Roc my world!

[SandpitMedic]

I'll just leave this here.

http://www.emdocs.net/roc-rocks-sux-sucks-rocuronium-agent-choice-rsi/

 

[MonkeyArrow]

While I agree with most of his points, I think we again come to the argument between elective vs. necessary intubations. I think we had a thread on this a while back arguing about the finer points of it and speaking as to if we actually do elective intubations in the field (or if we should), thus answering the question whether sux should still be used.

 

[NomadicMedic]

During a sux shortage a few years back, we had Roc as the RSI paralytic. I didn't notice much of a difference in time of onset or effect. Admittedly, I had only a handful of RSI in that time, but the safety profile of Roc vs Sux seemed like a positive in my limited experience.

 

[Carlos Danger]

The roc. vs. sux for RSI debate has being going on around the FOAMed world for a while now. I think it's a mildly interesting debate on an academic level. In the real world though, it all comes down to personal preference, because either drug can be used safely and effectively in 99% of intubations.

I do think there is a little inconsistency if not intellectual dishonesty in this article. In point 2, the author argues that 20 seconds faster desat with sux is important because it represents the loss of "a lot of extra safe apneic time". Not only does he leave out that the same study showed that fasciculations and resulting faster desaturation are easily mitigated (and I would argue that having to stop and mask at 2 minutes and 10 seconds vs. 2 minutes and 30 seconds is not clinically significant if you are having trouble with an airway), but back in the third paragraph of the article, he dismisses the time to onset advantage that sux has, as the two drugs being "virtually equivalent". Well, if by "virtually equivalent" you mean that sux is 10-20 seconds faster according to most studies (and my own experience), then I guess they are "equivalent". So which is it: is 20 seconds a "lot of time", or not?

I'm not against using roc for RSI - personally, I'm fine using either drug (or vec, or cis) 99% of the time. Sux is a little faster and gives a denser, more reliable block. But that is rarely a factor.

On the whole, I think the pro-roc people exaggerate the advantages that roc has over sux, and they completely dismiss the potential advantage that exists with having the option to let the patient regain spontaneous respiration. Not every intubation in the ED is a crash scenario where the patient's life depends on them being intubated immediately.

 

[DWR]

I agree that's it's personal preference. I have no problem with either medication. I've also only used roc a handful of times compared to the many times I've used sux. Personally I like like sux purely because it does act fast. In the land of RSI 20 seconds can be a long time. If I RSI someone it's usually always in less a then optimal environment and I wants things to move along in a "expeditious" manner. Unlike the physicians I work with who usually use roc for RSI but they aren't in a room belonging to a border, back of a moving ambulance and so on. I've also been pretty lucky to have some pretty uncomplicated RSI cases. When I run into that renal failure patient I need to drop and tube then I might develop a little more of an opinion between the two.

 

[Nova1300]

I agree that's it's personal preference. I have no problem with either medication. I've also only used roc a handful of times compared to the many times I've used sux. Personally I like like sux purely because it does act fast. In the land of RSI 20 seconds can be a long time. If I RSI someone it's usually always in less a then optimal environment and I wants things to move along in a "expeditious" manner. Unlike the physicians I work with who usually use roc for RSI but they aren't in a room belonging to a border, back of a moving ambulance and so on. I've also been pretty lucky to have some pretty uncomplicated RSI cases. When I run into that renal failure patient I need to drop and tube then I might develop a little more of an opinion between the two.

Let's talk about this renal failure thing. Are your medical directors ok with using sux in those patients?

 

[chaz90]

Let's talk about this renal failure thing. Are your medical directors ok with using sux in those patients?

I've done a little bit of research on the topic, and it seems like there's still a bit of disagreement on whether sux should be relatively or absolutely contraindicated in these patients. Obviously if alternatives are available, they should be strongly considered.

Firstly, how much truth is there to reports that transient succinylcholine induced hyperkalemia is more of an issue in patients suffering from acute renal failure vs. chronic? My understanding is that adaptive mechanisms in the chronic renal failure population and increased fecal excretion of K+ should allow for increased tolerance of the ~0.5-1.0 meq K+ increase assuming they had a well controlled serum potassium level pre-treatment with sux. That's the scary part to me though. We don't have lab values available prior to intubating these patients or iSTATs, so a shot in the dark as to our best guess on serum potassium levels doesn't exactly give me warm fuzzies...Perhaps I should hope that if I intubate a renal failure patient I pick them up at their dialysis center and they hand me lab results from 15 minutes before right as I walk in.

