus other intubation conditions.

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 3.2

Comparison 3 Rocuronium versus succinylcholine for induction agent, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 1 Excellent versus other intubation outcomes.
Figuras y tablas -
Analysis 4.1

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 1 Excellent versus other intubation outcomes.

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 4.2

Comparison 4 Rocuronium versus succinylcholine with narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 5.1

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 1 Excellent versus other intubation conditions.

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 5.2

Comparison 5 Rocuronium versus succinylcholine without narcotic, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 6 Comparison of children and adults, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 6.1

Comparison 6 Comparison of children and adults, Outcome 1 Excellent versus other intubation conditions.

Comparison 6 Comparison of children and adults, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 6.2

Comparison 6 Comparison of children and adults, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 7.1

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 1 Excellent versus other intubation conditions.

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 7.2

Comparison 7 Rocuronium versus succinylcholine in emergency intubation, Outcome 2 Acceptable versus suboptimal intubation conditions.

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 1 Excellent versus other intubation conditions.
Figuras y tablas -
Analysis 8.1

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 1 Excellent versus other intubation conditions.

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 2 Acceptable versus suboptimal intubation conditions.
Figuras y tablas -
Analysis 8.2

Comparison 8 Rocuronium versus succinylcholine by blinding of outcome assessment, Outcome 2 Acceptable versus suboptimal intubation conditions.

Summary of findings for the main comparison. Rocuronium any dose versus succinylcholine for rapid sequence induction intubation

Rocuronium any dose versus succinylcholine for rapid sequence induction intubation

Patient or population: People requiring rapid sequence induction intubation
Settings: Elective Operating Room, Emergency Room or Intensive Care Unit
Intervention: Rocuronium, any dose
Comparison: Succinylcholine

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk1

Corresponding risk

Succinylcholine

Rocuronium any dose 2

Excellent versus other intubation conditions

Study population

RR 0.86
(0.81 to 0.92)

4151
(50 RCTs)

⊕⊕⊕⊝
MODERATE ,

Risk of bias: 50% of the studies were at high risk for detection bias because the outcome assessor was not blinded to the fasciculations caused by succinylcholine.

Inconsistency: High statistical heterogeneity in the studies could not be explained by subgroup analyses. However we did not downgrade because exclusion of trials contributing to heterogeneity did not significantly change the direction or size of effect.

76 per 100

65 per 100
(61 to 69)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: risk ratio; RCT: randomized controlled trial

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Assumed risk is the average number of excellent intubations with succinylcholine.

2Rocuronium minimum dose 0.6 mg/kg. Succinylcholine minimal dose is 1mg/kg.

Figuras y tablas -
Summary of findings for the main comparison. Rocuronium any dose versus succinylcholine for rapid sequence induction intubation
Table 1. Intubating conditions

Score

Ease of laryngoscopy

Vocal cords

Intubation response

1. Excellent

Good

Open

None

2. Good

Fair

Open

Diaphragmatic movement

3. Poor

Difficult

Movement

Moderate coughing

4. Impossible

Poor

Closed

Severe coughing or bucking

Figuras y tablas -
Table 1. Intubating conditions
Comparison 1. Rocuronium any dose versus succinylcholine

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4151

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.81, 0.92]

1.1 Simulated RSI

23

2535

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.72, 0.89]

1.2 Modified RSI

25

1468

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.85, 0.99]

1.3 Mixed simulated and modified RSI

2

148

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.33, 1.08]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

3992

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

2.1 Simulated RSI

22

2416

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.90, 0.98]

2.2 Modified RSI

24

1428

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.99, 1.01]

2.3 Mixed simulated and modified RSI

2

148

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.66, 1.01]

Figuras y tablas -
Comparison 1. Rocuronium any dose versus succinylcholine
Comparison 2. Rocuronium specific dose versus succinylcholine

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4352

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.81, 0.92]

1.1 Rocuronium 0.6 ‐ 0.7mg/kg

39

2808

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.72, 0.88]

