Airway Management: Use of Succinylcholine or Rocuronium Practice Considerations
Introduction
Each healthcare facility and its clinicians determine the appropriate medications required to safely manage routine, unexpected, and emergent patient anesthesia needs. With the introduction of sugammadex, healthcare facilities and anesthesia providers have the option of replacing succinylcholine with rocuronium, a non-depolarizing muscle relaxant, or keeping succinylcholine for emergency use only. In certain settings, including ambulatory surgery centers, endoscopy clinics, and office-based practices, succinylcholine may be the sole malignant hyperthermia (MH) triggering agent available on formulary. Thus, removing it can help mitigate the need for dantrolene to manage an MH crisis.
Position Statement
Anesthesia professionals should consider patient comorbidities (e.g., end-stage renal disease) and medication contraindications and alternatives during the anesthesia assessment and evaluation, the development of the plan of care, and throughout the perioperative phases of care. With a focus on patient safety, anesthetizing locations have access to medications, identified by anesthesia professionals, to address routine and emergency oxygenation, ventilation, and airway management. All clinicians and staff are aware of the location of emergency equipment, supplies, and medications.
The facility, with input from anesthesia professionals, develops policies and procedures to support the delivery safe care for the patient populations served. The facility complies with applicable federal, state, and local law and regulations, accreditation standards, and established facility policies and procedures.
When appropriate for the patient, the combination of rocuronium and sugammadex, a neuromuscular blockade reversal agent, may be an alternative to succinylcholine for emergent airway management by providing complete reversal of the neuromuscular blockade (NMB) and limiting the need for prolonged ventilation.1-5
Practice Considerations
Medication Overview
• Succinylcholine is a depolarizing neuromuscular blocking agent (NMBA) with a rapid onset and elimination for spontaneous recovery used to manage a difficult or emergent airway when return to spontaneous ventilation is desired and prolonged ventilation may not be available.
• Rocuronium bromide (rocuronium) is a nondepolarizing NMBA indicated as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.6,7 Rocuronium may be used for difficult or emergent airway management, as it is fastacting and reversible.7
• Neostigmine is an acetylcholinesterase inhibitor which allows acetylcholine to continue to stimulate the neuromuscular junction and cause muscular stimulation, thereby competing more effectively with the nondepolarizing NMBA.8
• Sugammadex provides the rapid reversal of NMB induced by rocuronium and vecuronium. Its unique mechanism of action is responsible for the rapid and efficient reversal of the deep NMB, without autonomic cholinergic side effects.9,10 Sugammadex may be the preferred reversal agent for deep, moderate, and shallow depths of NMB induced by rocuronium or vecuronium.11,12
• The combination of rocuronium and sugammadex may be an alternative to succinylcholine for NMB for airway management in many patients.2
• Providers should consider patient contraindications and alternatives to medications during the anesthesia assessment and evaluation and development of the plan of care and throughout the perioperative phases of care.
Figure 1 highlights considerations and decision points for facilities and clinicians when determining which NMBA to have available in the anesthetizing location.
Selection of Neuromuscular Blocking Agent
CAUTION
Dantrolene is required if succinylcholine is available, even if only for emergencies.
Succinylcholine
• Short duration of action
• MH triggering agent
• Can be used for treatment of laryngospasm.
Ventilation Support
• Ventilation support available.
• Plan to transport the patient is in place in case of prolonged weakness or pseudocholinesterase deficiency.
Rocuronium
• Longer dose-dependent duration of action
Ventilation Support
• Ventilation support until reversal of neuromuscular blockade.
• Plan to transport the patient is in place.
