studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital. Whether this is due to MOI or something else "not fully understood". I will intubate someone if it becomes necessary, RSI or otherwise. If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.
Would you mind posting these studies? It's a bit of a meaningless statement without some context.
RSI is not necessarily just about airway control, there are many aspects of different patient presentations that may be managed with appropriate sedation and paralysis.
As for the OP's question: it comes down to what the MD is happy with you doing. In the setting of emergent cases where RSI is considered, it typically comes down to an argument between suxamethonium or rocuronium (other stuff like cisatracurium and what not aren't very common, vecuronium... meh) So really, it's either depolarising or non-depolarising.
Proponents of depolarising will cite suxamethonium's short duration of action as a good reason to use it: if you can't intubate it wears off quickly and the patient can breath again. On the downside there are a number of potential problems: hyperkalemia in some settings, raised intra-ocular pressure (although this may not be clinically significant) and so on.
On the other hand, rocuronium takes
slightly longer than sux to have an effect (although this may not be clinically significant either), but takes longer to wear off, leaving you with a non-ventilating patient. However, there are not the same concerns with the side effects like there are with sux.
BUT! While sux may wear off quickly, even healthy people will most likely still desaturate without ventilations being provided (1,2,3), so maybe the "short duration" argument is moot. Of course on the flip side, neuromuscular blockade may actually make bag-mask ventilation easier (4). Of course this is fine in your fasted patient, it may be sub-optimal in the typical "full of beer and pizza" patient we see. I'm keen to try the no desat method put forward by Dr Rich Levitan to see how well that works, it seems compelling and may remove this problem.
Rocuronium on the other hand
may actually provide an increased amount of time to achieve intubation before desaturation occurs, possibly due to the lack of fasciculations with it's use (5). However, how well this translates to the critically ill patient is unclear, as this study was in elective patients.
Sooooo..... where does this leave you? Beats me, all I have is sux for initial paralysis to achieve intubation, pancuronium for ongoing paralysis! To be fair I don't have too much of a problem with sux. I think the "can't ventilate" scenario should be a relatively rare beast anyway, especially if you are judicious about who you decide to give drugs to. A lot of the problems with sux are kind of irrelevant or at least not clinically significant.
However, if I HAD to pick ONE agent, it would be rocuronium which if nothing else is versatile.
There, glad I cleared that up for you! :wacko: :unsure:
1. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine.
Anesthesiology. 1997 Oct;87(4):979-8
2. Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.
Anesthesiology. 2001 May;94(5):754-9
3. Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients
Anesthesiology. 2005 Jan;102(1):35-40
4. The effect of neuromuscular blockade on mask ventilation
Anaesthesia. 2011 Mar;66(3):163-7
5. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction
Anaesthesia. 2010 Apr;65(4):358-61
.