I've discussed this a little bit with our medical director. In cases of RSI being indicated during suspected hyperkalemia or renal failure, we'd be consulting pretty heavily with med control. We only carry etomidate, Versed, sux, vecorunium, and fentanyl. In my eyes, if we're going to proceed with intubation in these cases, this leaves us the options of either medication assisted intubation without use of paralytics (really not my first choice), or using vec as the pre-intubation paralytic.

Is there any value in pre-treating these patients with calcium chloride prior to administering etomidate and sux in an effort to protect against the harmful cardiac effects of hyper K?

 

[SandpitMedic]

Why not just use the Etomidate for induction and Versed for sedation? (Provided the VS are able to tolerate and you're able to fluid bolus in case of a drop). Withhold paralytic agents on a suspected or known renal failure patient - since you don't have Roc, maybe?

 

[Carlos Danger]

Large doses of etomidate alone can be a messy proposition, with myoclonus and hypotension and all that.

 

[medicsb]

I've discussed this a little bit with our medical director. In cases of RSI being indicated during suspected hyperkalemia or renal failure, we'd be consulting pretty heavily with med control. We only carry etomidate, Versed, sux, vecorunium, and fentanyl. In my eyes, if we're going to proceed with intubation in these cases, this leaves us the options of either medication assisted intubation without use of paralytics (really not my first choice), or using vec as the pre-intubation paralytic.

Is there any value in pre-treating these patients with calcium chloride prior to administering etomidate and sux in an effort to protect against the harmful cardiac effects of hyper K?

Just use vec as the paralytic. You can go up to 0.3mg/kg for more rapid onset, but of course it will last much longer than the typical 0.1mg/kg dose.

Would not do succs at all in dialysis patients. Too risky, even if pre-treating with calcium (no idea if it would actually work, but it's a good thought).

 

[Carlos Danger]

Just use vec as the paralytic. You can go up to 0.3mg/kg for more rapid onset, but of course it will last much longer than the typical 0.1mg/kg dose.

Why vec instead of roc?

As an anesthetist, I prefer vec all day long. It's just a better drug all around, though it's advantages over roc aren't pertinent to emergency airway management.

As a paramedic, whose primary concerns are the fastest possible onset and ease of administration (the fact that roc doesn't need reconstitution is not an insignificant factor), I'd definitely prefer roc over vec.

When I was in school, I had this grumpy, crusty old CRNA teach me how to use propofol and just a standard (50mg) - but divided - dose of roc to get intubating conditions very nearly as fast as sux. Works great when you need to RSI a patient for an elective case that isn't going to take that long, but you want to avoid sux for whatever reason. I have yet to try it with vec, but I think it should work about the same.

 

[medicsb]

Why vec instead of roc?

Because chaz90's EMS system does not carry roc.

 

[Clare]

As an anesthetist, I prefer vec all day long. It's just a better drug all around, though it's advantages over roc aren't pertinent to emergency airway management.

As a paramedic, whose primary concerns are the fastest possible onset and ease of administration (the fact that roc doesn't need reconstitution is not an insignificant factor), I'd definitely prefer roc over vec.

I am assuming because you refer to yourself as an "anaesthetist" you are a consultant not a registrar, so, would it be fair to say that at no point during your vocational training in anaesthesia nor post-graduate exams (whatever the FANZCA equivalent is where you are) did you say that your primary concern is how fast a drug works and how easy it is to administer?

What if the drug with fastest onset also carries the most risk? Does that then make it OK to give to the pt because your primary concern is how fast it will work?

 

[chaz90]

Could we elaborate a bit regarding the vec vs. roc comparison?

I'll plead a bit of ignorance here as I know very little about roc. I know when compared to vec it has a shorter onset, longer duration of action, and is more readily reversible by suggamaddex. Otherwise, I'm a little in the dark as to some of the advantages/disadvantages some previous posters have mentioned.

I recognize vec has to be reconstituted, but what are some of its advantages? To my eyes, it would seem the major reason we carry vec instead of roc is in hopes of the paralysis wearing off earlier after arrival at the hospital, which may be reasonable for our system. We only administer it (under normal circumstances) to a portion of the patients we RSI and have an extended transport time by air/ground or were grossly combative pre-intubation and still not completely compliant after intubation and sedation with Versed and fent.

 

[Handsome Robb]

I am assuming because you refer to yourself as an "anaesthetist" you are a consultant not a registrar, so, would it be fair to say that at no point during your vocational training in anaesthesia nor post-graduate exams (whatever the FANZCA equivalent is where you are) did you say that your primary concern is how fast a drug works and how easy it is to administer?

What if the drug with fastest onset also carries the most risk? Does that then make it OK to give to the pt because your primary concern is how fast it will work?