Sugammadex
• Rapid reversal of rocuronium-induced neuromuscular blockade using 16 mg/kg after administration of a single dose of 1.2 mg/kg of rocuronium.1
• Reversal approximately 3 minutes.1
Succinylcholine
Historically, succinylcholine has been the drug of choice to manage difficult and emergent airway issues in settings where sedation or anesthesia services are provided.13 Succinylcholine is currently the only rapid-onset, short-duration depolarizing NMBA that produces an intense, consistent block used for rapid intubation, emergency airway management, and treatment of airway obstruction.2,14-18 When non-pharmacologic techniques do not resolve a laryngospasm, intravenous or intramuscular succinylcholine (if intravenous access is not available) may improve ventilation or facilitate intubation of the airway.19 Succinylcholine has several contraindications, including patients with pseudocholinesterase deficiency, and can cause adverse reactions including myalgia; hyperkalemia; bradycardia and cardiac dysrhythmias; prolonged apnea; increased intraocular, intracranial, and intragastric pressure; masseter spasm; and MH crisis.2,20-22 Recovery from NMB is unpredictable after succinylcholine.2 Facility policy should include procedures for ventilation and patient transport.
Dantrolene Required for Malignant Hyperthermia Crisis
Succinylcholine and certain inhaled anesthetic agents (e.g., halothane, sevoflurane, desflurane, isoflurane) are known MH triggering agents.23-26 Approximately 55 percent of MH cases in the United States and Canada included the administration of succinylcholine, either alone or in combination with volatile anesthetics.25,27,28 Therefore, when a facility stocks MH-triggering agents, including succinylcholine, even if only for emergency airway management, dantrolene should be available and an MH-crisis protocol in place.24,29 Immediate treatment of an MH crisis, including the use of dantrolene, is essential for patient survival.24,29,30 The Malignant Hyperthermia Association of the US (MHAUS) recommends stocking a minimum of 36 vials of Dantrium®/Revonto® (20 mg/60ml) or 3 vials of Ryanodex® (250 mg/5ml).29 There is no guarantee that, even with careful health history screening, all patients at risk of MH crisis will be identified.
Rocuronium/Succinylcholine Comparison
When considering the risks and benefits of using rocuronium or succinylcholine, clinicians weigh multiple factors that include airway management, ability to ventilate and oxygenate, anaphylaxis, unanticipated difficult airway, and possible need for assisted or mechanical ventilation.31,32 A “can’t ventilate, can’t intubate” scenario may be prolonged when rocuronium is administered.33,34 Equipment for oxygenation, airway management, and mechanical ventilation should be available when NMBAs are administered.6
Rocuronium has been administered as an alternative non-depolarizing NMBA for rapid airway management, including airway obstruction for adults and pediatric populations, and when succinylcholine was contraindicated.14,21,31,35-38 Research has shown no difference in intubation conditions when comparing rocuronium and succinylcholine, and both drugs were equivalent in regards to first attempt intubation success.2,36,37 Rocuronium has a similar onset of action as succinylcholine with a dose of 1.0-1.2 mg/kg IV, but a longer, dose-dependent duration of action.22,39
Rocuronium may be an alternative to succinylcholine when a similar rapid onset is desired or a longer period of recovery from NMB is appropriate.36,40 If rocuronium is used in place of succinylcholine for intubation at doses of 1.0-1.2 mg/kg IV, airway management supplies and equipment should be available to secure the airway and provide prolonged ventilation support until the NMB is resolved.41-43 While anaphylaxis is a rare event with NMBAs, rocuronium may have a relatively higher risk compared to other agents in the drug class. When replacing
succinylcholine with rocuronium, the anaphylaxis risk of sugammadex should be considered along with the anaphylaxis risk of the muscle relaxant.2 Calculate the full reversal dose necessary to prepare and have available in the anesthetizing location.44,45
Neostigmine
