Sux is still widely considered the gold standard for emergent intubation. That being said, a lot of people will use roc because of perceived dangers of using sux. Some think high-dose roc is just as fast as sux - it's not - which is why sux is still around.
I was taught primarily with Vec. so that what I like.
If I had to estimate, panc. and vec. are the 2 most common selected here outside of neuro, where roc is used almost exclusively.
Sugammadex may be a game changer but it will have to be in widespread use before that happens (Vene, you have it available already?).
I live in Contental Europe, it has been here at least 3 years. But in a major academic medical center, with every surgical discipline including transplant, and easily a total of 100 beds of various ICU, I have never even heard of it being used in my time here.
The EMS service in this city is physician based, mostly orthopods, and I will ask, but I doubt that EMS here even has sugammadex on the truck. (or neostigmine for that matter) The orthopods I know are deathly afraid to RSI or use conscious sedation without an anesthesiologist. Which in the local system, even with the drugs only raises the price of a procedure about $50-75 USD so calling anesthesia is not a big deal.
I doubt very much it will ever be a "game changer" even though it works with all of our most common blocks, that sounds like marketing.
The need for a reversal agent here is considered an error and will automatically trigger a review of the case. (which may go nowhere, but it will still be reviewed)
In order for this to be a game changer, it would have to be cheaper than it is now, and it would also have to be used far more frequently. Both of which are unlikely.
I think we can agree that if you are constantly using reversal agents, something is definately wrong with what is going on.
I know I hate using whopping doses of roc for RSI for short procedures, because it takes time for roc to wear off enough to that it's reversible with glyco/neostig. Try and reverse it too early and you dig yourself a deeper hole. Sugammadex will change that. Price will determine how popular it becomes. They could sell the hell out of it at a reasonable price point, but if it's too high, it will sit largely unused, kinda like flumazenil.
I thought flumazenil was unused because of its side effect profile? Even with easy access to thiopental, it is viewed here as a very last resort.
The whole reason I am curious is because, while it does sound very impressive, it just looks like one of those things that is going to have a hard time living up to the hype that precedes it. I frequently hear the term "game-changer" used to describe it, and some people speak of it the same way they do the second coming of Christ.
It looks to be a better agent (like I said, never seen it used) than neostigmine, but "game changer" is definately overgenerous in my opinion. I think choosing an agent based on ease of reversal is not something anyone should be considering. The agent should be chosen based on the need of the patient and the procedure to be performed.
Even in EMS, if you choose to RSI, you have a reason, in the event of failure of the procedure, that reason doesn't go away and will still have to be managed.
If you are using it for the "can't intubate, can't ventilate," let us consider how often the later comes into being, especially by skilled providers?
In both of your experiences, how many times have you had a difficult tube you could not get
and couldn't effectively ventilate? (I am thinking you could probably count them on one hand and jwk has done this many more years than I have)
I guess we'll just have to hope it's approved this year and see how it works out.
It hasn't changed anything here.
That is why succinylcholine is still also commonly used and also why suggamadex is potentially such a big deal.
I do not agree with the reasoning behind prehospital use of Sucs. It was selected because it assumes failure. In my opinion being prepaired for failure is one thing, planning to fail and basing your whole procedure around that means you shouldn't be doing whatever you are doing, airway related or not.