I didn't see anyone say that easy of delivery and faster onset overrule risks associated with the medication in a patient by patient basis...the way I read it was those are things to be considered in airway management in the emergent setting when time is of the essence. Emphasis on considered, not the only parameters that are looked at.

 

[Carlos Danger]

Because chaz90's EMS system does not carry roc.

It all makes sense now! Somehow I missed that what you wrote was a response to a specific post, lol.

Could we elaborate a bit regarding the vec vs. roc comparison?

I'll plead a bit of ignorance here as I know very little about roc. I know when compared to vec it has a shorter onset, longer duration of action, and is more readily reversible by suggamaddex. Otherwise, I'm a little in the dark as to some of the advantages/disadvantages some previous posters have mentioned.

I recognize vec has to be reconstituted, but what are some of its advantages? To my eyes, it would seem the major reason we carry vec instead of roc is in hopes of the paralysis wearing off earlier after arrival at the hospital, which may be reasonable for our system. We only administer it (under normal circumstances) to a portion of the patients we RSI and have an extended transport time by air/ground or were grossly combative pre-intubation and still not completely compliant after intubation and sedation with Versed and fent.

Hey Chaz, actually vec tends to last longer than roc. It's not a huge difference, though.

The advantages of vec over roc have to do with the reliability and density of the block it provides. With vec, it is easier to predict the duration of a specific dose, easier to maintain a specific block density, and easier to reverse reliably, especially at a higher block density. These can be pretty big considerations in anesthesia, but they generally aren't important for prehospital use, which is why I said I would trade vecs' predictability for roc's faster onset in the EMS setting. You certainly can RSI with vec, it just takes a little longer to get good intubating conditions. I wouldn't worry about the block lasting too long; if they really need to for some reason, they can just reverse it at the hospital.

Roc = faster on, faster off, less predictable in terms of duration and block density
Vec = a little slower to take effect, lasts a little longer, very predictable in terms of duration and block density

I am assuming because you refer to yourself as an "anaesthetist" you are a consultant not a registrar, so, would it be fair to say that at no point during your vocational training in anaesthesia nor post-graduate exams (whatever the FANZCA equivalent is where you are) did you say that your primary concern is how fast a drug works and how easy it is to administer?

What if the drug with fastest onset also carries the most risk? Does that then make it OK to give to the pt because your primary concern is how fast it will work?

Really not sure what you are getting at here, Clare? Seems like you are trying to make a point.

In the anesthesia setting, a small percentage of the airways I manage are emergent, and I often have things to think about aside from onset time. In the EMS setting however, where every intubation is (in theory, at least) in a really sick patient and airway complication rates are high, fast onset is, yes, a primary concern. The only concern? Of course not. But a major one.

 

[Clare]

In the anesthesia setting, a small percentage of the airways I manage are emergent, and I often have things to think about aside from onset time. In the EMS setting however, where every intubation is (in theory, at least) in a really sick patient and airway complication rates are high, fast onset is, yes, a primary concern. The only concern? Of course not. But a major one.

I wasn't trying to make a point, perhaps I interpreted what you wrote slightly differently to how you meant it.

I think anaesthesia is a really aligned speciality to work in the pre-hospital environment. All of our HEMS Doctors are either anaesthetists, ED or ICU consultants or occasionally a senior registrar.

 

[Carlos Danger]

I think anaesthesia is a really aligned speciality to work in the pre-hospital environment. All of our HEMS Doctors are either anaesthetists, ED or ICU consultants or occasionally a senior registrar.

I agree. With the exception of an EM physician, I think anesthesia easily translates the best to EMS. So much focus on airway management, resuscitation, pain management, and all the associated pharmacology. Unfortunately you see very few physicians in the field in the US....I've met a few CRNA's who worked part time as flight nurses; that's about the closest you get.

 

[Nova1300]

Take a look at the litterature re: hyperkalemia with sux. You will be very unimpressed. I think the fear is dogmatic and its avoidance in these scenarios is not necessary.

I use it not infrequently. I do not check the K beforehand. I would probably avoid it in a patient with known severe hyperkalemia. But I see no need to avoid it altogether in dialysis patients.

In my area of the world, the dialysis patients are usually on said dialysis because of their uncontrolled DM along with it's sequelae of morbid obesity and obstructive sleep apnea. they desaturate fast and need rapid onset of optimal intubating conditions in what may prove to be a challenging airway.

Sux is great for them!

I wish the teaching would shift to really focus on avoiding sux in denervation states, muscular dystrophy, MH. Much less emphasis on the K stuff.

We had a missed MH in our ER a few months back. They missed the MH, but damn were they sure the sux was the culprit behind that hyperkalemia.