Non-depolarizing NMBAs, such as rocuronium, can be reversed with neostigmine after approximately 40 percent of neuromuscular function has returned.8 Intravenous neostigmine has a peak onset of 5 minutes, a duration of action from 0.5 up to 4 hours, and an elimination half-life of 24 to 113 minutes.46,47 Neostigmine is associated with several negative cholinergic side effects such as bradycardia, hypotension, dysrhythmias, bronchospasm, and gastrointestinal upset.48,49
Neostigmine may not effectively reverse profound or long-lasting neuromuscular blockade, which is why its use for reversal is rarely indicated or useful in emergency situations.8
Sugammadex
Sugammadex has been shown to be safe and effective for rapid reversal of NMB induced by rocuronium and vecuronium in three minutes or less.3-5,33,50-55 Sugammadex provides anesthesia professionals an alternative for rocuronium-induced NMB reversal, minimizing or eliminating the need for succinylcholine for rapid airway management, intubation, and treatment of airway obstruction.33,40,44 The rocuronium-sugammadex combination may optimize surgical conditions by allowing anesthesia professionals to maintain deep NMB throughout the procedure.40,56,57 Sugammadex reversal of NMB by rocuronium has been shown to be safe and effective in pediatric populations, and similar recovery times have been noted in pediatric and adult populations from sugammadex reversal of rocuronium-induced NMB 56,58-62 The assessment of neuromuscular recovery using a NMB monitor is recommended prior to extubation.15,63
Sugammadex has been shown to be safe and effective for rapid reversal of NMB induced by rocuronium and vecuronium in three minutes or less.3-5,33,50-55 Sugammadex provides anesthesia professionals an alternative for rocuronium-induced NMB reversal, minimizing or eliminating the need for succinylcholine for rapid airway management, intubation, and treatment of airway obstruction.33,40,44 The rocuronium-sugammadex combination may optimize surgical conditions by allowing anesthesia professionals to maintain deep NMB throughout the procedure.40,56,57 Sugammadex reversal of NMB by rocuronium has been shown to be safe and effective in pediatric populations, and similar recovery times have been noted in pediatric and adult populations from sugammadex reversal of rocuronium-induced NMB.56,58-62 The assessment of neuromuscular recovery using a NMB monitor is recommended prior to extubation.15,63,64-68
While sugammadex appears well tolerated, adverse drug reactions may include nausea, vomiting, allergy, hypertension, and headache.1,47,69 In an analysis of 10 years of post-market sugammadex adverse event data, Lyu et al. found that recurrence of NMB, laryngospasm, bronchospasm and bradycardia were the most commonly reported adverse drug reactions.70 Patients should be closely monitored after sugammadex administration, especially pediatric and geriatric populations or those with cardiac and renal diseases 69-71
Reestablishment of NMB After Sugammadex Administration
Sugammadex is not metabolized and is unchanged as it’s excreted renally.1,48,72 In adult anesthetized patients with normal renal function, the elimination half-life is approximately 2 hours.1 The decision to use rapid sequence induction and intubation for reestablishing NMB depends on the clinical context and the patient's risk factors.72,73 Additional NMB may be required after a rapid sequence induction and intubation is performed.
If NMB is required after sugammadex administration, benzylisoquinolinium NMBAs (e.g., atracurium, cisatracurium, mivacurium) may be used as sugammadex does not affect NMB induced by these NMBAs.1,33,47,72 Other options may be readminstration of rocuronium or use of succinylcholine, but these options have specific clinical considerations.33,72,74-77 If rocuronium is administered soon after neuromuscular reversal with sugammadex, unbound sugammadex can bind to the administered rocuronium.72 In such a scenario, reonset time of rocuronium might be prolonged and duration of action might be shortened 72-76,78-80 If succinylcholine is administered, residual unbound nondepolarizing muscle relaxants may cause resistance to the effects of succinylcholine.72,77 See additional succinylcholine discussion above.