1.2 Rocuronium 0.9 ‐ 1.0mg/kg

16

1458

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.89, 1.00]

1.3 Rocuronium 1.2 mg/kg

3

86

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.75, 1.15]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

4193

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.96, 0.99]

2.1 Rocuronium 0.6 ‐ 0.7mg/kg

38

2768

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.93, 0.99]

2.2 Rocuronium 0.9 ‐ 1.0mg/kg

15

1339

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.98, 1.01]

2.3 Rocuronium 1.2 mg/kg

3

86

Risk Ratio (M‐H, Random, 95% CI)

1.0 [0.92, 1.08]

Figuras y tablas -
Comparison 2. Rocuronium specific dose versus succinylcholine
Comparison 3. Rocuronium versus succinylcholine for induction agent

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

49

3750

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.80, 0.91]

1.1 Propofol

22

1448

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.84, 1.01]

1.2 Thiopental

28

2302

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.73, 0.88]

2 Acceptable versus suboptimal intubation conditions Show forest plot

47

3591

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 1.00]

2.1 Propofol

21

1408

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.97, 1.01]

2.2 Thiopental

27

2183

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.92, 0.99]

Figuras y tablas -
Comparison 3. Rocuronium versus succinylcholine for induction agent
Comparison 4. Rocuronium versus succinylcholine with narcotic

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation outcomes Show forest plot

34

2292

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.78, 0.93]

1.1 Propofol Induction

17

992

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.78, 1.01]

1.2 Thiopental Induction

17

1300

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.73, 0.92]

2 Acceptable versus suboptimal intubation conditions Show forest plot

32

2193

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.94, 1.00]

2.1 Propofol Induction

16

952

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.96, 1.02]

2.2 Thiopental Induction

16

1241

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.90, 1.00]

Figuras y tablas -
Comparison 4. Rocuronium versus succinylcholine with narcotic
Comparison 5. Rocuronium versus succinylcholine without narcotic

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

15

1428

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.76, 0.95]

1.1 Propofol Induction

4

426

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.85, 1.06]

1.2 Thiopental Induction

12

1002

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.69, 0.94]

2 Acceptable versus suboptimal intubation conditions Show forest plot

14

1368

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.95, 1.01]

2.1 Propofol Induction

4

426

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.94, 1.02]

2.2 Thiopental Induction

11

942

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.94, 1.02]

Figuras y tablas -
Comparison 5. Rocuronium versus succinylcholine without narcotic
Comparison 6. Comparison of children and adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4151

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.80, 0.91]

1.1 Adults

45

3615

Risk Ratio (M‐H, Random, 95% CI)

0.85 [0.80, 0.92]

1.2 Children

5

536

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.70, 1.06]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

3992

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

2.1 Adults

43

3456

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

2.2 Children

5

536

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.97, 1.02]

Figuras y tablas -
Comparison 6. Comparison of children and adults
Comparison 7. Rocuronium versus succinylcholine in emergency intubation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

5

1073

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.73, 0.98]

2 Acceptable versus suboptimal intubation conditions Show forest plot

5

1073

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.96, 1.01]

Figuras y tablas -
Comparison 7. Rocuronium versus succinylcholine in emergency intubation
Comparison 8. Rocuronium versus succinylcholine by blinding of outcome assessment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Excellent versus other intubation conditions Show forest plot

50

4151

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.81, 0.92]

1.1 Low Risk

21

1880

Risk Ratio (M‐H, Random, 95% CI)

0.83 [0.75, 0.92]

1.2 Unclear Risk

4

229

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.72, 1.18]

1.3 High Risk

25

2042

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.80, 0.96]

2 Acceptable versus suboptimal intubation conditions Show forest plot

48

3992

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.95, 0.99]

2.1 Low Risk

23

1970

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.94, 1.00]

2.2 Unclear Risk

3

110

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.92, 1.07]

2.3 High Risk

22

1912

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.94, 1.00]

Figuras y tablas -
Comparison 8. Rocuronium versus succinylcholine by blinding of outcome assessment