More on Rocuronium (and Sugammadex)

While I am gradually being persuaded rocuronium might after all be a better choice than suxamethonium for rapid sequence intubation in critically ill patients- partly due to its relative preservation of apnoea time before desaturation in elective anaesthesia patients1 – I don’t believe that the existence and availability of its reversal agent, sugammadex, should really … Continue reading More on Rocuronium (and Sugammadex)

Rocuronium reusable after sugammadex

Sugammadex currently has no role in my own emergency / critical care practice. However a helpful paper informs us that patients whose rocuronium-induced neuromuscular blockade had been reversed by sugammadex may be effectively re-paralysed by a second high dose (1.2 mg/kg) of rocuronium. Onset was slower and duration shorter if the second dose of rocuronium … Continue reading Rocuronium reusable after sugammadex

It’s Tamponade – Now What?

You ultrasound the chest of your shocked patient in resus with fluid refractory hypotension. You see fluid around the heart. The right ventricle keeps bowing inwards, which you recall being described as ‘a little invisible man jumping up and down using the RV as a trampoline’, and you know this is in fact a sign … Continue reading It’s Tamponade – Now What?

Ketamine & cardiovascular stability

I ‘jumped ship’ from etomidate to ketamine for rapid sequence intubation (RSI) in sick patients about seven years ago. Good thing too, since I later moved to Australia where we don’t have etomidate. I’ve been one of the aggressive influences behind my prehospital service’s switch to ketamine as the standard induction agent for prehospital RSI. … Continue reading Ketamine & cardiovascular stability

Preoxygenation and Prevention of Desaturation

This paper is an excellent review article citing the cogent relevant evidence for optimal preoxygenation prior to RSI in the critically ill patient. The evidence has been interpreted with pertinent recommendations by two of the world’s heavy hitters in emergency medicine – Scott Weingart and Rich Levitan. If you can get a full text copy of … Continue reading Preoxygenation and Prevention of Desaturation

Longer apnoea time with roc in the obese too

Suxamethonium increases muscle oxygen consumption as a result of skeletal muscle fasciculation. In a comparison between sux and rocuronium in rapid sequence intubation, this resulted in faster desaturation in the sux group. A further study demonstrates a similar finding in obese patients. BACKGROUND: Rapid sequence induction may be associated with hypoxemia. The purpose of this … Continue reading Longer apnoea time with roc in the obese too

Easy on the ELM

A first report of thyroid cartilage fracture resulting from laryngoscopy and intubation has been published. An elective surgery patient underwent paralysis with 60 mg rocuronium after which ‘laryngoscopy and intubation attempts with a Macintosh 3 blade, Miller 2 blade, stylet, and vigorous external laryngeal manipulation yielded only Cormack Lehane grade 3 views of the larynx‘. … Continue reading Easy on the ELM

Neuromuscular blockade facilitates mask ventilation

A blinded randomised controlled trial of rocuronium versus saline in anaesthetised patients demonstrated that mask ventilation was easier in paralysed patients. The authors comment on the implications of this finding: ‘Our finding that neuromuscular blockade facilitates mask ventilation has important implications for the practice of managing difficult or impossible mask ventilation after administration of these … Continue reading Neuromuscular blockade facilitates mask ventilation

Sux vs Roc in ED RSI

Suxamethonium and rocuronium were compared in a database of prospectively recorded cases of RSI in the emergency department. A total of 327 RSI were included in the final analyses. All patients received etomidate as the induction sedative and were successfully intubated. Of these, 113 and 214 intubations were performed using succinylcholine and rocuronium, respectively. The … Continue reading Sux vs Roc in ED RSI