Rocuronium versus succinylcholine for rapid sequence induction intubation

Diem TT Tran; Ethan K Newton; Victoria AH Mount; Jacques S Lee; George A Wells; Jeffrey J Perry

doi:10.1002/14651858.CD002788.pub3

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Figure 1

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

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Figure 2

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

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Figure 3

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

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Figure 4

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

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Figure 5

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

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Figure 6

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

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 3.1

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

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Analysis 3.2

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

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Analysis 4.1

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

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Analysis 4.2

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

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Analysis 5.1

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

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Analysis 5.2

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

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Analysis 6.1

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

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Analysis 6.2

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

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Analysis 7.1

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

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Analysis 7.2

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

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Analysis 8.1

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

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Analysis 8.2

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

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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.

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

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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

Table 1. Intubating conditions

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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]

Comparison 1. Rocuronium any dose versus succinylcholine

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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]

Comparison 2. Rocuronium specific dose versus succinylcholine

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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]

Comparison 3. Rocuronium versus succinylcholine for induction agent

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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]

Comparison 4. Rocuronium versus succinylcholine with narcotic

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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]

Comparison 5. Rocuronium versus succinylcholine without narcotic

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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]

Comparison 6. Comparison of children and adults

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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]

Comparison 7. Rocuronium versus succinylcholine in emergency intubation

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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]

Comparison 8. Rocuronium versus succinylcholine by blinding of outcome assessment

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