Sugammadex Use in End-Stage Renal Disease Patients
While sugammadex is not approved for use in patients with end-stage renal disease (ESRD), its administration in this patient population has been reported.55,81-85 Caution for sugammadex use in renal failure patients stems from the delayed clearance of the sugammadex-rocuronium complex, which may increase the risk of hypersensitivity reactions, anaphylaxis, or recurrence of NMB 32,81-84,86 Based on a systematic review and meta-analysis, Kim, et al. concluded that sugammadex may effectively and safely reverse rocuronium-induced NMB in patients with ESRD, although the recovery to a TOF ratio of 0.9 may be prolonged compared to patients with normal renal function.85 In a retrospective observational study, Adams, et al. noted that none of the investigated adult surgical patients with ESRD who received reversal of rocuronium paralysis with sugammadex exhibited any evidence of recurrence of neuromuscular blockade.84 Hemodialysis using a high-flux dialysis method with 24-28 hours after surgery may be effective in removing sugammadex and the sugammadex-rocuronium complex in patients with ESRD.69,83,85,87 Patients who do not undergo hemodialysis require closer monitoring for a longer period to prevent postoperative complications.83 Considering the potential risk of cardiopulmonary complications in patients with ESRD, close monitoring, including electrocardiogram, oxygen saturation, blood pressure, and blood tests for electrolytes, is required during the perioperative period.83
While a rocuronium-sugammadex combination is feasible for NMB management in patients with ESRD, routine sugammadex use is not yet recommended and further studies are required with a longer follow-up period on the efficacy and safety of administration of sugammadex in patients with ESRD.55,81,83-85 Consider benzylisoquinolinium NMBAs (e.g., atracurium, cisatracurium, mivacurium) with neostigmine for NMB reversal as an alternative.
Train-of-Four Monitoring
Objective monitoring measures (e.g., train-of-four) should be performed to determine residual depth of blockade and degree of recovery.12,33,47,88-90 Train-of-four (TOF) monitoring assesses the level of NMB by delivering 4 consecutive electrical stimuli to a peripheral nerve and measuring the resulting muscle response (T1 through T4). The
degree of muscle response can be used to determine the level of muscle paralysis caused by muscle relaxants. When administrating sugammadex, monitoring for twitch response to determine the timing and dose is essential.1,47,90 Sugammadex is a single bolus injection with dosing based on actual body weight.1,33,47,91 Recommended sugammadex dosages are:
For rocuronium and vecuronium:
• 4 mg/kg is recommended if spontaneous recovery of the twitch response has reached 1 to 2 post-tetanic counts (PTC) and there are no twitch responses to TOF stimulation.1
• 2 mg/kg is recommended if spontaneous recovery has reached the reappearance of the second twitch in response to TOF stimulation.1
For rocuronium only:
• 16 mg/kg is recommended if there is a clinical need to reverse neuromuscular blockade soon (approximately 3 minutes) after administration of a single dose of 1.2 mg/kg of rocuronium.1
Contraception Precaution
Since the efficacy of hormonal contraceptives may be reduced, patients using hormonal contraceptives should be advised to use an additional, non-hormonal contraceptive for seven days following sugammadex administration.1 See package insert for full details on drug contraindications.1
Cost Effectiveness
The cost effectiveness of sugammadex is difficult to determine as numerous confounders exist.33,65,92-95 Drug costs are a major consideration as facilities determine which drugs to stock on their formulary.65,95,96 Other factors that impact facility costs include time to NMB reversal, time for extubation, OR time, PACU time, unplanned mechanical ventilation, postoperative length of stay, and the need to purchase additional required drugs (i.e., dantrolene if stocking succinylcholine).66,93,95,97-99 Based on facility type and patient acuity, the incremental cost of sugammadex could be offset by improved outcomes and potentially lead to an overall decrease of the budgetary impact, compared to neostigmine or spontaneous recovery.65,66,94,96-98 Ultimately, each facility must determine, with input from anesthesia providers, whether reductions in OR or PACU time have led to additional procedural cases, faster turnover times, or improved organizational resource utilization 33,65,66,92
Conclusion
The ability of sugammadex to reverse rocuronium-induced NMB within three minutes of administration is a consideration for providers to use rocuronium as an alternative to succinylcholine. Facilities and clinicians should work together to develop the drug formulary that is best for the patient population they serve, as well as policies and procedures for medications, supplies, equipment, and skills necessary for patient safety and improved outcomes.
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