Suxamethonium or rocuronium for rapid sequence induction of anaesthesia? A reply
Bibliographic record
Abstract
I thank Dr. Dinsmore for his comments on our systematic review comparing succinylcholine and rocuronium for rapid sequence intubation 1, which is the fourth update of the original paper reported in 2002 2. The study comparison of succinylcholine 1.0 mg.kg−1 vs. a minimum of 0.6 mg.kg−1 rocuronium was a relevant dosing question, as the efficacy of 1.0 mg.kg−1 rocuronium was not established practice at that time. The subgroup analyses for this study with the specific dosing comparisons were made a priori, as well as the primary outcome definition of ‘excellent intubating conditions’ in 2002. ‘Acceptable intubating conditions’ was a secondary outcome, encompassing both ‘excellent’ and ‘good’ intubating conditions. The Cochrane collaboration encourages the updating systematic reviews to accommodate data from new trials, especially if the conclusions of the systematic review may change. With this update, we have maintained our consistent methodology in reporting the primary outcome: excellent intubating conditions with the same subgroup analyses of rocuronium dosing. In the discussion, we concluded that ‘succinylcholine created significantly more excellent intubation conditions than rocuronium at doses of 0.6–0.7 mg.kg−1’, but in the next sentence we also stated that ‘there was no statistically significant difference for the 0.9–1.0 mg.kg−1 or 1.2 mg.kg−1 groups, reaffirming the current practice of using 1 mg.kg−1 of rocuronium for rapid sequence intubation when succinylcholine is not clinically indicated’. This statement allowed us to report the answer to our original research question from 2002 comparing 1.0 mg.kg−1 of succinylcholine vs. 0.6 mg.kg−1 of rocuronium, but also to highlight the current practice of using a higher dose of rocuronium for rapid intubation. With regard to the resultant prolonged neuromuscular block with higher doses of rocuronium, this is the first update to mention the new reversal agent sugammadex. Its availability certainly makes the prolonged effects of rocuronium less concerning for those who have immediate access to it. Sugammadex is well suited for the treatment of unwanted residual muscle paralysis, but its use in difficult airway management or emergencies has not been studied. The availability of sugammadex is not consistent within the affluent nations and its cost is prohibitive for many countries around the world. Thus, the authors felt it was still prudent to continue to warn readers that 1.0 mg.kg−1 of rocuronium was equally effective as 1.0 mg.kg−1 of succinylcholine, at the cost of a much longer paralysis period. Certainly the clinical question addressed in this systematic review has been settled in current clinical practice, with the administration of 1.0 mg.kg−1 rocuronium to patients for rapid sequence induction when succinylcholine is not appropriate. Conversely, this review should also remind readers that, when selected appropriately, succinylcholine is still an excellent choice to produce the most optimal intubation conditions, especially in emergencies and when the airway is challenging to secure.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.022 | 0.167 |
| Meta-epidemiology (narrow) | 0.001 | 0.002 |
| Meta-epidemiology (broad) | 0.003 | 0.003 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.002 | 0.003 |
| Scholarly communication | 0.003 | 0.010 |
| Open science | 0.004 | 0.003 |
| Research integrity | 0.033 | 0.042 |
| Insufficient payload (model declined to judge) | 0.012 | 0.006 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".